Reversible neurologic abnormalities associated with prolonged intravenous midazolam and fentanyl administration

Incidence of iatrogenic withdrawal syndrome and associated factors in surgical pediatric intensive care

BACKGROUND

Iatrogenic withdrawal syndrome (IWS) is a complication of prolonged sedation/analgesia in pediatric intensive care unit (PICU) patients. The epidemiology of IWS is poorly understood, as validated diagnostic tools are rarely used. The main objective of our study was to use the WAT-1 score to assess the incidence of IWS in our unit. The secondary objectives were to evaluate the consequences of IWS, associated factors, and management modalities.

MATERIAL AND METHODS

From July 2018 to January 2019, 48 children receiving endotracheal ventilation and sedation/analgesia by continuous infusion (>48 h) of benzodiazepines and/or opioids were included. As soon as sedation/analgesia was decreased and until 72 h after its complete discontinuation, the WAT-1 score was determined every 12 h. Substitution therapy was used for 98% of patients upon opioid and/or benzodiazepine withdrawal. IWS was defined as a WAT-1 score ≥3. Factors associated with IWS were assessed by univariate analysis.

RESULTS

IWS occurred in 25 (52%) patients. IWS was associated with a higher number of ventilator-associated pneumonia episodes (17 [68%] vs. one [4%]) and a longer PICU stay (13 [7; 25] vs. 9.0 [5.0; 10.5]) (p<0.001). Overall, 11 patients developed IWS after less than 5 days of sedation/analgesia. Severe head injury was associated with IWS (p = 0.03). Neither sedation discontinuation nor IWS prevention was standardized.

CONCLUSION

The high incidence and adverse consequences of IWS require improved prevention. Risk groups should be defined and a standardized withdrawal protocol established. The occurrence of IWS should be monitored routinely using a validated score.

Midazolam nasal spray to treat intermittent, stereotypic episodes of frequent seizure activity: pharmacology and clinical role, a comprehensive review

An intranasal formulation of midazolam, Nayzilam, has been FDA-approved to treat intermittent, stereotypic episodes of frequent seizure activity. Nayzilam is easy to administer and can quickly treat seizures that occur outside of the hospital. The intra-nasal route of administration allows non-medical personal to administer the drug which makes it more accessible and user-friendly in the event of a seizure. Many studies have indicated quick cessation of seizures with Nayzilam compared to rectal diazepam, which has been the standard of care treatment. Nayzilam has been proven to be safe and effective for acute seizures in children, deeming it a revolutionary alternative in times where intravenous administration is not possible.

Opioid Weaning Protocol Using Morphine Compared With Nonprotocolized Methadone Associated With Decreased Dose and Duration of Opioid After Norwood Procedure

OBJECTIVES

Opioids are used to manage pain, comfort, maintain devices, and decrease oxygen consumption around Norwood palliation (NP), but in high dose and prolonged exposure, they increase risk of tolerance and iatrogenic withdrawal syndrome (IAWS). Variability in practice for IAWS prevention potentially increases opioid dose and duration. We hypothesize that protocolized weaning with morphine (MOR) versus nonprotocolized methadone (MTD) is associated with reduction in opioid exposure.

DESIGN

A before-versus-after study of outcomes of patients weaned with protocolized MOR versus nonprotocolized MTD including subset analysis for those patients with complications postoperatively. Primary endpoints include daily, wean phase, and total morphine milligram equivalent (MMEq) dose, duration, and, secondarily, length of stay (LOS).

SETTING

Quaternary-care pediatric cardiac ICU.

PATIENTS

Neonates undergoing single-ventricle palliation.

INTERVENTIONS

Introduction of IAWS prevention protocol.

MEASUREMENTS AND MAIN RESULTS

Analysis included 54 patients who underwent the NP in 2017-2018 including the subset analysis of 34 who had a complicated postoperative course. The total and wean phase opioid doses for the MTD group were significantly higher than that for the MOR group: 258 versus 22 and 115 versus 6 MMEq/kg; p < 0.001. Duration of opioid exposure was 63 days in the MTD group and 12 days in MOR group (p < 0.001). Subanalysis of the complicated subset also identifies higher total and wean dose for MTD group (293 vs 41 and 116 vs 7 MMEq/kg; p < 0.001) with a longer duration (65 vs 22 days; p = 0.001). Within the subset, LOS was 55% longer in the MTD group than that in the MOR group (150 vs 67 d; p = 0.01) and not different in the uncomplicated group.

CONCLUSIONS

After complex NP, a protocolized opioid weaning using MOR versus MTD is associated with 65% shorter opioid duration, 10-fold decreased dose, and shortened LOS.

Acute Movement Disorders in Childhood

Acute-onset movement disorders (MDs) are an increasingly recognized neurological emergency in both adults and children. The spectrum of possible causes is wide, and diagnostic work-up is challenging. In their acute presentation, MDs may represent the prominent symptom or an important diagnostic clue in a broader constellation of neurological and extraneurological signs. The diagnostic approach relies on the definition of the overall clinical syndrome and on the recognition of the prominent MD phenomenology. The recognition of the underlying disorder is crucial since many causes are treatable. In this review, we summarize common and uncommon causes of acute-onset movement disorders, focusing on clinical presentation and appropriate diagnostic investigations. Both acquired (immune-mediated, infectious, vascular, toxic, metabolic) and genetic disorders causing acute MDs are reviewed, in order to provide a useful clinician’s guide to this expanding field of pediatric neurology.

Sedative and Analgesic Pharmacokinetics During Pediatric ECMO

Sedatives and analgesics are often administered to critically ill children supported by extracorporeal membrane oxygenation (ECMO) to facilitate comfort and to decrease risks of life-threatening complications. Optimization of sedative and analgesic dosing is necessary to achieve desired therapeutic benefits and must consider interactions between the circuit and patient that may affect drug metabolism, clearance, and impact on target organs. This paper reviews existing in vitro and pediatric in vivo literature concerning the effects of the ECMO circuit on sedative and analgesic disposition and offers dosing guidance for the management of critically ill children receiving these drugs.

Opioid-induced Hallucinations: A Review of the Literature, Pathophysiology, Diagnosis, and Treatment

Despite their association with multiple adverse effects, opioid prescription continues to increase. Opioid-induced hallucination is an uncommon yet significant adverse effect of opioid treatment. The practitioner may encounter patient reluctance to volunteer the occurrence of this phenomenon because of fears of being judged mentally unsound. The majority of the literature concerning opioid-induced hallucinations arises from treatment during end-of-life care and cancer pain. Because the rate of opioid prescriptions continues to increase in the population, the rate of opioid-associated hallucinations may also conceivably increase. With a forecasted increase in the patient-to-physician ratio, opioid therapy is predicted to be provided by practitioners of varying backgrounds and medical specialties. Hence, knowledge of the pharmacology and potential adverse effects of these agents is required. This review seeks to increase awareness of this potential complication through a discussion of the literature, potential mechanisms of action, diagnosis, and treatment strategies.

