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Knapp T, DiLeonardo O, Maul T, Hochwald A, Li Z, Hossain J, Lowry A, Parker J, Baker K, Wearden P, Nelson J. Dexmedetomidine Withdrawal Syndrome in Children in the PICU: Systematic Review and Meta-Analysis. Pediatr Crit Care Med 2024; 25:62-71. [PMID: 37855676 DOI: 10.1097/pcc.0000000000003376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2023]
Abstract
OBJECTIVES To systematically review literature describing the clinical presentation, risk factors, and treatment for dexmedetomidine withdrawal in the PICU (PROSPERO: CRD42022307178). DATA SOURCES MEDLINE/PubMed, Cochrane, Web of Science, and Scopus databases were searched. STUDY SELECTION Eligible studies were published from January 2000 to January 2022 and reported clinical data for patients younger than 21 years old following discontinuation of dexmedetomidine after greater than or equal to 24 hours of infusion. DATA EXTRACTION Abstracts identified during an initial search were screened and data were manually abstracted after full-text review of eligible articles. The Newcastle-Ottawa Scale was used to assess study quality. Summary statistics were provided and Spearman rank correlation coefficient was used to identify relationships between covariates and withdrawal signs. A weighted prevalence for each withdrawal sign was generated using a random-effects model. DATA SYNTHESIS Twenty-three studies (22 of which were retrospective cohort studies) containing 28 distinct cohorts were included. Median cumulative dexmedetomidine exposure by dose was 105.95 μg/kg (range, 30-232.7 μg/kg), median dexmedetomidine infusion duration was 131.75 hours (range, 20.5-525.6 hr). Weighted estimates for proportion (95% CI) of subjects experiencing withdrawal signs across all cohorts were: hypertension 0.34 (range, 0.0-0.92), tachycardia 0.26 (range, 0.0-0.87), and agitation 0.26 (range, 0.09-0.77). Meta-analysis revealed no correlation between dexmedetomidine exposure variables and withdrawal signs. A moderate negative monotonic relationship existed between the proportion of patients who had undergone cardiac surgery and the proportion experiencing hypertension (correlation coefficient, -0.47; p = 0.048) and tachycardia (correlation coefficient, -0.57; p = 0.008), indicating that in cohorts with a higher proportion of patients who were postcardiac surgery, there were fewer occurrences of hypertension and or tachycardia. CONCLUSIONS On review of the 2000-2022 literature, dexmedetomidine withdrawal may be characterized by tachycardia, hypertension, or agitation, particularly with higher cumulative doses or prolonged durations. Since most studies included in the review were retrospective, prospective studies are needed to further clarify risk factors, establish diagnostic criteria, and identify optimal management strategies.
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Affiliation(s)
- Thomas Knapp
- University of Central Florida, College of Medicine, Orlando, FL
| | - Olivia DiLeonardo
- Department of Medical Education, Nemours Children's Health, Orlando, FL
| | - Tim Maul
- Department of Cardiovascular Services, Nemours Children's Health, Florida, Orlando, FL
| | - Alexander Hochwald
- Division of Clinical Trials and Biostatistics, Mayo Clinic, Jacksonville, FL
| | - Zhuo Li
- Division of Clinical Trials and Biostatistics, Mayo Clinic, Jacksonville, FL
| | - Jobayer Hossain
- Department of Biomedical Research, Nemours Children's Health, Wilmington, DE
| | - Adam Lowry
- Department of Cardiovascular Services, Nemours Children's Health, Florida, Orlando, FL
| | - Jason Parker
- Department of Cardiovascular Services, Nemours Children's Health, Florida, Orlando, FL
| | - Kimberly Baker
- Department of Cardiovascular Services, Nemours Children's Health, Florida, Orlando, FL
| | - Peter Wearden
- Department of Cardiovascular Services, Nemours Children's Health, Florida, Orlando, FL
| | - Jennifer Nelson
- Department of Cardiovascular Services, Nemours Children's Health, Florida, Orlando, FL
- Department of Surgery, University of Central Florida College of Medicine, Orlando, FL
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Nir R, Sperotto F, Godsay M, Lu M, Kheir JN. Impact of Dexmedetomidine Infusion on Opioid and Benzodiazepine Doses in Ventilated Pediatric Patients in the Cardiac Intensive Care Unit. Paediatr Drugs 2023; 25:709-718. [PMID: 37550522 DOI: 10.1007/s40272-023-00587-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/23/2023] [Indexed: 08/09/2023]
Abstract
