Pediatric Withdrawal Identification and Management

Manifestations of potential xylazine withdrawal: A retrospective cohort study with nested case series

PURPOSE

The alpha2-agonist xylazine is an increasingly common adulterant of illicitly manufactured fentanyl. A potential xylazine withdrawal syndrome (XWS) is poorly characterized. We assessed for XWS.

METHODS

We conducted a retrospective cohort study of all hospitalized patients with urine GC-MS xylazine testing performed at three academic hospitals in Philadelphia, PA from 3/2022-2/2023. We used linear and logistic regression to compare peak systolic blood pressure, peak heart rate, and intensive care unit (ICU) admissions for patients with vs. without xylazine detected. Additionally, addiction specialist physicians assessed for candidate signs and symptoms of XWS (otherwise unexplained agitation, elevated blood pressure or heart rate, diaphoresis, tremor) using chart review.

RESULTS

Of 121 xylazine tests, each among unique patients (mean age 44.6 years, 33.1 % female), 73 (60 %) were positive. Xylazine detection was not associated with differences in peak systolic blood pressure or heart rate, but was associated with lower odds of ICU admission (aOR 0.24, 95 % CI 0.09-0.60). Among 73 patients with xylazine detected, chart review determined 54 (74.0 %) did not have candidate signs of XWS, 12 (16.4 %) were indeterminate, and 5 (6.8 %) were excluded due to severe critical illness. Two patients (2.7 %) had otherwise unexplained blood pressure and heart rate elevation consistent with possible XWS. Co-occurring opioid, benzodiazepine, and alcohol withdrawal were common.

CONCLUSIONS

In a cohort of hospitalized patients, there was no association between xylazine detection and vital sign instability, xylazine detection was associated with lower ICU admission rate, and chart review did not detect distinct signs or symptoms of XWS.

Verifying the Japanese Version of Pediatric Delirium and Withdrawal Syndrome Assessment Scale: SOS-PD Validation Study for Iatrogenic Withdrawal Syndrome

Background: Iatrogenic withdrawal syndrome (IWS) poses a significant clinical challenge in pediatric intensive care units (PICUs) within Japan. Despite the existing availability of tools to assess pain and delirium, a validated instrument specifically designed for IWS has been notably absent in Japanese clinical practice. The Sophia Observation withdrawal Symptoms-Paediatric Delirium (SOS-PD) scale is globally recognized as an effective tool for IWS evaluation. To bridge this gap, this study aimed to validate the Japanese version of the SOS-PD scale. Methods: A prospective, cohort, observational study was undertaken in a single-center PICU in Japan. Participants ranged from neonates to children aged 20 years, excluding those with pre-existing neurological conditions or coma. Criterion validity was evaluated by comparing Japanese SOS-PD scale scores between a Weaning Group (WEAN) undergoing sedative/opioid tapering and a Maintenance Group (MAIN) receiving stable medication. Correlation analysis was also conducted against pediatric intensivists' observational NRS (NRSobs). Inter-rater reliability of the Japanese SOS-PD scale was assessed utilizing kappa statistics and intraclass correlation coefficient (ICC). Results: In support of criterion validity, the WEAN group demonstrated significantly higher scores in both NRSobs and the IWS component of the Japanese SOS-PD scale compared to the MAIN group (p < 0.001). A strong correlation was observed between the Japanese SOS-PD IWS component and NRSobs (r = 0.91, p < 0.001). Inter-rater reliability was also robust, with a kappa coefficient of 0.95 and an ICC of 0.98. Conclusions: The Japanese version of the SOS-PD scale exhibits strong validity and inter-rater reliability for IWS assessment within Japanese PICUs. This validated instrument can support the early detection and appropriate management of pediatric IWS in Japan, with the potential to enhance the quality of patient care.