Intravenous midazolam infusion for sedation of infants in the neonatal intensive care unit

BACKGROUND

Proper sedation for neonates undergoing uncomfortable procedures may reduce stress and avoid complications. Midazolam is a short-acting benzodiazepine that is used increasingly in neonatal intensive care units (NICUs). However, its effectiveness as a sedative in neonates has not been systematically evaluated.

OBJECTIVES

Primary objeciveTo assess the effectiveness of intravenous midazolam infusion for sedation, as evaluated by behavioural and/or physiological measurements of sedation levels, in critically ill neonates in the NICU. Secondary objectivesTo assess effects of intravenous midazolam infusion for sedation on complications including the following.1. Incidence of intraventricular haemorrhage (IVH)/periventricular leukomalacia (PVL).2. Mortality.3. Occurrence of adverse effects associated with the use of midazolam (hypotension, neurological abnormalities).4. Days of ventilation.5. Days of supplemental oxygen.6. Incidence of pneumothorax.7. Length of NICU stay (days).8. Long-term neurodevelopmental outcomes.

SELECTION CRITERIA

We selected for review randomised and quasi-randomised controlled trials of intravenous midazolam infusion for sedation in infants aged 28 days or younger.

DATA COLLECTION AND ANALYSIS

We abstracted data regarding the primary outcome of level of sedation. We assessed secondary outcomes such as intraventricular haemorrhage, periventricular leukomalacia, death, length of NICU stay and adverse effects associated with midazolam. When appropriate, we performed meta-analyses using risk ratios (RRs) and risk differences (RDs), and if the RD was statistically significant, we calculated the number needed to treat for an additional beneficial outcome (NNTB) or an additional harmful outcome (NNTH), along with their 95% confidence intervals (95% CIs) for categorical variables, and weighted mean differences (WMDs) for continuous variables. We assessed heterogeneity by performing the I-squared (I2) test.

MAIN RESULTS

We included in the review three trials enrolling 148 neonates. We identified no new trials for this update. Using different sedation scales, each study showed a statistically significantly higher sedation level in the midazolam group compared with the placebo group. However, none of the sedation scales used have been validated in preterm infants; therefore, we could not ascertain the effectiveness of midazolam in this population. Duration of NICU stay was significantly longer in the midazolam group than in the placebo group (WMD 5.4 days, 95% CI 0.40 to 10.5; I2 = 0%; two studies, 89 infants). One study (43 infants) reported significantly lower Premature Infant Pain Profile (PIPP) scores during midazolam infusion than during dextrose (placebo) infusion (MD -3.80, 95% CI -5.93 to -1.67). Another study (46 infants) observed a higher incidence of adverse neurological events at 28 days' postnatal age (death, grade III or IV IVH or PVL) in the midazolam group compared with the morphine group (RR 7.64, 95% CI 1.02 to 57.21; RD 0.28, 95% CI 0.07 to 0.49; NNTH 4, 95% CI 2 to 14) (tests for heterogeneity not applicable). We considered these trials to be of moderate quality according to GRADE assessment based on the following outcomes: mortality during hospital stay, length of NICU stay, adequacy of analgesia according to PIPP scores and poor neurological outcomes by 28 days' postnatal age.

AUTHORS' CONCLUSIONS

Data are insufficient to promote the use of intravenous midazolam infusion as a sedative for neonates undergoing intensive care. This review raises concerns about the safety of midazolam in neonates. Further research on the effectiveness and safety of midazolam in neonates is needed.

Pentobarbital for Sedation during Mechanical Ventilation in the Pediatric ICU Patient

In most pediatric intensive care units (PICUs), sedation is provided using opioids and benzodiazepines, either alone or in combination. While these agents are effective in most patients, certain situations may arise in which this usual combination is ineffective. There are no large series outlining the use of pentobarbital for sedation in the PICU population. The current report is a retrospective review of the use of pentobarbital for sedation of 50 patients in the PICU and provides information concerning the use of phenobarbital to prevent withdrawal symptoms following the prolonged administration of pentobarbital. The 50 patients ranged in age from 1 month to 14 years and in weight from 3.1 to 56 kg. All required sedation during mechanical ventilation. Prior to changing to pentobarbital, sedation was inadequate despite midazolam doses of ≥0.4 mg/kg/hr, fentanyl doses of ≥10 μg/kg/hr, and morphine doses of ≥100 μg/kg/hr. The duration of pentobarbital infusion ranged from 2 to 37 days (median 4 days) in doses ranging from 1 to 6 mg/kg/hr (median 2 mg/kg/hr). Twelve patients also received an ongoing opioid infusion for more than 48 hours after starting the pentobarbital infusion to control pain related to a surgical procedure or an acute medical illness. There was an increase in pentobarbital infusion requirements over time. In the 14 patients that received pentobarbital for 5 days or more, the requirements increased from 1.2 ± 0.4 mg/kg/hr on day 1 to 3.4 ± 0.7 mg/kg/hr on day 5 ( p < 0.01). Pentobarbital was effective in all 50 patients without significant adverse effects.

Impact of a Standardized Treatment Guideline for Pediatric Iatrogenic Opioid Dependence: A Quality Improvement Initiative

OBJECTIVES

To determine whether utilization of a hospital-based clinical practice guideline for the care of pediatric iatrogenic opioid dependence (IOD) would promote a decrease in opioid exposure and improve management of opioid abstinence syndrome (AS).

METHODS

This study is a retrospective chart review of critically ill patients from a tertiary care children's hospital. Inclusion criteria included mechanically ventilated patients up to 18 years of age who received continuous opioid infusions for at least 7 days and any length of methadone administration. Data on IOD patients from January 2005 to June 2010 was divided into 3 periods: baseline, phase 1, and phase 2. Primary outcome was decrease in opioid exposure, measured by methadone duration of use and any additional opioid bolus doses used in AS management. Documentation of additional opioid bolus doses was regarded as a surrogate measure of AS. Secondary outcomes included total cumulative fentanyl dose, continuous fentanyl infusion duration of use, and hospital and pediatric intensive care unit length of stay.

RESULTS

There was a significant decrease in methadone duration of use in IOD patients from 15.3 ± 8.7 days at baseline to 9.5 ± 3.7 days during phase 1 (p = 0.002), to 8.1 ± 3.7 days on phase 2 (reduction not significant, p = 0.106) of this evaluation. Additional opioid bolus doses were significantly lower from baseline to phase 1 (5.5 ± 5.1 vs. 1.8 ± 2.3, p = 0.001) and from phase 1 to phase 2 (1.8 ± 2.3 vs. 0.2 ± 1.5, p = 0.003). For the remaining outcomes, differences were not observed among the evaluation periods, except for the total cumulative fentanyl dose, which was reduced from 2.8 ± 3.7 mg/kg at baseline to 1 ± 1 mg/kg only during phase 1 (p = 0.017).

