High doses of benzodiazepine predict analgesic and sedative drug withdrawal syndrome in paediatric intensive care patients

Barriers and enablers in nurses implementing light sedation in intubated and ventilated children: A qualitative exploratory descriptive study

OBJECTIVE

To explore barriers and enablers in nurses implementing light sedation in mechanically ventilated children.

DESIGN

A qualitative exploratory descriptive study.

SETTING

The study was conducted in a quaternary paediatric intensive care unit in Queensland, Australia.

METHODS

Focus groups (n = 4) were conducted with nurses (n = 32) caring for children requiring mechanical ventilation and sedation. The Capability, Opportunity and Motivation model of Behaviour change (COM-B) provided the conceptual framework for this study. Qualitative data were thematically analysed.

FINDINGS

Nurse reported challenges in balancing sedation needs with patient safety. Knowledge and experience with sedation management in mechanically ventilated children, and continuity of care, positively influenced light sedation. Resources in both the physical and social environment, including family engagement, play a positive role in enhancing the practice of light sedation. Light sedation in the younger paediatric population, and those with delirium, was identified as challenging. Nonpharmacological measures facilitated management of lightly sedated patients whereas inconsistent practice among physicians and lack of nursing autonomy were identified as barriers.

CONCLUSIONS

The practice of light sedation is most effectively promoted when it is prioritized at the organisational level. Ensuring adequate human resources, modifying the physical environment, and fostering collaboration among multidisciplinary teams, including family, are all likely to enhance its implementation. Nurses' knowledge and experience in sedation management, alongside continuity of care and utilising nonpharmacological interventions, can further promote its practice. However, factors such as nurses' concerns for their own professional and patient safety, high acuity levels in the unit, and a lack of support may hinder the adoption of light sedation practices.

IMPLICATIONS FOR CLINICAL PRACTICE

The findings from this study suggest engaging multidisciplinary team to support light sedation practice. Likewise, training and skill development of nurses in the assessment and management of sedation may help implement light sedation. Continuity of care, adequate staffing, patient visibility and minimising stimulation should be considered to support the same. Nurses need to be empowered to practice light sedation, and sedation protocols may be helpful in this regard.

Impact of Nurse-Driven Analgesia and Sedation Protocols on Medication Exposure and Withdrawal in Critically Ill Children: A Systematic Review

BACKGROUND

The administration of analgesia and sedation is essential for patients admitted to the paediatric intensive care unit (PICU). However, over-sedation can cause side effects, including iatrogenic withdrawal syndrome (IWS). The use of nurse-led analgesia and sedation protocols may improve patient outcomes.

AIM

The primary aim of this systematic review was to determine whether the use of such protocols can reduce opioid and benzodiazepine doses. Secondary outcome measures included documentation of pain and sedation scores, incidence of IWS, duration of mechanical ventilation (MV) and PICU/hospital length of stay (LOS).

STUDY DESIGN

A systematic review of the literature was conducted, searching several databases, including CINAHL, MEDLINE, Academic Search Complete and Cochrane Library. Pertinent articles were selected according to pre-determined eligibility criteria. The internal validity of included studies was assessed using validated critical appraisal tools for quantitative research from the Cochrane Library. Narrative synthesis was utilised for data analysis due to the heterogeneity of study characteristics.

RESULTS

Nurse-led protocolised sedation significantly reduced the administered doses of benzodiazepines and the incidence of IWS. Moreover, the use of protocols significantly improved the documentation of pain and sedation scores across included studies. No significant difference in opioid use, duration of MV, and PICU/hospital LOS has been found. However, sub-group analyses for duration of MV and PICU/hospital LOS showed positive results in older children and those post-cardiac surgery.

CONCLUSIONS

Nurse-driven analgesia and sedation protocols can reduce over-sedation and IWS in critically ill children. Further studies should explore the use of protocols in patient sub-groups where positive results have been reported.

RELEVANCE TO CLINICAL PRACTICE

Nurse-led analgesia and sedation protocols in PICU can improve outcomes and reduce costs. Effective implementation requires training and audits to boost nurses' confidence and autonomy.

Nurses' and physicians' experience of a new algorithm for tapering analgosedation in the paediatric intensive care unit: A focus-group investigation

AIM/OBJECTIVE

Iatrogenic withdrawal syndrome occurs frequently during the tapering phase of opioids and benzodiazepines in paediatric intensive care units. The aim of this study was to explore physicians' and nurses' experiences in patient care and staff collaboration during the tapering phase using a new "algorithm for tapering analgosedation" METHODS: We used a qualitative explorative design with focus groups. The framework method was followed including transcription, familiarisation, coding, developing a framework, applying the framework, charting data into the framework matrix, and interpreting the data. The study was conducted at two paediatric intensive care units at Oslo University Hospital in Norway. Nurses and physicians who had used the new algorithm participated in the study.