Refractory agitation in the NICU: challenges in prevention, diagnosis, and treatment

In this paper we explore refractory agitation in the neonatal population, focusing on the limitations of existing evidence on appropriate prevention, diagnosis, and treatment options. We highlight seven patients identified in an urban single-center level IV NICU with agitation unresponsive to standard non-pharmacologic interventions and escalation of standard neurosedative medications. We analyzed baseline characteristics and clinical courses of these patients with the aim to identify the NICU subpopulation at greatest risk for development of refractory agitation and to gain insight into the potential benefits of alternative medical management of agitation on later neurodevelopment. Based on these experiences we propose a practical approach to infants at increased risk for refractory agitation including standardized screening guidelines and a clinical pathway for developmentally appropriate non-pharmacologic and pharmacologic management.

Investigating the Relationship Between Midazolam Serum Concentrations and Paediatric Delirium in Critically Ill Children

OBJECTIVES

Intravenous midazolam is widely used for sedation in critically ill children. Sometimes, these children develop a paediatric delirium (PD). Our aim was to determine the relationship between midazolam serum concentration and the development of new PD in critically ill children.

DESIGN

Prospective observational pilot study.

SETTING

Paediatric Intensive Care Unit (PICU), Groningen, the Netherlands.

PATIENTS

All children admitted to the PICU from October-December 2019 who received continuous midazolam administration.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Twenty-five percent (n = 7) of the included patients (n = 28) developed new PD. In most patients, PD occurred following midazolam dose reduction. The median cumulative midazolam dose was higher in patients who developed PD compared to those without PD. We analysed 104 blood samples to determine the midazolam concentrations. To determine whether patients had PD, the Sophia Observation withdrawal Symptoms-Paediatric Delirium (SOS-PD) score was used. Patients suffering PD (n = 7) had a lower median midazolam concentration on that day compared with the day prior to PD detection. Analysis of the active metabolites, 1-hydroxymidazolam and 1-hydroxymidazolam glucuronide, showed similar results.

CONCLUSIONS

PD may be linked to a sudden and significant reduction in the midazolam concentration in critically ill children. Further investigation in larger patient populations is necessary to validate our findings.

Emergency department management of opioid use disorder in pediatric patients

Opioid use disorder (OUD) has emerged as a significant public health crisis affecting individuals across all age groups. However, there remains a critical gap in understanding the specific nuances and challenges associated with OUD in pediatric populations. This article provides a comprehensive review of the epidemiology, definition of OUD, screening recommendations for OUD, and evidence-based management strategies for OUD in pediatric patients.

Implementation of an algorithm for tapering analgosedation reduces iatrogenic withdrawal syndrome in pediatric intensive care

BACKGROUND

Proper analgosedation is a cornerstone in the treatment of critically ill patients in Pediatric Intensive Care Units (PICUs). Medications, such as fentanyl, morphine, and midazolam, are essential to safe and respectful care. The use of these medications over time may lead to side effects such as iatrogenic withdrawal syndrome (IWS) in the tapering phase. The aim of the study was to test an algorithm for tapering analgosedation to reduce the prevalence of IWS in two Norwegian PICUs at Oslo University Hospital.

METHODS

A cohort of mechanically ventilated patients from newborn to 18 years with continuous infusions of opioids and benzodiazepines for 5 days or more were included consecutively from May 2016 to December 2021. A pre- and posttest design, with an intervention phase using an algorithm for tapering analgosedation after the pretest, was used. The ICU staffs were trained in using the algorithm after the pretest. The primary outcome was a reduction in IWS. The Withdrawal Assessment Tool-1 (WAT-1) was used to identify IWS. A WAT-1 score ≥3 indicates IWS.

RESULTS

We included 80 children, 40 in the baseline group, and 40 in the intervention group. Age and diagnosis did not differ between the groups. The prevalence of IWS was 95% versus 52.5% in the baseline group versus the intervention group, and the peak WAT-1 median was 5.0 (IQR 4-6.8) versus 3.0 (IQR 2.0-6.0) (p = .012). Based on SUM WAT-1 ≥ 3, which describes the burden over time better, we demonstrated a reduction of IWS, from a median of 15.5 (IQR 8.25-39) to a median of 3 (IQR 0-20) (p = <.001).

CONCLUSION

We suggest using an algorithm for tapering analgosedation in PICUs since the prevalence of IWS was significantly lower in the intervention group in our study.

Challenges in Nursing Care of Children With Substance Withdrawal Syndrome in the PICU

Introduction

Substance withdrawal is one of the most common advert events in the Pediatric Intensive Care Unit (PICU), as the administration of potent opiates and sedative drugs is frequently performed several times each day.