CONCLUSIONS

Introduction of a standardized, hospital-based clinical practice guideline for children with IOD reduced the length of exposure to opioids and improved opioid AS management.

Age-dependent vulnerability of cyclosporine-associated encephalopathy in children

INTRODUCTION

Cyclosporine (CsA) is an immunosuppressant known for its neurotoxicity, which presents with acute encephalopathy and seizures in the most severe form. However, whether there is age-related neurological susceptibility in pediatric population is poorly defined. The study aims to examine the vulnerability of CsA neurotoxicity among different age groups of pediatric patients in terms of occurrence rate, acute presentations, long-term outcomes, and neuroimaging findings.

METHODS

Pediatric patients (age <18 years) who received CsA in a tertiary referral center between July 1, 1988 and August 31, 2011 were retrospectively reviewed for CsA-related encephalopathy. The clinical presentations, demographic data, and laboratory examinations were analyzed through t-test for numerical and Fisher's exact test for categorical variables. Exact logistic regression was used to examine the effect of each variables.

RESULTS

Twelve (8%) of the enrolled 146 patients developed CsA-induced encephalopathy. Compared to the non-neurotoxicity group, the neurotoxicity group was significantly younger upon starting CsA (p = 0.008) and had higher percentages of hypertension after CsA treatment (p = 0.01). Regression analysis showed that age <6 years (OR 7.6, 95% CI 1.6-51.5; p = 0.007) and hypertension after CsA (OR 6.3, 95% CI 1.4-35.4; p = 0.016) were significantly associated with CsA encephalopathy. Younger children were prone to have more severe seizures in the acute stage and more epilepsy and neuropsychiatric disorders in the future. Follow-up neuroimaging showed parietal cerebral atrophy in all examined children <6 years of age.

CONCLUSIONS

Age-dependent susceptibility of CsA neurotoxicity occurs in children, with severe acute presentations and long-term sequelae in children below 6 years old.

Risk factors associated with iatrogenic opioid and benzodiazepine withdrawal in critically ill pediatric patients: a systematic review and conceptual model

OBJECTIVES

Analgesia and sedation are common therapies in pediatric critical care, and rapid titration of these medications is associated with iatrogenic withdrawal syndrome. We performed a systematic review of the literature to identify all common and salient risk factors associated with iatrogenic withdrawal syndrome and build a conceptual model of iatrogenic withdrawal syndrome risk in critically ill pediatric patients.

DATA SOURCES

Multiple databases, including PubMed/Medline, EMBASE, CINAHL, and the Cochrane Central Registry of Clinical Trials, were searched using relevant terms from January 1, 1980, to August 1, 2014.

STUDY SELECTION

Articles were included if they were published in English and discussed iatrogenic withdrawal syndrome following either opioid or benzodiazepine therapy in children in acute or intensive care settings. Articles were excluded if subjects were neonates born to opioid- or benzodiazepine-dependent mothers, children diagnosed as substance abusers, or subjects with cancer-related pain; if data about opioid or benzodiazepine treatment were not specified; or if primary data were not reported.

DATA EXTRACTION

In total, 1,395 articles were evaluated, 33 of which met the inclusion criteria. To facilitate analysis, all opioid and/or benzodiazepine doses were converted to morphine or midazolam equivalents, respectively. A table of evidence was developed for qualitative analysis of common themes, providing a framework for the construction of a conceptual model. The strongest risk factors associated with iatrogenic withdrawal syndrome include duration of therapy and cumulative dose. Additionally, evidence exists linking patient, process, and system factors in the development of iatrogenic withdrawal syndrome.

FINDINGS

Most articles were prospective observational or interventional studies.

CONCLUSIONS

Given the state of existing evidence, well-designed prospective studies are required to better characterize iatrogenic withdrawal syndrome in critically ill pediatric patients. This review provides data to support the construction of a conceptual model of iatrogenic withdrawal syndrome risk that, if supported, could be useful in guiding future research.

Clinical pharmacology of midazolam in neonates and children: effect of disease-a review

Midazolam is a benzodiazepine with rapid onset of action and short duration of effect. In healthy neonates the half-life (t_1/2) and the clearance (Cl) are 3.3-fold longer and 3.7-fold smaller, respectively, than in adults. The volume of distribution (Vd) is 1.1 L/kg both in neonates and adults. Midazolam is hydroxylated by CYP3A4 and CYP3A5; the activities of these enzymes surge in the liver in the first weeks of life and thus the metabolic rate of midazolam is lower in neonates than in adults. Midazolam acts as a sedative, as an antiepileptic, for those infants who are refractory to standard antiepileptic therapy, and as an anaesthetic. Information of midazolam as an anaesthetic in infants are very little. Midazolam is usually administered intravenously; when minimal sedation is required, intranasal administration of midazolam is employed. Disease affects the pharmacokinetics of midazolam in neonates; multiple organ failure reduces the Cl of midazolam and mechanical ventilation prolongs the t_1/2 of this drug. ECMO therapy increases t_1/2, Cl, and Vd of midazolam several times. The adverse effects of midazolam in neonates are scarce: pain, tenderness, and thrombophlebitis may occur. Respiratory depression and hypotension appear in a limited percentage of infants following intravenous infusion of midazolam. In conclusion, midazolam is a safe and effective drug which is employed as a sedative, as antiepileptic agent, for infants who are refractory to standard antiepileptic therapy, and as an anaesthetic.

Epileptic seizures induced by dexmedetomidine in a neonate

BACKGROUND

Dexmedetomidine hydrochloride, a highly selective 2-adrenoceptoragonist, is used in combination with local anesthetics for sedation and analgesia. It is known to be efficacious in adult patients and is enthusiastically expected to be successful for sedation in neonates.

PATIENT

The present case report details a term infant who was sedated by dexmedetomidine during artificial ventilation. He underwent electroencephalograms that confirmed epileptic seizures and non-epileptic abnormal movements. Twelve hours after the discontinuation of dexmedetomidine, both symptoms gradually disappeared without the use of any antiepileptic medication. After then, he had achieved normal development, with no obvious neurological abnormalities.

CONCLUSION

Dexmedetomidine acts throughout the central nervous system and leads to a reduction in the anticonvulsant activity of the locus coeruleus. This case suggests potential adverse effects of dexmedetomidine in terms of inducing both epileptic seizures and non-epileptic movements in neonates.