FINDINGS

Three focus-group interviews were conducted with a total of 15 informants. Three main themes were identified with relevant subthemes: "Caring for a child in withdrawal", "Advantages of the algorithm", and "Challenges of the algorithm". The algorithm positively affected patient care and staff collaboration during tapering. The use of the Withdrawal Assessment Tool-1 integrated in the algorithm required experienced nurses due to the risk of false-positive patient assessments.

CONCLUSION

Nurses and physicians in our study experienced that the new algorithm promoted staff collaboration and positively affected patient care. The use of the Withdrawal Assessment Tool-1 integrated in the algorithm required experienced staff and resources for continuous staff education.

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.

Validation of the withdrawal assessment tool-1 (WAT-1) in pediatric cardiovascular patients on an inpatient unit

PURPOSE

Sedation and analgesia are administered to critically ill patients, which may result in physical dependence and subsequent iatrogenic withdrawal. The Withdrawal Assessment Tool-1 (WAT-1) was developed and validated as an objective measurement of pediatric iatrogenic withdrawal in intensive care units (ICUs), with a WAT-1 score ≥ 3 indicative of withdrawal. This study's objectives were to test interrater reliability and validity of the WAT-1 in pediatric cardiovascular patients in a non-ICU setting.

DESIGN AND METHODS

This prospective observational cohort study was conducted on a pediatric cardiac inpatient unit. WAT-1 assessments were performed by the patient's nurse and a blinded expert nurse rater. Intra-class correlation coefficients were calculated, and Kappa statistics were estimated. A two-sample, one-sided test of proportions of weaning (n = 30) and nonweaning (n = 30) patients with a WAT-1 ≥3 were compared.

RESULTS

Interrater reliability was low (K = 0.132). The WAT-1 area under the receiver operating curve was 0.764 (95% confidence interval; ± 0.123). There was a significantly higher proportion (50%, p = 0.009) of weaning patients with WAT-1 scores ≥3 compared to the nonweaning patients (10%). The WAT-1 elements of moderate/severe uncoordinated/repetitive movement and loose, watery stools were significantly higher in the weaning population.

PRACTICE IMPLICATIONS

Methods to improve interrater reliability warrant further examination. The WAT-1 had good discrimination at identifying withdrawal in cardiovascular patients on an acute cardiac care unit. Frequent nurse re-education may increase accurate tool use. The WAT-1 tool may be used in the management of iatrogenic withdrawal in pediatric cardiovascular patients in a non-ICU setting.

Recommendations for analgesia and sedation in critically ill children admitted to intensive care unit

We aim to develop evidence-based recommendations for intensivists caring for children admitted to intensive care units and requiring analgesia and sedation. A panel of national paediatric intensivists expert in the field of analgesia and sedation and other specialists (a paediatrician, a neuropsychiatrist, a psychologist, a neurologist, a pharmacologist, an anaesthesiologist, two critical care nurses, a methodologist) started in 2018, a 2-year process. Three meetings and one electronic-based discussion were dedicated to the development of the recommendations (presentation of the project, selection of research questions, overview of text related to the research questions, discussion of recommendations). A telematic anonymous consultation was adopted to reach the final agreement on recommendations. A formal conflict-of-interest declaration was obtained from all the authors. Eight areas of direct interest and one additional topic were considered to identify the best available evidence and to develop the recommendations using the Evidence-to-Decision framework according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. For each recommendation, the level of evidence, the strength of the recommendation, the benefits, the harms and the risks, the benefit/harm balance, the intentional vagueness, the values judgement, the exclusions, the difference of the opinions, the knowledge gaps, and the research opportunities were reported. The panel produced 17 recommendations. Nine were evaluated as strong, 3 as moderate, and 5 as weak. Conclusion: a panel of national experts achieved consensus regarding recommendations for the best care in terms of analgesia and sedation in critically ill children.

Implementation of a sedation protocol: a quality improvement project to enhance sedation management in the paediatric intensive care unit

BACKGROUND

Proper sedation is integral to ensuring the safety and comfort of children on mechanical ventilation (MV). Sedation protocols help to achieve this goal and reduce the duration of MV. We have observed varied sedation approaches, sedation score targets and sedative use by our physicians, which were manifested as oversedation and undersedation with associated accidental extubation. Hence, we aimed to implement a standardised sedation protocol and assess its impact on mechanically ventilated paediatric patients.

METHODS

A multidisciplinary quality improvement team was formed to develop and implement a standardised sedation protocol for mechanically ventilated paediatric patients. COMFORT-Behaviour (COMFORT-B) Scale score was used to assess the sedation targets and define undersedation, oversedation or adequate sedation. Our goal was to achieve adequate sedation during 90% of the sedation period. Based on the model for improvement methodology, we used plan-do-study-act cycles to develop, test and implement the new sedation protocol.