INTRODUCTION Dexmedetomidine (DEX) is frequently used as an adjunct agent for prolonged sedation in the intensive care unit (ICU), though its effect on concomitant opioids or benzodiazepines infusions is unclear. We explored the impact of DEX on concomitant analgosedation in a cohort of ventilated pediatric patients in a cardiac ICU, with stratification of patients according to duration of ventilation (< 5 versus ≥ 5 days) following DEX initiation. METHODS We conducted a retrospective analysis on ventilated patients receiving a DEX infusion ≥ 24 h and at least one other sedative/analgesic infusion (January 2011-June 2021). We evaluated trends of daily doses of opioids and benzodiazepines from 24 h before to 72 h following DEX initiation, stratifying patients based on ventilation duration after DEX initiation (< 5 versus ≥ 5 days). RESULTS After excluding 1146 patients receiving DEX only, 1073 patients were included [median age 234 days (interquartile range 90, 879)]. DEX was associated with an opioid infusion in 99% of patients and a benzodiazepine infusion in 62%. Among patients ventilated for < 5 days (N = 761), opioids increased in the first 24 h following DEX initiation [+ 1.12 mg/kg/day (95% CI 0.96, 1.23), P < 0.001], then decreased [- 0.90 mg/kg/day (95% CI - 0.89, - 0.71), P < 0.001]; benzodiazepines slowly decreased [- 0.20 mg/kg/day (95% CI - 0.21, - 0.19), P < 0.001]. Among patients ventilated for ≥ 5 days (N = 312), opioid administration doubled [+ 2.09 mg/kg/day (95% CI 1.82, 2.36), P < 0.001] in the first 24 h, then diminished minimally [- 0.18 mg/kg/day (95% CI - 0.32, - 0.04), P = 0.015] without returning to baseline; benzodiazepine administration decreased minimally [- 0.03 mg/kg/day (95% CI - 0.05, - 0.01), P = 0.010]. Similar trends were confirmed when adjusting for age, gender, surgical complexity, recent major invasive procedures, duration of mechanical ventilation before DEX initiation, extubation within 72 h following DEX initiation, mean hourly DEX dose, and use of neuromuscular blocking infusion. CONCLUSION While in patients ventilated < 5 days opioids initially increased and then quickly decreased in the 72 h following DEX initiation, among patients ventilated ≥ 5 days opioids doubled, then decreased only minimally; benzodiazepines decreased minimally in both groups, although more slowly in the long-ventilation cohort. These findings may inform decision-making on timing of DEX initiation in ventilated patients already being treated with opioid or benzodiazepine infusions.
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Affiliation(s)
- Reuth Nir
- Department of Cardiology, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, 02115, USA
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Francesca Sperotto
- Department of Cardiology, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, 02115, USA
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Manasee Godsay
- Department of Cardiology, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, 02115, USA
| | - Minmin Lu
- Department of Cardiology, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, 02115, USA
| | - John N Kheir
- Department of Cardiology, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, 02115, USA.
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA.
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Wang H, Zhang C, Li Y, Jia Y, Yuan S, Wang J, Yan F. Dexmedetomidine and acute kidney injury following cardiac surgery in pediatric patients—An updated systematic review and meta-analysis. Front Cardiovasc Med 2022; 9:938790. [PMID: 36093139 PMCID: PMC9448974 DOI: 10.3389/fcvm.2022.938790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2022] [Accepted: 08/09/2022] [Indexed: 11/18/2022] Open
Abstract
Background Acute kidney injury (AKI) is a common postoperative complication in pediatric patients undergoing cardiac surgery and associated with poor outcomes. Dexmedetomidine has the pharmacological features of organ protection in cardiac surgery patients. The aim of this meta-analysis is to investigate the effect of dexmedetomidine infusion on the incidence of AKI after cardiac surgery in pediatric patients. Methods The databases of Pubmed, Embase, and Cochrane Library were searched until April 24, 2022 following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. RevMan 5.3 was used to perform statistical analyses. Results Five relevant trials with a total of 630 patients were included. The pooled result using fixed-effects model with OR demonstrated significant difference in the incidence of AKI between patients with dexmedetomidine and placebo (OR = 0.49, 95% CI: [0.33, 0.73], I2 = 0%, p for effect = 0.0004). Subgroup analyses were performed based on congenital heart disease (CHD) types and dexmedetomidine intervention time. Pooled results did not demonstrate considerable difference in the incidence of AKI in pediatric patients receiving intraoperative (OR = 0.53, 95% CI: [0.29, 0.99], I2 = 0%, p for effect = 0.05) or postoperative dexmedetomidine infusion (OR = 0.56, 95% CI: [0.31, 1.04], p for effect = 0.07), but a significant difference in patients receiving