The role of systematic reviews in pharmacovigilance planning and Clinical Trials Authorisation application: example from the SLEEPS trial

BACKGROUND

Adequate sedation is crucial to the management of children requiring assisted ventilation on Paediatric Intensive Care Units (PICU). The evidence-base of randomised controlled trials (RCTs) in this area is small and a trial was planned to compare midazolam and clonidine, two sedatives widely used within PICUs neither of which being licensed for that use. The application to obtain a Clinical Trials Authorisation from the Medicines and Healthcare products Regulatory Agency (MHRA) required a dossier summarising the safety profiles of each drug and the pharmacovigilance plan for the trial needed to be determined by this information. A systematic review was undertaken to identify reports relating to the safety of each drug.

METHODOLOGY/PRINCIPAL FINDINGS

The Summary of Product Characteristics (SmPC) were obtained for each sedative. The MHRA were requested to provide reports relating to the use of each drug as a sedative in children under the age of 16. Medline was searched to identify RCTs, controlled clinical trials, observational studies, case reports and series. 288 abstracts were identified for midazolam and 16 for clonidine with full texts obtained for 80 and 6 articles respectively. Thirty-three studies provided data for midazolam and two for clonidine. The majority of data has come from observational studies and case reports. The MHRA provided details of 10 and 3 reports of suspected adverse drug reactions.

CONCLUSIONS/SIGNIFICANCE

No adverse reactions were identified in addition to those specified within the SmPC for the licensed use of the drugs. Based on this information and the wide spread use of both sedatives in routine practice the pharmacovigilance plan was restricted to adverse reactions. The Clinical Trials Authorisation was granted based on the data presented in the SmPC and the pharmacovigilance plan within the clinical trial protocol restricting collection and reporting to adverse reactions.

Opioid analgesia in mechanically ventilated children: results from the multicenter Measuring Opioid Tolerance Induced by Fentanyl study

OBJECTIVE

To examine the clinical factors associated with increased opioid dose among mechanically ventilated children in the pediatric intensive care unit.

DESIGN

Prospective, observational study with 100% accrual of eligible patients.

SETTING

Seven pediatric intensive care units from tertiary-care children's hospitals in the Collaborative Pediatric Critical Care Research Network.

PATIENTS

Four hundred nineteen children treated with morphine or fentanyl infusions.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Data on opioid use, concomitant therapy, demographic and explanatory variables were collected. Significant variability occurred in clinical practices, with up to 100-fold differences in baseline opioid doses, average daily or total doses, or peak infusion rates. Opioid exposure for 7 or 14 days required doubling of the daily opioid dose in 16% patients (95% confidence interval 12%-19%) and 20% patients (95% confidence interval 16%-24%), respectively. Among patients receiving opioids for longer than 3 days (n = 225), this occurred in 28% (95% confidence interval 22%-33%) and 35% (95% confidence interval 29%-41%) by 7 or 14 days, respectively. Doubling of the opioid dose was more likely to occur following opioid infusions for 7 days or longer (odds ratio 7.9, 95% confidence interval 4.3-14.3; p < 0.001) or co-therapy with midazolam (odds ratio 5.6, 95% confidence interval 2.4-12.9; p < 0.001), and it was less likely to occur if morphine was used as the primary opioid (vs. fentanyl) (odds ratio 0.48, 95% confidence interval 0.25-0.92; p = 0.03), for patients receiving higher initial doses (odds ratio 0.96, 95% confidence interval 0.95-0.98; p < 0.001), or if patients had prior pediatric intensive care unit admissions (odds ratio 0.37, 95% confidence interval 0.15-0.89; p = 0.03).

CONCLUSIONS

Mechanically ventilated children require increasing opioid doses, often associated with prolonged opioid exposure or the need for additional sedation. Efforts to reduce prolonged opioid exposure and clinical practice variation may prevent the complications of opioid therapy.

Intravenous midazolam infusion for sedation of infants in the neonatal intensive care unit

BACKGROUND

Proper sedation for neonates undergoing uncomfortable procedures may reduce stress and avoid complications. Midazolam is a short-acting benzodiazepine that is increasingly used in neonatal intensive care units (NICU). However, its effectiveness as a sedative in neonates has not been systematically evaluated.

OBJECTIVES

To determine whether intravenous midazolam infusion is an effective sedative, as evaluated by behavioural or physiological measurements, or both, for critically ill neonates undergoing intensive care and to assess clinically significant short- and long-term adverse effects associated with its use.

SEARCH METHODS

We performed a literature search according to the Cochrane Neonatal Review Group search strategy. Randomised and quasi-randomised controlled trials of intravenous midazolam use in neonates were identified by searching the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 3, 2012), MEDLINE (1985 to 2012), EMBASE (1980 to 2012), CINAHL (1981 to 2012), reference lists of published studies, personal files, and abstracts published in The Pediatric Academic Societies Meeting Abstract Archives from 1990 to 2011.

SELECTION CRITERIA

Randomised and quasi-randomised controlled trials of intravenous midazolam infusion in infants aged 28 days or less for sedation were selected for review.

DATA COLLECTION AND ANALYSIS

Data regarding the primary outcome of level of sedation were abstracted. Secondary outcomes such as intraventricular haemorrhage (IVH), periventricular leukomalacia (PVL), death, length of NICU stay, and adverse effects associated with midazolam were assessed. When appropriate, meta-analyses were performed using risk ratio (RR), risk difference (RD), along with their 95% confidence intervals (95% CI) for categorical variables and weighted mean difference (WMD) for continuous variables.

MAIN RESULTS

Three trials were included in the review. Using different sedation scales, each study showed a statistically significantly higher sedation level in the midazolam group compared to the placebo group. However, since none of the sedation scales used have been validated in preterm infants, the effectiveness of midazolam in this population could not be ascertained. One study showed a statistically significant higher incidence of adverse neurological events (death, grade III or IV IVH, PVL), and meta-analysis of data from two studies showed a statistically significant longer duration of NICU stay in the midazolam group compared to the placebo group.

AUTHORS' CONCLUSIONS

There are insufficient data to promote the use of intravenous midazolam infusion as a sedative for neonates undergoing intensive care. This review raises concerns about the safety of midazolam in neonates. Further research on the effectiveness and safety of midazolam in neonates is needed.

Dexmedetomidine for opioid and benzodiazepine withdrawal in pediatric patients

PURPOSE

The published literature on the use of dexmedetomidine as an adjunct to sedation and analgesia in the management of pediatric narcotic withdrawal was reviewed.