RESULTS

There was an immediate percentage increase in COMFORT-B Scale scores within the target sedation level, which was associated with a gradual decrease in the need for intermittent sedation doses over sedation infusion in the preimplementation, improvement and control phases (6.3, 4.9 and 3.1 sedation doses/12 hours/patient, respectively) to achieve adequate sedation target.

CONCLUSIONS

The standardisation of sedation protocols was safe and efficient, and improved the sedation quality in mechanically ventilated paediatric patients.

Rosland G, Egerod I, Bentsen GK. Iatrogenic withdrawal syndrome frequently occurs in paediatric intensive care without algorithm for tapering of analgosedation

BACKGROUND

Analgesics and sedatives are key elements to reduce physiological and psychological stress associated with treatment in paediatric intensive care. Prolonged drug use may induce tolerance and development of iatrogenic withdrawal syndrome (IWS) during the tapering phase. Our primary aim was to describe the prevalence of IWS among critically ill ventilated patients in two Norwegian paediatric intensive care units (PICUs), and secondary to investigate what motivated bedside nurses to administer additional drug doses.

METHODS

Mechanically ventilated patients (n = 40) from newborn to eighteen years of age, with continuous infusions of opioids and benzodiazepines for 5 days or more, were included consecutively from May 2016 to June 2018. By using Withdrawal Assessment Tool-1 (WAT-1) twice daily we recorded the prevalence of IWS. Additionally, we recorded signs and symptoms that led bedside nurses to administration extra bolus medication.

RESULTS

Peak WAT-1 score indicated an IWS prevalence of 95% in this selected group. The first days of the tapering phase were most critical for IWS. The most frequent symptoms triggering administration of additional bolus doses were agitation/restlessness, and thiopental and propofol were the bolus drugs used most frequently.

CONCLUSIONS

IWS affected 95% of the children having received infusions of opioids and benzodiazepines for 5 days or more in PICUs without a tapering protocol for these drugs. This calls for implementation and testing of such weaning protocols.

Current State of Analgesia and Sedation in the Pediatric Intensive Care Unit

Critically ill pediatric patients often require complex medical procedures as well as invasive testing and monitoring which tend to be painful and anxiety-provoking, necessitating the provision of analgesia and sedation to reduce stress response. Achieving the optimal combination of adequate analgesia and appropriate sedation can be quite challenging in a patient population with a wide spectrum of ages, sizes, and developmental stages. The added complexities of critical illness in the pediatric population such as evolving pathophysiology, impaired organ function, as well as altered pharmacodynamics and pharmacokinetics must be considered. Undersedation leaves patients at risk of physical and psychological stress which may have significant long term consequences. Oversedation, on the other hand, leaves the patient at risk of needing prolonged respiratory, specifically mechanical ventilator, support, prolonged ICU stay and hospital admission, and higher risk of untoward effects of analgosedative agents. Both undersedation and oversedation put critically ill pediatric patients at high risk of developing PICU-acquired complications (PACs) like delirium, withdrawal syndrome, neuromuscular atrophy and weakness, post-traumatic stress disorder, and poor rehabilitation. Optimal analgesia and sedation is dependent on continuous patient assessment with appropriately validated tools that help guide the titration of analgosedative agents to effect. Bundled interventions that emphasize minimizing benzodiazepines, screening for delirium frequently, avoiding physical and chemical restraints thereby allowing for greater mobility, and promoting adequate and proper sleep will disrupt the PICU culture of immobility and reduce the incidence of PACs.

Dexmedetomidine and Iatrogenic Withdrawal Syndrome in Critically Ill Children

BACKGROUND

Iatrogenic withdrawal syndrome is a well-known adverse effect of sedatives and analgesics commonly used in patients receiving mechanical ventilation in the pediatric intensive care unit, with an incidence of up to 64.6%. When standard sedative and analgesic treatment is inadequate, dexmedetomidine may be added. The effect of supplemental dexmedetomidine on iatrogenic withdrawal syndrome is unclear.

OBJECTIVE

To explore the potentially preventive effect of dexmedetomidine, used as a supplement to standard morphine and midazolam regimens, on the development of iatrogenic withdrawal syndrome in patients receiving mechanical ventilation in the pediatric intensive care unit.

METHODS

This retrospective observational study used data from patients on a 10-bed general pediatric intensive care unit. Iatrogenic withdrawal syndrome was measured using the Sophia Observation withdrawal Symptoms-scale.

RESULTS

In a sample of 102 patients, the cumulative dose of dexmedetomidine had no preventive effect on the development of iatrogenic withdrawal syndrome (P = .19). After correction for the imbalance in the baseline characteristics between patients who did and did not receive dexmedetomidine, the cumulative dose of midazolam was found to be a significant risk factor for iatrogenic withdrawal syndrome (P < .03).

CONCLUSION

In this study, supplemental dexmedetomidine had no preventive effect on iatrogenic withdrawal syndrome in patients receiving sedative treatment in the pediatric intensive care unit. The cumulative dose of midazolam was a significant risk factor for iatrogenic withdrawal syndrome.