combination of intra- and postoperative dexmedetomidine infusion (OR = 0.27, 95% CI: [0.09, 0.77], p for effect = 0.01). Besides, there was no significant difference in duration of mechanical ventilation (SMD: –0.19, 95% CI: –0.46 to 0.08, p for effect = 0.16; SMD: –0.16, 95% CI: –0.37 to 0.06, p for effect = 0.15), length of ICU (SMD: 0.02, 95% CI: –0.41 to 0.44, p for effect = 0.93) and hospital stay (SMD: 0.2, 95% CI: –0.13 to 0.54, p for effect = 0.23), and in-hospital mortality (OR = 1.26, 95% CI: 0.33–4.84, p for effect = 0.73) after surgery according to the pooled results of the secondary outcomes. Conclusion Compared to placebo, dexmedetomidine could significantly reduce the postoperative incidence of AKI in pediatric patients undergoing cardiac surgery with cardiopulmonary bypass (CPB), but the considerable difference was reflected in the pediatric patients receiving combination of intra- and postoperative dexmedetomidine infusion. Besides, there was no significant difference in duration of mechanical ventilation, length of ICU and hospital stay, or in-hospital mortality after surgery.
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Affiliation(s)
- Hongbai Wang
- Department of Anesthesiology, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Chaobin Zhang
- Department of Anesthesiology, Fuwai Hospital, Chinese Academy of Medical Sciences, Shenzhen (Sun Yat-sen Cardiovascular Hospital, Shenzhen), Shenzhen, China
| | - Yinan Li
- Department of Anesthesiology, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yuan Jia
- Department of Anesthesiology, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Su Yuan
- Department of Anesthesiology, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jianhui Wang
- Department of Anesthesiology, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- *Correspondence: Jianhui Wang,
| | - Fuxia Yan
- Department of Anesthesiology, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- Fuxia Yan,
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Amigoni A, Conti G, Conio A, Corno M, Fazio PC, Ferrero F, Gentili M, Giugni C, L’erario M, Masola M, Moliterni P, Pagano G, Ricci Z, Romagnoli S, Vasile B, Vitale F, Marinosci GZ, Mondardini MC. Recommendations for analgesia and sedation in critically ill children admitted to intensive care unit. J Anesth Analg Crit Care 2022; 2. [DOI: 10.1186/s44158-022-00036-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
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.
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Xiao Z, He T, Jiang X, Xie F, Xia L, Zhou H. Effect of dexmedetomidine and propofol sedation on the prognosis of children with severe respiratory failure: a systematic review and meta-analysis. Transl Pediatr 2022; 11:260-269. [PMID: 35282029 PMCID: PMC8905109 DOI: 10.21037/tp-22-20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Accepted: 02/16/2022] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND During treatment of acute respiratory failure (ARF) in children, sedation can reduce pain, improve tolerance, and reduce the incidence of adverse events, so selecting an appropriate sedation strategy is very important for improving prognosis and quality of life. Both dexmedetomidine and propofol have good sedative effects, so we investigated the application of these drugs in critically ill children with ARF by literature search and meta-analysis. METHODS We searched Embase, The Cochrane Library, PubMed, Ovid, Clinicaltrials.org, and Google Scholar for randomized controlled trials (RCTs) preferentially but not exclusively, and used RevMan 5.4 to analyze the screened literature. RESULTS Seven studies were included in the quantitative meta-analysis, with a total of 1,188 patients. There was no significant difference in the effect of dexmedetomidine and propofol on the duration of tracheal intubation in children with ARF [mean difference (MD) =-0.05; 95% confidence interval (CI): (-0.42, 0.32); Z=0.26; P=0.79], but dexmedetomidine sedation could reduce the intensive care unit (ICU) stay in children with ARF [MD =-0.62; 95% CI: (-1.08, -0.16); Z=2.65; P=0.008], and shorten the total hospital stay [MD =-1.94; 95% CI: (-2.63, -1.25); Z=5.48; P<0.00001]. There was no significant effect on mortality between the two groups [odds ratio (OR) =0.48; 95% CI: (0.19, 1.25); Z=1.50; P=0.13]. The incidence rate of bradycardia with dexmedetomidine sedation was higher than with propofol [OR =12.30; 95% CI: (2.28, 66.47); Z=2.92; P=0.004], and the incidence of hypotension was also higher [OR =6.99, 95% CI: (1.22, 39.86); Z=2.19; P=0.03]. DISCUSSION Compared with propofol, dexmedetomidine can significantly reduce the ICU stay and hospital stay. However, bradycardia and hypotension may occur during the use of dexmedetomidine, which requires close attention and timely intervention.