SUMMARY

Pediatric narcotic withdrawal syndromes are reported to be increasingly frequent in pediatric intensive care units. A number of tools specifically designed for assessment of withdrawal in newborns and infants are in current use, including the widely used Finnegan Scoring System. A limited number of studies and case reports suggest that dexmedetomidine, an α(2)-receptor agonist with a mechanism of action similar to that of clonidine but with greater α(2)-receptor specificity, might have a role in the treatment of pediatric withdrawal (by blunting withdrawal symptoms without causing respiratory depression and by permitting shorter narcotic tapering schedules) and also in the prevention of pediatric narcotic withdrawal (by reducing narcotic requirements). Potential adverse effects associated with dexmedetomidine use in pediatric patients are generally associated with use of bolus doses and mainly involve central nervous system effects (e.g., hypotension, bradycardia), with no hemodynamic manifestations. When bolus doses are used, strategies described in published reports entail a loading dose of 0.5-1.0 μg/kg administered over 5-10 minutes, followed by a continuous infusion at 0.1-1.4 μg/kg/hr for a period of 1-16 days. More research is needed to define the optimal use of dexmedetomidine in the management of pediatric narcotic withdrawal.

CONCLUSION

A limited body of published evidence from retrospective studies and case reports suggests a potential role for dexmedetomidine as an adjunct therapy to provide sedation and analgesia to reduce narcotic withdrawal symptoms in pediatric patients.

Tolerance and withdrawal from prolonged opioid use in critically ill children

OBJECTIVE

After prolonged opioid exposure, children develop opioid-induced hyperalgesia, tolerance, and withdrawal. Strategies for prevention and management should be based on the mechanisms of opioid tolerance and withdrawal.

PATIENTS AND METHODS

Relevant manuscripts published in the English language were searched in Medline by using search terms "opioid," "opiate," "sedation," "analgesia," "child," "infant-newborn," "tolerance," "dependency," "withdrawal," "analgesic," "receptor," and "individual opioid drugs." Clinical and preclinical studies were reviewed for data synthesis.

RESULTS

Mechanisms of opioid-induced hyperalgesia and tolerance suggest important drug- and patient-related risk factors that lead to tolerance and withdrawal. Opioid tolerance occurs earlier in the younger age groups, develops commonly during critical illness, and results more frequently from prolonged intravenous infusions of short-acting opioids. Treatment options include slowly tapering opioid doses, switching to longer-acting opioids, or specifically treating the symptoms of opioid withdrawal. Novel therapies may also include blocking the mechanisms of opioid tolerance, which would enhance the safety and effectiveness of opioid analgesia.

CONCLUSIONS

Opioid tolerance and withdrawal occur frequently in critically ill children. Novel insights into opioid receptor physiology and cellular biochemical changes will inform scientific approaches for the use of opioid analgesia and the prevention of opioid tolerance and withdrawal.

Is anesthesia bad for the newborn brain?

Although certain data suggest that common general anesthetics may be neurotoxic to immature animals, there are also data suggesting that these same anesthetics may be neuroprotective against hypoxicischemic injury, and that inadequate analgesia during painful procedures may lead to increased neuronal cell death in animals and long-term behavioral changes in humans. The challenge for the pediatric anesthesia community is to design and implement studies in human infants to ascertain the safety of general anesthesia. In this article, the authors review the relevant preclinical and clinical data that are currently available on this topic.

Opioid and benzodiazepine withdrawal syndromes in the paediatric intensive care unit: a review of recent literature

AIMS AND OBJECTIVES

This paper aims to critically review and analyse available literature to inform and advance patient care.

BACKGROUND

Withdrawal syndromes related to the routine administration of sedation and analgesia in paediatric intensive care unit (PICU) have been recognized since the 1990 s. Common symptoms include tremors, agitation, inconsolable crying and sleeplessness.

SEARCH STRATEGIES

A critical review was undertaken to assess developments in this area. Four databases were searched using Ovid Online. These were Ovid Medline, CINAHL, BNI and Embase. Key terms included were 'Paediatric', 'Sedation', 'Withdrawal' and 'Intensive care'.

INCLUSION AND EXCLUSION CRITERIA

Articles from 1980 onwards were reviewed for their relevance to paediatric iatrogenic withdrawal. Additionally, seminal work from the 1970s was included. Because of the scarcity of literature, relevant editorials and opinion pieces were included.

RESULTS

A total of 2,232,586 papers resulted from keyword searches. Use of Boolean operators to combine terms reduced the number of results to 62. Exclusion criteria reduced the number of suitable papers to 20. Tracking reference lists yielded a further 18 papers. In total, 38 papers were retrieved examining 1375 patients. Four papers surveyed drug usage on PICU, 14 listed withdrawal symptoms, 4 described the frequency of withdrawal in the PICU population, 9 described risk factors, 4 presented or validated clinical tools and 14 describe treatment strategies.

CONCLUSIONS

Withdrawal syndromes may affect 20% of exposed children and are related to infusion duration and total dose. Fifty-one symptoms are described in the literature. Future studies need accurate, validated clinical tools to be effective. Risk factors, signs and symptoms have been identified, and validation studies must now take place.

RELEVANCE TO CLINICAL PRACTICE

Withdrawal syndromes continue to be widespread and difficult to diagnose. Awareness of their causes and treatments should influence clinical decisions at the bedside.

Withdrawal symptoms in critically ill children after long-term administration of sedatives and/or analgesics: a first evaluation

OBJECTIVE

To establish frequencies of benzodiazepine and opioid withdrawal symptoms, and correlations with total doses and duration of administration.

DESIGN

A prospective, repeated-measures design.

SETTING

Two pediatric intensive care units in a university children's hospital.

PATIENTS

Seventy-nine children, aged 0 days to 16 yrs, who received intravenous midazolam and/or opioids for >5 days.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Pediatric intensive care unit nurses assessed withdrawal symptoms using the Sophia Benzodiazepine and Opioid Withdrawal Checklist, which includes all withdrawal symptoms (n = 24) described in the pediatric literature. Over 6 months, 2188 observations in 79 children were recorded. Forty-two percent of observations were performed within 24 hrs after tapering off or discontinuation of medication. Symptoms representing overstimulation of the central nervous system, such as anxiety, agitation, grimacing, sleep disturbance, increased muscle tension, and movement disorder, were observed in >10% of observations. Of symptoms reflecting gastrointestinal dysfunction, diarrhea and gastric retention were most frequently observed. Tachypnea, fever, sweating, and hypertension as manifestations of autonomic dysfunction were observed in >13% of observations. The Spearman's rank-correlation coefficient between total doses of midazolam and maximum sum score (of the Sophia Benzodiazepine and Opioid Withdrawal Checklist) was .51 (p < 0.001). The correlation between total doses of opioids and the maximum sum score was .39 (p < 0.01). A significant correlation (.52; p < 0.001) was also found between duration of use and maximum sum score.

CONCLUSIONS

This is the first study to report frequencies of all 24 withdrawal symptoms observed in children after decrease or discontinuation of benzodiazepines and/or opioids. Agitation, anxiety, muscle tension, sleeping <1 hr, diarrhea, fever, sweating, and tachypnea were observed most frequently. Longer duration of use and high dosing are risk factors for development of withdrawal symptoms in children.