Exposure-Based Methadone and Lorazepam Weaning Protocol Reduces Wean Length in Children

OBJECTIVE

Determine if a standardized methadone and lorazepam weaning protocol that is based on dose and duration of exposure can reduce the length of opioid and benzodiazepine weaning and shorten hospital stay.

METHODS

Retrospective cohort study performed in a 24-bed medical/surgical PICU. A total of 177 patients on opioid and/or benzodiazepine infusions for >3 days were included; 75 patients pre protocol (June 2012- June 2013) were compared with 102 patients post implementation of a standardized weaning protocol of methadone and lorazepam (March 2014-March 2015). The recommended wean was based on duration of infusions of >3 days up to 5 days (no wean), 5 to 13 days (short wean), and ≥14 days (long wean).

RESULTS

Median number of days on methadone for patients on opioid infusions for 5 to 13 days was reduced from 8.5 to 5.7 days (p = 0.001; n = 45 [pre], n = 68 [post]) and for patients on opioid infusions for ≥14 days, from 29.7 to 11.5 days (p = 0.003; n = 9 [pre], n = 9 [post]) after protocol implementation. The median number of days on lorazepam for patients on benzodiazepine infusions for 5 to 13 days was reduced from 8.1 to 5.2 days (p = 0.020; n = 43 [pre], n = 55 [post]) and for patients on benzodiazepine infusions for ≥14 days, from 27.4 to 9.3 days (p = 0.011; n = 9 [pre], n = 8 [post]). There was no difference in methadone or lorazepam wean length for patients on 3 to 5 days of infusions. There was no difference in adverse events or hospital length of stay.

CONCLUSIONS

A methadone and lorazepam weaning protocol based on patient's exposure to opioids and benzodiazepines (dose and duration) reduces weaning length.

Dexmedetomidine Sedation in Mechanically Ventilated Critically Ill Children: A Pilot Randomized Controlled Trial

OBJECTIVES

To assess the feasibility, safety, and efficacy of a sedation protocol using dexmedetomidine as the primary sedative in mechanically ventilated critically ill children.

DESIGN

Open-label, pilot, prospective, multicenter, randomized, controlled trial. The primary outcome was the proportion of sedation scores in the target sedation range in the first 48 hours. Safety outcomes included device removal, adverse events, and vasopressor use. Feasibility outcomes included time to randomization and protocol fidelity.

SETTING

Six tertiary PICUs in Australia and New Zealand.

PATIENTS

Critically ill children, younger than 16 years old, requiring intubation and mechanical ventilation and expected to be mechanically ventilated for at least 24 hours.

INTERVENTIONS

Children randomized to dexmedetomidine received a dexmedetomidine-based algorithm targeted to light sedation (State Behavioral Scale -1 to +1). Children randomized to usual care received sedation as determined by the treating clinician (but not dexmedetomidine), also targeted to light sedation.

MEASUREMENTS AND MAIN RESULTS

Sedation with dexmedetomidine as the primary sedative resulted in a greater proportion of sedation measurements in the light sedation range (State Behavioral Scale -1 to +1) over the first 48 hours (229/325 [71%] vs 181/331 [58%]; p = 0.04) and the first 24 hours (66/103 [64%] vs 48/116 [41%]; p < 0.001) compared with usual care. Cumulative midazolam dosage was significantly reduced in the dexmedetomidine arm compared with usual care (p = 0.002).There were more episodes of hypotension and bradycardia with dexmedetomidine (including one serious adverse event) but no difference in vasopressor requirements. Median time to randomization after intubation was 6.0 hours (interquartile range, 2.0-9.0 hr) in the dexmedetomidine arm compared with 3.0 hours (interquartile range, 1.0-7.0 hr) in the usual care arm (p = 0.24).

CONCLUSIONS

A sedation protocol using dexmedetomidine as the primary sedative was feasible, appeared safe, achieved early, light sedation, and reduced midazolam requirements. The findings of this pilot study justify further studies of sedative agents in critically ill children.

Implementation of an opioid weaning protocol to improve pain management, and to prevent or decrease iatrogenic withdrawal syndrome in the neonatal intensive care

AIM

The aim of this evidence implementation project was to improve pain assessment and management of the neonate receiving an opioid infusion, and to prevent or decrease the incidence of iatrogenic withdrawal syndrome (IWS).

METHODS

The current project was carried out in two intensive care areas of a 79 bed tertiary Neonatal Unit in Australia. A pre/postaudit design was utilized. Patient charts were reviewed to collect baseline audit data on pain assessments and titration of opioids. A weaning protocol was developed and implemented along with targeted staff education to align current practice with best practice recommendations. A postimplementation audit was then conducted to evaluate changes in practice.