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Affiliation(s)
- Zizhen Xiao
- Department of Anesthesiology, The Central Hospital of Loudi, Loudi, China
| | - Tao He
- Department of Anesthesiology, The Central Hospital of Loudi, Loudi, China
| | - Xinping Jiang
- Department of Pediatrics, The Central Hospital of Loudi, Loudi, China
| | - Fengyong Xie
- Department of Anesthesiology, The Central Hospital of Loudi, Loudi, China
| | - Lihua Xia
- Department of Anesthesiology, The Central Hospital of Loudi, Loudi, China
| | - Huiming Zhou
- Department of Pediatrics, The Central Hospital of Loudi, Loudi, China
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Mondardini MC, Daverio M, Caramelli F, Conti G, Zaggia C, Lazzarini R, Muscheri L, Azzolina D, Gregori D, Sperotto F, Amigoni A. Dexmedetomidine for prevention of opioid/benzodiazepine withdrawal syndrome in pediatric intensive care unit: Interim analysis of a randomized controlled trial. Pharmacotherapy 2021; 42:145-153. [PMID: 34882826 DOI: 10.1002/phar.2654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2021] [Revised: 11/07/2021] [Accepted: 11/10/2021] [Indexed: 11/09/2022]
Abstract
STUDY OBJECTIVE Withdrawal syndrome (WS) may be a critical drawback of opioid/benzodiazepine weaning in children. The most effective intervention to reduce WS prevalence is yet to be determined. Dexmedetomidine (DEX) was estimated to be effective in reducing WS-related symptoms, but no randomized trial has been conducted to prove its efficacy so far. We aimed to evaluate the efficacy and safety of DEX in reducing the occurrence of WS. DESIGN AND SETTING This was an adaptive randomized double-blind placebo-controlled trial conducted at three Italian Pediatric Intensive Care Units (PICUs). PATIENTS It included children admitted to PICU, undergoing at least five days of opioids/benzodiazepines continuous infusion, and ready to start the analgosedation weaning. INTERVENTION Twenty-four hours before the start of weaning, an infusion of DEX/placebo was started. WS symptoms were monitored using the Withdrawal-Assessment-Tool-version-1 (WAT-1). In case of WS symptoms (WAT-1 ≥ 3) an opioid/benzodiazepine bolus was given and the DEX/placebo infusion-rate was increased. MEASUREMENTS The primary outcome measure was the prevalence of WS. Secondary outcomes were the trend of WAT-1 over time, number of rescue doses, length of weaning and PICU-stay, and onset of adverse events (AEs). MAIN RESULTS Forty-five patients were enrolled, of whom 5 dropped-out and 40 entered the interim analysis. There were no significant baseline differences between groups. WS prevalence did not significantly differ between groups (77.8% DEX vs 90.9% placebo, p = 0.381). By generalized linear mixed modeling, the WAT-1 trend showed a significant increase per unit of time in the DEX arm (estimate 0.27, CI 0.07-0.47, p = 0.009) compared to placebo. Most frequent AEs were hemodynamic, and all of them happened in the DEX arm. CONCLUSIONS A continuous infusion of DEX, started 24 h before the analgosedation weaning and increased based on WS signs, was not able to significantly modify the prevalence of WS in children who received at least five days of opioids/benzodiazepines treatment compared to placebo.