Orofacial automatisms induced by acute withdrawal from high-dose midazolam mimicking nonconvulsive status epilepticus in a child

Nonconvulsive Status Epilepticus (NCSE) is not uncommon in children, and can be challenging to diagnose and treat. Etiologies vary widely and include infection, trauma and acute withdrawal from medications such as anticonvulsants. We report a child who experienced orofacial dyskinesias concerning for NCSE after withdrawal from high dose benzodiazepines andopiates. Automonic signs typically associated with sedative withdrawal were absent and treatment with benzodiazepines did not improve his symptoms. Diagnostic testing was negative, including electroencephalogram, and resolution was complete within five days. Our case demonstrates the orofacial dyskinesias that may occur during sedative medication withdrawal, and highlights potential confusion with non-convulsive status epilepticus.

Minimizing tolerance and withdrawal to prolonged pediatric sedation: case report and review of the literature

Midazolam and fentanyl infusions are commonly used for prolonged sedation and analgesia in the pediatric intensive care setting. Tolerance and withdrawal are major concerns when these infusions are used for days or weeks. Here, we review the current approaches to prolonged pediatric sedation using midazolam and fentanyl and discuss newer strategies to avoid tolerance and withdrawal syndromes. We report the case of a pediatric burn patient who developed tolerance syndrome and a movement disorder in our institution. We also review the relevant literature and methods of minimizing tolerance and withdrawal. Prolonged sedation is often necessary in treating critically ill children, and tolerance and abstinence syndrome can complicate a successful recovery. Scoring systems can be used to minimize oversedation and to titrate effectively. "Drug cycling," "wake-up protocols," and weaning regimens, possibly combined with adjuvant drugs, are being implemented successfully. Such novel approaches may decrease the incidence of tolerance and withdrawal associated with prolonged sedative and analgesic use.

Withdrawal symptoms in children after long-term administration of sedatives and/or analgesics: a literature review. "Assessment remains troublesome"

BACKGROUND

Prolonged administration of benzodiazepines and/or opioids to children in a pediatric intensive care unit (PICU) may induce physiological dependence and withdrawal symptoms.

OBJECTIVE

We reviewed the literature for relevant contributions on the nature of these withdrawal symptoms and on availability of valid scoring systems to assess the extent of symptoms.

METHODS

The databases PubMed, CINAHL, and Psychinfo (1980-June 2006) were searched using relevant key terms.

RESULTS

Symptoms of benzodiazepine and opioid withdrawal can be classified in two groups: central nervous system effects and autonomic dysfunction. However, symptoms of the two types show a large overlap for benzodiazepine and opioid withdrawal. Symptoms of gastrointestinal dysfunction in the PICU population have been described for opioid withdrawal only. Six assessment tools for withdrawal symptoms are used in children. Four of these have been validated for neonates only. Two instruments are available to specifically determine withdrawal symptoms in the PICU: the Sedation Withdrawal Score (SWS) and the Opioid Benzodiazepine Withdrawal Scale (OBWS). The OBWS is the only available assessment tool with prospective validation; however, the sensitivity is low.

CONCLUSIONS

Withdrawal symptoms for benzodiazepines and opioids largely overlap. A sufficiently sensitive instrument for assessing withdrawal symptoms in PICU patients needs to be developed.

Analgesia and local anesthesia during invasive procedures in the neonate

BACKGROUND

Preterm and full-term neonates admitted to the neonatal intensive care unit or elsewhere in the hospital are routinely subjected to invasive procedures that can cause acute pain. Despite published data on the complex behavioral, physiologic, and biochemical responses of these neonates and the detrimental short- and long-term clinical outcomes of exposure to repetitive pain, clinical use of pain-control measures in neonates undergoing invasive procedures remains sporadic and suboptimal. As part of the Newborn Drug Development Initiative, the US Food and Drug Administration and the National Institute of Child Health and Human Development invited a group of international experts to form the Neonatal Pain Control Group to review the therapeutic options for pain management associated with the most commonly performed invasive procedures in neonates and to identify research priorities in this area.

OBJECTIVE

The goal of this article was to review and synthesize the published clinical evidence for the management of pain caused by invasive procedures in preterm and full-term neonates.

METHODS

Clinical studies examining various therapies for procedural pain in neonates were identified by searches of MEDLINE (1980-2004), the Cochrane Controlled Trials Register (The Cochrane Library, Issue 1, 2004), the reference lists of review articles, and personal files. The search terms included specific drug names, infant-newborn, infant-preterm, and pain, using the explode function for each key word. The English-language literature was reviewed, and case reports and small case series were discarded.

RESULTS

The most commonly performed invasive procedures in neonates included heel lancing, venipuncture, IV or arterial cannulation, chest tube placement, tracheal intubation or suctioning, lumbar puncture, circumcision, and SC or IM injection. Various drug classes were examined critically, including opioid analgesics, sedative/hypnotic drugs, nonsteroidal anti-inflammatory drugs and acetaminophen, injectable and topical local anesthetics, and sucrose. Research considerations related to each drug category were identified, potential obstacles to the systematic study of these drugs were discussed, and current gaps in knowledge were enumerated to define future research needs. Discussions relating to the optimal design for and ethical constraints on the study of neonatal pain will be published separately. Well-designed clinical trials investigating currently available and new therapies for acute pain in neonates will provide the scientific framework for effective pain management in neonates undergoing invasive procedures.

Withdrawal from lorazepam in critically ill children

BACKGROUND

Sedatives are used in critically ill children to facilitate mechanical ventilation. Although tolerance and withdrawal are associated with use of sedatives, information about withdrawal from benzodiazepines in children is limited.

OBJECTIVE

To document the occurrence of lorazepam withdrawal in critically ill children and identify predictors for the development of withdrawal.

METHODS

This prospective, investigational, open-label study enrolled pediatric patients receiving a continuous infusion of lorazepam for at least 72 hours. The lorazepam dosage was tapered in a uniform fashion over 6 days by decreasing the total daily dose by 50% every other day on 3 occasions; it was then discontinued. The occurrence of withdrawal from lorazepam was determined by pediatric intensive care unit attending physicians based on clinical judgment. Patients were assessed for withdrawal twice daily beginning 48 hours after the initiation of the lorazepam taper. Assessments were continued for 72 hours after lorazepam discontinuation or until the patient experienced withdrawal, whichever came first. Patient demographic, sedative dosing, and lorazepam serum concentration data were collected to identify risk factors for withdrawal.

RESULTS

Twenty-nine patients completed the study. They received lorazepam for a median duration of about 21 days, and withdrawal occurred in 7 patients. There were no significant differences in demographic variables, lorazepam dosage or other sedative therapy, or lorazepam serum concentrations between patients with withdrawal and those without withdrawal. No predictors of withdrawal were identified.