RESULTS

A total of 32 charts (13 pre/19 post) were reviewed to evaluate pain assessment, titration of opioids, and the identification of any signs and symptoms of IWS. The results demonstrated an improvement in the completion of pain assessments by 34%, and 100% compliance to withdrawal assessment following the introduction of an IWS assessment tool. For neonates receiving analgesics for less than 4 days, adherence to the weaning schedule occurred in 75%. No clinical signs of IWS were seen in this cohort. For neonates receiving analgesics for greater than 4 days, adherence to the weaning schedule occurred in only 55%. Of those neonates where the protocol was not followed, 67% developed clinical signs of IWS.

CONCLUSION

Although this project demonstrated improvements in pain assessment and the identification of IWS, lack of adherence to the pain management policy and weaning tool has increased awareness of the importance of collaboration within the multidisciplinary team to improve outcomes. Several barriers were identified prior to implementation and various methods were employed to overcome these. Despite this, consistency of practice and change-management remain a challenge in clinical care.

Efficacy and safety of dexmedetomidine for prevention of withdrawal syndrome in the pediatric intensive care unit: protocol for an adaptive, multicenter, randomized, double-blind, placebo-controlled, non-profit clinical trial

Background

Prolonged treatment with analgesic and sedative drugs in the pediatric intensive care unit (PICU) may lead to undesirable effects such as dependence and tolerance. Moreover, during analgosedation weaning, patients may develop clinical signs of withdrawal, known as withdrawal syndrome (WS). Some studies indicate that dexmedetomidine, a selective α2-adrenoceptor agonist, may be useful to prevent WS, but no clear evidence supports these data. The aims of the present study are to evaluate the efficacy of dexmedetomidine in reducing the occurrence of WS during analgosedation weaning, and to clearly assess its safety.

Methods

We will perform an adaptive, multicenter, randomized, double-blind, placebo-controlled trial. Patients aged < 18 years receiving continuous intravenous analgosedation treatment for at least 5 days and presenting with clinical conditions that allow analgosedation weaning will be randomly assigned to treatment A (dexmedetomidine) or treatment B (placebo). The treatment will be started 24 h before the analgosedation weaning at 0.4 μg/kg/h, increased by 0.2 μg/kg/h per hour up to 0.8 μg/kg/h (neonate: 0.2 μg/kg/h, increased by 0.1 μg/kg/h per hour up to 0.4 μg/kg/h) and continued throughout the whole weaning time. The primary endpoint is the efficacy of the treatment, defined by the reduction in the WS rate among patients treated with dexmedetomidine compared with patients treated with placebo. Safety will be assessed by collecting any potentially related adverse event. The sample size assuring a power of 90% is 77 patients for each group (total N = 154 patients). The study was approved by the Ethics Committee of the University-Hospital S.Orsola-Malpighi of Bologna on 22 March 2017.

Discussion

The present trial will allow us to clearly assess the efficacy of dexmedetomidine in reducing the occurrence of WS during weaning from analgosedation drugs. In addition, the study will provide a unique insight into the safety profile of dexmedetomidine.

Trial registration

ClinicalTrials.gov, NCT03645603. Registered on 24 August 2018.

EudraCT, 2015–002114-80. Retrospectively registered on 2 January 2019.

Sedative and Analgesic Drug Rotation Protocol in Critically Ill Children With Prolonged Sedation: Evaluation of Implementation and Efficacy to Reduce Withdrawal Syndrome

OBJECTIVES

The first aim of this study was to assess the implementation of a sedative and analgesic drug rotation protocol in a PICU. The second aim was to analyze the incidence of withdrawal syndrome, drug doses, and time of sedative or analgesic drug infusion in children after the implementation of the new protocol.

DESIGN

Prospective observational study.

SETTING

PICU of a tertiary care hospital between June 2012 and June 2016.

PATIENTS

All patients between 1 month and 16 years old admitted to the PICU who received continuous IV infusion of sedative or analgesic drugs for more than 4 days were included in the study.

INTERVENTIONS

A sedative and analgesic drug rotation protocol was designed. The level of sedation, analgesia, and withdrawal syndrome were monitored with validated scales. The relationship between compliance with the protocol and the incidence of withdrawal syndrome was studied.

MEASUREMENTS AND MAIN RESULTS

One-hundred pediatric patients were included in the study. The protocol was followed properly in 35% of patients. Sixty-seven percent of the overall cohort presented with withdrawal syndrome. There was a lower incidence rate of withdrawal syndrome (34.3% vs 84.6%; p < 0.001), shorter PICU length of stay (median 16 vs 25 d; p = 0.003), less time of opioid infusion (median 5 vs 7 d for fentanyl; p = 0.004), benzodiazepines (median 5 vs 9 d; p = 0.001), and propofol (median 4 vs 8 d; p = 0.001) in the cohort of children in which the protocol was followed correctly.