Objectives

The present study explored the challenges in nursing care of children with substance withdrawal syndrome in the PICU.

Method

The study has an explorative and descriptive semi-structured qualitative interview design, with a strategic selection of informants. It was conducted at one out of three pediatric intensive care units in Sweden.

Results

Three different main themes were identified describing the different challenges regarding withdrawal symptoms: monitor the child’s interest, work with structured support, and understand the observation.

Conclusions

There is a discrepancy between the medical perspective and the nursing care perspective regarding children in PICU suffering from withdrawal syndrome. The lack of joint guidelines, language, and nursing diagnoses may lead to subjective evaluations and increase suffering for these children.

Suspected benzodiazepine withdrawal-associated seizures in 3 young dogs undergoing mechanical ventilation

OBJECTIVE

To describe new onset of generalized seizures in 3 young dogs following cessation of a benzodiazepine-containing sedation protocol to facilitate mechanical ventilation (MV) for hypoxemia.

SERIES SUMMARY

Three dogs under 5 months of age underwent MV due to severe hypoxemia. All 3 dogs were sedated with a constant rate infusion of benzodiazepines as part of their sedation protocol to facilitate MV. All 3 dogs had an acute onset of generalized seizures within 36 hours of sedation cessation and weaning from MV. All 3 dogs' seizures were successfully managed with a slow, tapering course of benzodiazepines. One dog was additionally treated with levetiracetam at the time of initial seizure activity, which was discontinued 1 year following discharge and absence of ongoing seizure activity. All 3 dogs were discharged successfully with no reports of ongoing seizures or neurologic deficits after discharge.

NEW OR UNIQUE INFORMATION PROVIDED

Young dogs managed with benzodiazepines to facilitate MV may have acute onset of generalized seizures following cessation, which can be successfully managed with short-term benzodiazepine therapy. The 3 cases in this series demonstrated a positive outcome and were successfully managed following acute onset of generalized seizure activity post-MV.

Short-Acting Sedative-Analgesic Drugs Protect Against Development of Ventilator-Associated Events in Children: Secondary Analysis of the EUVAE Study

BACKGROUND

The U.S. Centers for Disease Control and Prevention proposed a shift in its surveillance paradigm from ventilator-associated pneumonia to ventilator-associated events (VAE) to broaden the focus of prevention and achieve a greater impact on outcomes. The main objective of the present study was to identify factors associated with pediatric VAEs in children undergoing mechanical ventilation ≥ 48 h.

METHODS

This was a secondary analysis of a pediatric cohort of a multicenter prospective study. Children who underwent mechanical ventilation ≥ 48 h were included. Exclusion criteria were previous ventilation, extracorporeal life support, and right-to-left shunt or pulmonary hypertension. In the subjects with multiple episodes of mechanical ventilation, only the first episode was considered. Remifentanil and propofol are classified as short-acting sedative and analgesic agents. Pediatric VAE is defined as an "increase in PEEP ≥ 2 cm of H₂O, an increase in [Formula: see text] of 0.20, or an increase in [Formula: see text] of 0.15 plus an increase in PEEP ≥ 1 cm of H₂O sustained for ≥1 d. Associations with pediatric VAE were estimated through multivariate Cox proportional hazards analysis. Hazard ratios and 95% CI were computed.

RESULTS

In a cohort of 90 children, 24 pediatric VAEs were documented in 906 ventilator-days. Pediatric VAEs developed after a median of 4.5 (interquartile range, 4-7.25) d. Surgical admissions, spontaneous breathing trials, early mobility, vasopressors, red blood cell units transfusion, type of sedation (continuous vs intermittent), benzodiazepine use for >3 d, and pharmacologic paralysis were not associated with pediatric VAE, whereas the use of continuous short-acting sedative-analgesic agents was identified as a strong protective factor against pediatric VAE (hazard ratio 0.06 [95% CI 0.007-0.5]).

CONCLUSIONS

Treatment with short-acting sedative-analgesic agents should be preferred for sedation of mechanically ventilated children in intensive care.