CONCLUSIONS

Withdrawal occurred in 24% of critically ill children receiving long-term sedation from lorazepam. Risk factors for withdrawal are unknown.

Tolerance and Withdrawal Issues with Sedation

The stay in an ICU is a complex mixture of providing optimal care while keeping the patient safe. Means of reducing the anxiety associated with the ICU stay include frequent reorientation and maintenance of patient comfort with sedation supplemented by analgesia as needed. The most common agents used to provide sedation include benzodiazepines, propofol, and the newer dexmedetomidine. Others include barbiturate agents, neuroleptics, clonidine, etomidate, ketamine, and supplemental opioid analgesics for pain control. A common complication of sedation is tolerance, which can lead to withdrawal if the sedation is discontinued hastily. This article evaluates the occurrence of tolerance and withdrawal in the most commonly used sedatives in critically ill patients.

Opioid and benzodiazepine withdrawal symptoms in paediatric intensive care patients

The purposes of this prospective repeated measures study were to: (a) describe the occurrence of withdrawal symptoms with the use of a standardised protocol to slowly taper opioids and benzodiazepines; and (b) to test the predictive validity of an opioid and benzodiazepine withdrawal assessment scoring tool in critically ill infants and young children after prolonged opioid and benzodiazepine therapy. Fifteen children (6 weeks-28 months of age) with complex congenital heart disease and/or respiratory failure who received opioids and benzodiazepines for 4 days or greater were evaluated for withdrawal symptoms using a standardized assessment tool. Thirteen children showed moderate to severe withdrawal symptoms a median 3 days after commencement of tapering. Symptom intensity was not related to prior opioid or benzodiazepine exposure, extracorporeal membrane oxygenation (ECMO) therapy or length of tapering. Children who received fentanyl in addition to morphine more often exhibited signs of withdrawal. This study demonstrated that significant withdrawal symptoms occur in critically ill children even with the use of a standardised assessment tool and tapering management protocol. The predictive validity and utility of the Opioid and Benzodiazepine Withdrawal Score (OBWS) was adequate for clinical use, but areas for further improvement of the tool were identified. Problems with the clinical withdrawal prevention and management guidelines were also identified. More research is needed to establish the optimal methods for prevention and management of iatrogenic opioid and benzodiazepine withdrawal in paediatric critical care.

Continuous pentobarbital infusion in children is associated with high rates of complications

PURPOSE

To evaluate the incidence and severity of complications related to continuous pentobarbital (PB) infusion for sedation in the Pediatric Intensive Care Unit (PICU).

MATERIALS AND METHODS

We conducted a retrospective, chart review study. All patients admitted to the PICU from January 1997 through June 1998 who received continuous IV PB infusion for sedation (n = 8) were included.

RESULTS

All patients were intubated and mechanically ventilated prior to PB infusion. PB was used only as a second line sedative after a combination of an opioid and benzodiazepine failed to achieve adequate sedation. After initiation of PB, we were able to decrease or discontinue benzodiazepines and/or opioid doses and discontinue neuromuscular blocking drugs in all patients. We observed a high incidence of complications (62.5%) related to PB or the phenobarbital treatment used for barbiturate weaning, including blood pressure instability (25%), oversedation (12.5%), drug reaction (12.5%) and neurologic sequelae (12.5%). Discontinuation of the drug was required in 25% of the cases.

CONCLUSIONS

We found continuous PB infusion to be an effective sedative for children when other drugs fail. However, we observed a high rate of clinically significant complications requiring discontinuation of the drug.

Albumin administration--what is the evidence of clinical benefit? A systematic review of randomized controlled trials

BACKGROUND AND OBJECTIVE

The advantages of albumin over less costly alternative fluids continue to be debated. Meta-analyses focusing on survival have been inconclusive, and other clinically relevant end-points have not been systematically addressed. We sought to determine whether albumin confers significant clinical benefit in acute illness compared with other fluid regimens.

METHODS

Database searches (MEDLINE, EMBASE, Cochrane Library) and other methods were used to identify randomized controlled trials comparing albumin with crystalloid, artificial colloid, no albumin or lower-dose albumin. Major findings for all end-points were extracted and summarized. A quantitative meta-analysis was not attempted.

RESULTS

Seventy-nine randomized trials with a total of 4755 patients were included. No significant treatment effects were detectable in 20/79 (25%) trials. In cardiac surgery, albumin administration resulted in lower fluid requirements, higher colloid oncotic pressure, reduced pulmonary oedema with respiratory impairment and greater haemodilution compared with crystalloid and hydroxyethylstarch increased postoperative bleeding. In non-cardiac surgery, fluid requirements, and pulmonary and intestinal oedema were decreased by albumin compared with crystalloid. In hypoalbuminaemia, higher doses of albumin reduced morbidity. In ascites, albumin reduced haemodynamic derangements, morbidity and length of stay and improved survival after spontaneous bacterial peritonitis. In sepsis, albumin decreased pulmonary oedema and respiratory dysfunction compared with crystalloid, while hydroxyethylstarch induced abnormalities of haemostasis. Complications were lowered by albumin compared with crystalloid in burn patients. Albumin-containing therapeutic regimens improved outcomes after brain injury.

CONCLUSIONS

Albumin can bestow benefit in diverse clinical settings. Further trials are warranted to delineate optimal fluid regimens, in particular indications.

Sleeping beauties: the impact of sedation on neonatal development

Sedatives are frequently administered in neonatal intensive care to induce sleep for diagnostic and radiology procedures, calm irritable infants, manage pain-related agitation, and enhance ventilation. The pharmacology and side effects of sedatives commonly used with neonates will be reviewed and placed within the context of their potential effect on neonatal development. Alternative caregiving strategies to minimize or eliminate the need for sedation will be discussed.

Toxicity of intravenous anaesthetics

Intravenous anaesthetic agents are generally remarkably safe. However, it is clear that propofol infusion syndrome is a real, albeit rare, entity. This often lethal syndrome of metabolic acidosis, acute cardiomyopathy and skeletal myopathy is strongly associated with infusions of propofol at rates of 5 mg/kg/hour and greater for more than 48 hours. There is evidence to support the hypothesis that the syndrome is caused by the failure of free fatty acid metabolism due to inhibition of free fatty acid entry into the mitochondria and also specific sites in the mitochondrial respiratory chain. The syndrome therefore mimics the mitochondrial myopathies. Midazolam causes seizure-like activity in very-low-birthweight premature infants requiring the drug prior to tracheal intubation or during prolonged positive pressure ventilation. This can be successfully reversed with the specific benzodiazepine antagonist flumazenil. Midazolam can also cause paradoxical reactions, including increased agitation, poor co-operation and aggressive or violent behaviour, which has been successfully managed with flumazenil.