CONCLUSIONS

Our results show that compliance with the drug rotation protocol in critically ill children requiring prolonged sedation may reduce the appearance of withdrawal syndrome without increasing the risk of adverse effects. Furthermore, it may reduce the time of continuous IV infusions for most sedative and analgesic drugs and the length of stay in PICU.

The association between frequency of opioid misuse and opioid use disorder among youth and adults in the United States

BACKGROUND

Studies have shown the frequency of drug misuse is important in the development of a substance use disorder, but little is known about this relationship in the context of opioid misuse and opioid use disorder and withdrawal symptoms.

METHODS

Our study included 2694 civilian respondents from the United States 12 years and older who had misused prescription opioids in the past year from the 2014 National Survey on Drug Use and Health. Logistic regression was used to model the association between frequency of prescription opioid misuse and opioid use disorder and withdrawal symptoms, adjusting for age, sex, race/ethnicity, and income level.

RESULTS

Misusing prescription opioids more frequently was significantly associated with opioid use disorder in a dose-dependent manner (daily misuse: OR = 14.92, 95% confidence interval (CI) 9.29, 23.95; 1-2 days/week: OR = 4.46 95% CI: 2.52, 7.89}; 1-4 times/month: OR = 2.40, 95% CI: 1.37, 4.18) compared to use less than 1 time a month. OR = 2.89, 95% CI 1.90, 4.40, respectively) after controlling for sex, age, race/ethnicity, and income. A dose-dependent relationship was found between frequency of opioid misuse and withdrawal symptoms (daily misuse: OR = 2.89, 95% CI: 1.90, 4.40; 1-2 times/week: OR = 1.91, 95% CI: 1.05, 3.45; and 1-4 times/month: 1.74, 95% CI: 1.90, 4.40) after controlling for all covariates mentioned above.

CONCLUSIONS

Our results provide evidence that higher frequency of opioid misuse is associated with both opioid use disorder and withdrawal symptoms. Frequency of use should be considered in the development of more effective opioid use disorder prevention strategies.

Analgesia, sedation, and delirium in pediatric surgical critical care

The alleviation of discomfort and distress is an essential component of the management of critically ill surgical patients. Pain and anxiety have multifocal etiologies that may be related to an underlying disease or surgical procedure, ongoing medical therapy, invasive monitors, an unfamiliar, complex and chaotic environment, as well as fear. Pharmacologic and non-pharmacologic therapies have complex risk benefit profiles. A fundamental understanding of analgesia, sedation, and delirium is essential for optimizing important outcomes in critically ill pediatric surgical patients. There has been a recent emphasis on goal directed, evidence based, and patient-centered management of the physical and psychological needs of these children. The purpose of this article is to review and summarize recent advances and describe current practice of these important subjects in the pediatric surgical intensive care environment.

Oral lorazepam can be substituted for intravenous midazolam when weaning paediatric intensive care patients off sedation

AIM

Intravenous sedatives used in the paediatric intensive care unit (PICU) need to be tapered after prolonged use to prevent iatrogenic withdrawal syndrome (IWS). We evaluated the occurrence of IWS and the levels of sedation before and after conversion from intravenous midazolam to oral lorazepam.

METHODS

This was a retrospective, observational, single cohort study of children under the age of 18 admitted to the PICU of the Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands, between January 2013 and December 2014. The outcome parameters were the Sophia Observation withdrawal Symptoms (SOS) scale scores and COMFORT Behaviour scale scores before and after conversion.

RESULTS

Of the 79 patients who were weaned, 32 and 39 had before and after SOS scores and 77 had COMFORT-B scores. IWS was reported in 15 of 79 patients (19.0%) during the 48 hours before the start of lorazepam and 17 of 79 patients (21.5%) during the 48 hours after treatment started. Oversedation was seen in 16 of 79 patients (20.3%) during the 24 hours before substitution and in 30 of 79 patients (38.0%) during the 24 hours after substitution.

CONCLUSION

The weaning protocol was not able to prevent IWS in all patients, but converting from intravenous midazolam to oral lorazepam did not increase the incidence.

Iatrogenic Opioid Withdrawal in Critically Ill Patients: A Review of Assessment Tools and Management

OBJECTIVE

To (1) provide an overview of the epidemiology, clinical presentation, and risk factors of iatrogenic opioid withdrawal in critically ill patients and (2) conduct a literature review of assessment and management of iatrogenic opioid withdrawal in critically ill patients.

DATA SOURCES

We searched MEDLINE (1946-June 2017), EMBASE (1974-June 2017), and CINAHL (1982-June 2017) with the terms opioid withdrawal, opioid, opiate, critical care, critically ill, assessment tool, scale, taper, weaning, and management. Reference list of identified literature was searched for additional references as well as www.clinicaltrials.gov .

STUDY SELECTION AND DATA EXTRACTION

We restricted articles to those in English and dealing with humans.

DATA SYNTHESIS

We identified 2 validated pediatric critically ill opioid withdrawal assessment tools: (1) Withdrawal Assessment Tool-Version 1 (WAT-1) and (2) Sophia Observation Withdrawal Symptoms Scale (SOS). Neither tool differentiated between opioid and benzodiazepine withdrawal. WAT-1 was evaluated in critically ill adults but not found to be valid. No other adult tool was identified. For management, we identified 5 randomized controlled trials, 2 prospective studies, and 2 systematic reviews. Most studies were small and only 2 studies utilized a validated assessment tool. Enteral methadone, α-2 agonists, and protocolized weaning were studied.

CONCLUSION

We identified 2 validated assessment tools for pediatric intensive care unit patients; no valid tool for adults. Management strategies tested in small trials included methadone, α-2 agonists, and protocolized sedation/weaning. We challenge researchers to create validated tools assessing specifically for opioid withdrawal in critically ill children and adults to direct management.

Nursing judgement and decision-making using the Sedation Withdrawal Score (SWS) in children

AIMS

The aim of the study was to evaluate registered children's nurses' approaches to the assessment and management of withdrawal syndrome in children.

BACKGROUND

Assessment of withdrawal syndrome is undertaken following critical illness when the child's condition may be unstable with competing differential diagnoses. Assessment tools aim to standardize and improve recognition of withdrawal syndrome. Making the right decisions in complex clinical situations requires a degree of mental effort and it is not known how nurses make decisions when undertaking withdrawal assessments.

DESIGN

Cognitive interviews with clinical vignettes.

METHODS

Interviews were undertaken with 12 nurses to explore the cognitive processes they used when assessing children using the Sedation Withdrawal Score (SWS) tool. Interviews took place in Autumn 2013.

FINDINGS

Each stage of decision-making-noticing, interpreting and responding-presented cognitive challenges for nurses. When defining withdrawal behaviours nurses tended to blur the boundaries between Sedation Withdrawal Score signs. Challenges in interpreting behaviours arose from not knowing if the patient's behaviour was a result of withdrawal or other co-morbidities. Nurses gave a range of diagnoses when interpreting the vignettes, despite being provided with identical information. Treatment responses corresponded to definite withdrawal diagnoses, but varied when nurses were unsure of the diagnosis.

CONCLUSION

Cognitive interviews with vignettes provided insight into nurses' judgement and decision-making. The SWS does not standardize the assessment of withdrawal due to the complexity of the context where assessments take place and the difficulties of determining the cause of equivocal behaviours in children recovering from critical illness.

Implementation and evaluation of a paediatric nurse-driven sedation protocol in a paediatric intensive care unit

Background

Optimal sedation and analgesia is a challenge in paediatric intensive care units (PICU) because of difficulties in scoring systems and specific metabolism inducing tolerance and withdrawal. Excessive sedation is associated with prolonged mechanical ventilation and hospitalisation. Adult and paediatric data suggest that goal-directed sedation algorithms reduce the duration of mechanical ventilation. We implemented a nurse-driven sedation protocol in a PICU and evaluated its impact.

Methods

We conducted a before and after protocol implementation study in a population of children aged 0–18 years who required mechanical ventilation for at least 24 h between January 2013 and March 2015. After the protocol implementation in January 2014, nurses managed analgesia and sedation following an algorithm that included the COMFORT behaviour scale (COMFORT-B). Duration of mechanical ventilation was the primary outcome; secondary outcomes were total doses and duration of medications, PICU length of stay, incidence of ventilator-associated pneumonia, and occurrence of withdrawal symptoms. Pre–post analysis followed with segmented regression analysis of interrupted time series was used to assess the effect of protocol.

Results

A total of 200 children were analysed, including 107 before implementation and 93 children after implementation of the protocol. After implementation of the protocol, the total number of COMFORT-B scores per day of mechanical ventilation significantly increased from 3.9 ± 2.5 times during the pre-implementation period to 6.6 ± 3.5 times during the post-implementation period (p < 10⁻³). Mean duration of mechanical ventilation tended to be lower in the post-implementation period (8.3 ± 7.3 vs 6.6 ± 5.6 days, p = 0.094), but changes in either the trend per trimester from pre-implementation to post-implementation (p = 0.933) or the immediate change after implementation (p = 0.923) were not significant with segmented regression analysis. No significant change between pre- and post-implementation was shown for total dose of sedatives, withdrawal symptoms, agitation episodes, or unplanned endotracheal extubations.

Conclusions

These results were promising and suggested that implementation of a nurse-driven sedation protocol in a PICU was feasible. Evaluation of sedation and analgesia was better after the protocol implementation; duration of mechanical ventilation and occurrence of withdrawal symptoms tended to be reduced.

Electronic supplementary material

The online version of this article (doi:10.1186/s13613-017-0256-7) contains supplementary material, which is available to authorized users.