Intravenous midazolam infusion for sedation of infants in the neonatal intensive care unit

BACKGROUND

The need for sedation for neonates undergoing uncomfortable procedures in the neonatal intensive care unit (NICU) has often been overlooked. Proper sedation may reduce stress and avoid complications during procedures such as mechanical ventilation. Midazolam is a short acting benzodiazepine that has been increasingly used in the NICU. However, the effectiveness of intravenous midazolam as a sedative in neonates has not been systematically evaluated.

OBJECTIVES

To determine whether intravenous midazolam infusion is an effective sedative, as evaluated by behavioural and/or physiologic measurements, for critically ill neonates undergoing intensive care, and to assess clinically significant short and long term adverse effects associated with its use.

SEARCH STRATEGY

Literature search according to the Cochrane Neonatal Review Group search strategy. Randomized and quasi-randomized controlled trials of intravenous midazolam use in neonates were identified by searching the Cochrane Controlled Trials Register (The Cochrane Library, Issue 3, 2002), MEDLINE (1985-2002), EMBASE (1980-2002), reference lists of published studies, personal files, and abstracts published in Pediatric Research from 1990-2002.

SELECTION CRITERIA

Randomized and quasi-randomized controlled trials of intravenous midazolam infusion in infants </= 28 days of age for sedation during mechanical ventilation or radiologic investigations were selected for review. Studies on midazolam use as an anesthetic or an anticonvulsant were excluded. Studies involving neonates and older infants and children were excluded if data for neonates could not be extracted.

DATA COLLECTION AND ANALYSIS

Data regarding the primary outcome of level of sedation (as evaluated by behavioural scales or physiologic parameters) were abstracted. Secondary outcomes including intraventricular hemorrhage (IVH), periventricular leukomalacia (PVL), death within 28 days of age, adverse effects associated with midazolam (hemodynamic and neurologic), days of ventilation, days of supplemental oxygen use, pneumothorax, length of NICU stay, and long term neurodevelopmental outcome were assessed. When appropriate, meta-analyses were performed using relative risk (RR), risk difference (RD), along with their 95% confidence intervals (95% CI) for categorical variables and weighted mean difference (WMD) for continuous variables.

MAIN RESULTS

Three trials were eligible for inclusion in the review. Data on level of sedation from the three trials could not be combined for meta-analysis because of differences in tools used to measure sedation levels. Two studies (Jacqz-Aigrain 1994, Arya 2001) showed a statistically significantly higher level of sedation in the midazolam group compared to the placebo group. The third study (Anand 1999) comparing midazolam to morphine and placebo found no statistically significant difference in sedation level among the three groups, but a statistically significantly higher level of sedation was found in the midazolam group compared with the placebo group during the treatment infusion. However, since the sedation scales used in all three studies have not been validated in preterm infants, the effectiveness of midazolam as a sedative in this population could not be ascertained. In the study by Jacqz-Aigrain et al (Jacqz-Aigrain 1994), blood pressure was statistically significantly lower in the midazolam group than in the placebo group on days one and two, although there was no statistically significant difference in the incidence of hypotension requiring albumin or vasoactive drugs between groups. The study by Anand et al (Anand 1999) showed a statistically significant higher incidence of adverse neurologic events (death, grade III-IV IVH, PVL) in the midazolam group compared with the other groups. In addition, meta-analysis of available data from two studies (Jacqz-Aigrain 1994, Anand 1999) showed a statistically significantly longer duration of NICU stay in the midazolam group compared to the placebo group (WMD 5.4 days, 95%CI 0.4, 10.5). Meta-analyses of other secondary outcomes showed no statistically significant differences between the midazolam and placebo groups.

REVIEWER'S CONCLUSIONS

There are insufficient data to promote the use of intravenous midazolam infusion as a sedative for neonates undergoing intensive care. This review raises concerns about the safety of midazolam in neonates. Further research on the effectiveness and safety of midazolam in neonates is needed.

Safety of benzodiazepines in newborns

BACKGROUND

Benzodiazepines are being used in neonatal intensive care units for sedation and control of seizures. However, anecdotal reports suggest that their use in infants may be associated with serious adverse effects (AEs).

OBJECTIVE

To determine the incidence of AEs from benzodiazepine use in preterm and full-term infants.

METHODS

Retrospective chart review of 63 infants who received benzodiazepines as a sedative or anticonvulsant over a 16-month period.

RESULTS

Mean +/- SD gestational age of the infants was 33.1 +/- 6.2 weeks, and birth weight was 2.3 +/- 1.2 kg. Median (range) postnatal age at commencement of drug administration was 19 (5-54) days. Forty-one infants received lorazepam, 8 received midazolam, and 14 received both. Ten (16%) of the infants had 14 documented adverse events: seizures (n = 6), hypotension (n = 5), and respiratory depression (n = 3). Using a validated adverse drug reaction probability scale, a probable association with benzodiazepine use was demonstrated in 12 of the AEs. Due to the retrospective nature of the data, a score for definite association was not attainable. Anticonvulsant administration was required for 4 of 6 infants and, in all cases of respiratory depression, ventilatory support was initiated or increased. Two cases of significant hypotension were treated with inotropes. There was no statistically significant correlation between AEs and benzodiazepine dose or concomitant use of inotropes or analgesics (morphine), although most infants had underlying medical conditions or received multiple drugs that may have predisposed them to experience AEs.

CONCLUSIONS

Administration of benzodiazepines was frequently associated with AEs in full-term and preterm infants. It is possible that underlying illnesses and concomitant drug use predisposed these effects. Until the benefit-to-risk ratio is determined by further studies, judicious use of benzodiazepines is recommended in this vulnerable population.

Neurologic outcome of choreoathetoid encephalopathy after cardiac surgery

Postoperative encephalopathy with choreoathetosis is a serious neurologic complication of childhood cardiac surgery. An inadequate understanding of the long-term outcome has limited family counseling and the institution of intervention strategies. Our objective was to define the long-term neurologic, cognitive, and behavioral outcome in this group of patients. By retrospective review we identified all cases of choreoathetosis in our cardiac intensive care unit from 1986 through 1995. During this decade we described a sudden transient increase in postoperative choreoathetosis that disappeared as we modified treatment strategies in perioperative care. These children underwent a comprehensive battery of neurologic, cognitive, and behavioral tests to determine in detail their long-term outcome. Of the 36 cases identified of which three were deceased, four were abroad, and eight were lost to follow-up, 21 families were approached, and 15 of the 21 (71%) consented to testing. We found pervasive deficits in memory, attention, and language, with a median full-scale IQ of 67 (range = 40-122), as well as in motor function, including persistent dyskinesia in seven of 15 (47%). The pervasive and enduring cognitive and motor deficits in survivors of postoperative choreoathetosis caution for guarded predictions of outcome and highlight the need for careful neurologic and cognitive evaluation in all children with choreoathetosis after open heart surgery.