Editor's Choice-The cardiovascular implications of sedatives in the cardiac intensive care unit

Patients admitted to the cardiac intensive care unit frequently develop multi-organ system dysfunction associated with their cardiac disease. In many cases, invasive mechanical ventilation is required, which often necessitates sedation for patient-ventilator synchrony, reduction of work of breathing, and patient comfort. In this paper, we describe the use of common sedatives available in the endotracheally intubated critically ill patient and emphasize the clinical and cardiovascular effects. We review γ-aminobutyric acid agonists such as etomidate, benzodiazepines, and propofol, the centrally acting α₂-agonist dexmedetomidine, and the N-methyl-D-aspartate receptor antagonist ketamine. Additionally, we outline the use of opioids and their role in potentiating other sedatives. We note that some sedatives are associated with increased delirium rates, and emphasize that judicious strategies minimizing sedative use are associated with decreases in morbidity and mortality. We also discuss standardized sedation assessment scales and highlight the importance of sedation weaning. Finally, we offer recommendations for sedation use during therapeutic hypothermia, and discuss the use of adjuvant neuromuscular blocking agents.

Withdrawal Assessment Tool-1 Monitoring in PICU: A Multicenter Study on Iatrogenic Withdrawal Syndrome

OBJECTIVES

Withdrawal syndrome is an adverse reaction of analgesic and sedative therapy, with a reported occurrence rate between 17% and 57% in critically ill children. Although some factors related to the development of withdrawal syndrome have been identified, there is weak evidence for the effectiveness of preventive and therapeutic strategies. The main aim of this study was to evaluate the frequency of withdrawal syndrome in Italian PICUs, using a validated instrument. We also analyzed differences in patient characteristics, analgesic and sedative treatment, and patients' outcome between patients with and without withdrawal syndrome.

DESIGN

Observational multicenter prospective study.

SETTING

Eight Italian PICUs belonging to the national PICU network Italian PICU network.

PATIENTS

One hundred thirteen patients, less than 18 years old, mechanically ventilated and treated with analgesic and sedative therapy for five or more days. They were admitted in PICU from November 2012 to May 2014.

INTERVENTIONS

Symptoms of withdrawal syndrome were monitored with Withdrawal Assessment Tool-1 scale.

MEASUREMENTS AND MAIN RESULTS

The occurrence rate of withdrawal syndrome was 64.6%. The following variables were significantly different between the patients who developed withdrawal syndrome and those who did not: type, duration, and cumulative dose of analgesic therapy; duration and cumulative dose of sedative therapy; clinical team judgment about analgesia and sedation's difficulty; and duration of analgesic weaning, mechanical ventilation, and PICU stay. Multivariate logistic regression analysis revealed that patients receiving morphine as their primary analgesic were 83% less likely to develop withdrawal syndrome than those receiving fentanyl or remifentanil.

CONCLUSIONS

Withdrawal syndrome was frequent in PICU patients, and patients with withdrawal syndrome had prolonged hospital treatment. We suggest adopting the lowest effective dose of analgesic and sedative drugs and frequent reevaluation of the need for continued use. Further studies are necessary to define common preventive and therapeutic strategies.

Implementation of a Nurse-Driven Sedation Protocol in a PICU Decreases Daily Doses of Midazolam

OBJECTIVES

To evaluate the impact of a nurse-driven sedation protocol on the length of mechanical ventilation, total daily doses of sedatives, and complications of sedation.

DESIGN

A single-center prospective before and after study was conducted from October 2010 to December 2013.

SETTING

Twelve-bed surgical and medical PICU of the university-affiliated hospital in Nantes, France.

PATIENTS

A total of 235 patients, between 28 days and 18 years old, requiring mechanical ventilation for at least 24 hours were included in the study; data from 194 patients were analyzed.

INTERVENTIONS

During the first study phase, no protocol was used. During the second phase, patients were sedated according to a nurse-driven protocol.

MEASUREMENTS AND MAIN RESULTS

In the whole population, the length of mechanical ventilation did not differ between protocol and control groups (protocol, 4 [3-8] vs control, 5 [3-7.5]; p = 0.44). Analyzing age subgroups, the length of mechanical ventilation was significantly shorter in the protocol group than in the control group in children older than 12 months (4 [3-8] vs 5 [2.75-11.25] d; p = 0.04). Daily dose of midazolam decreased during the protocol phase compared with the control phase (1 [0.56-1.8] and 1.2 [0.85-2.4] mg/kg/d, respectively; p = 0.02). No differences were shown regarding other daily dose of drugs. In the control group, 68% of children had more than 20% of COMFORT-behavior scale assessment under the target (oversedation) versus 59% in the protocol group (p = 0.139).

CONCLUSIONS

Implementation of a nurse-driven sedation protocol in a PICU is feasible and safe, allowed a decrease in daily dose of benzodiazepines, and decreased the duration of mechanical ventilation in older patients.