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Affiliation(s)
- Maria Cristina Mondardini
- Pediatric Anesthesia and Intensive Care Unit, Department of Woman's and Child's Health, University Hospital of Bologna IRCCS S. Orsola Polyclinic, Bologna, Italy
| | - Marco Daverio
- Pediatric Intensive Care Unit, Department of Woman's and Child's Health, University-Hospital, Padua, Italy
| | - Fabio Caramelli
- Pediatric Anesthesia and Intensive Care Unit, Department of Woman's and Child's Health, University Hospital of Bologna IRCCS S. Orsola Polyclinic, Bologna, Italy
| | - Giorgio Conti
- Pediatric Intensive Care Unit and Pediatric Trauma Center, Department of Anesthesia and Intensive Care, Catholic University of Rome, A Gemelli Polyclinic, Rome, Italy
| | - Cristina Zaggia
- Pediatric Intensive Care Unit, Department of Woman's and Child's Health, University-Hospital, Padua, Italy
| | - Rossella Lazzarini
- Pediatric Anesthesia and Intensive Care Unit, Department of Woman's and Child's Health, University Hospital of Bologna IRCCS S. Orsola Polyclinic, Bologna, Italy
| | - Lidia Muscheri
- Pediatric Intensive Care Unit and Pediatric Trauma Center, Department of Anesthesia and Intensive Care, Catholic University of Rome, A Gemelli Polyclinic, Rome, Italy
| | - Danila Azzolina
- Unit of Biostatistics, Epidemiology and Public Health, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University-Hospital of Padua, Padua, Italy
| | - Dario Gregori
- Unit of Biostatistics, Epidemiology and Public Health, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University-Hospital of Padua, Padua, Italy
| | - Francesca Sperotto
- Pediatric Intensive Care Unit, Department of Woman's and Child's Health, University-Hospital, Padua, Italy.,Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Angela Amigoni
- Pediatric Intensive Care Unit, Department of Woman's and Child's Health, University-Hospital, Padua, Italy
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Gulla KM, Sankar J, Jat KR, Kabra SK, Lodha R. Dexmedetomidine vs Midazolam for Sedation in Mechanically Ventilated Children: A Randomized Controlled Trial. Indian Pediatr 2021. [DOI: 10.1007/s13312-021-2124-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Geven BM, Maaskant JM, Ward CS, van Woensel JBM. Dexmedetomidine and Iatrogenic Withdrawal Syndrome in Critically Ill Children. Crit Care Nurse 2021; 41:e17-e23. [PMID: 33560432 DOI: 10.4037/ccn2021462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
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.
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Affiliation(s)
- Barbara M Geven
- Barbara M. Geven is a pediatric intensive care nurse and clinical epidemiologist, Amsterdam UMC/Emma Children's Hospital, University of Amsterdam, Amsterdam, the Netherlands
| | - Jolanda M Maaskant
- Jolanda M. Maaskant is a senior nurse researcher and clinical epidemiologist, Department of Clinical Epidemiology, Biostatistics, and Bioinformatics, Amsterdam UMC/University of Amsterdam
| | - Catherine S Ward
- Catherine S. Ward is a general and pediatric anesthesiologist, Amsterdam UMC/Emma Children's Hospital
| | - Job B M van Woensel
- Job B.M. van Woensel is medical director of the pediatric intensive care unit, Amsterdam UMC/Emma Children's Hospital
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Cavaliere F, Biancofiore G, Bignami E, De Robertis E, Giannini A, Piastra M, Scolletta S, Taccone FS, Terragni P. A year in review in Minerva Anestesiologica 2019. Critical care. Minerva Anestesiol 2020; 86:102-113. [PMID: 31994860 DOI: 10.23736/s0375-9393.20.14384-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Franco Cavaliere
- Institute of Anesthesia and Intensive Care, A. Gemelli University Polyclinic, IRCCS and Foundation, Sacred Heart Catholic University, Rome, Italy -
| | - Gianni Biancofiore
- Transplant Anesthesia and Critical Care, University School of Medicine, Pisa, Italy
| | - Elena Bignami
- Division of Anesthesiology, Critical Care and Pain Medicine, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Edoardo De Robertis
- Section of Anesthesia, Analgesia and Intensive Care, Department of Surgical and Biomedical Sciences, University of Perugia, Perugia, Italy
| | - Alberto Giannini
- Unit of Pediatric Anesthesia and Intensive Care, ASST - Spedali Civili Children's Hospital, Brescia, Italy
| | - Marco Piastra
- Pediatric Intensive Care Unit and Trauma Center, A. Gemelli University Polyclinic, IRCCS and Foundation, Sacred Heart Catholic University, Rome, Italy
| | - Sabino Scolletta
- Department of Accident and Emergency, of Organ Transplantation, Anesthesia and Intensive Care, Siena University Hospital, Siena, Italy
| | - Fabio S Taccone
- Department of Intensive Care, Erasme Hospital, Free University of Brussels (ULB), Brussels, Belgium
| | - Pierpaolo Terragni
- Division of Anesthesia and General Intensive Care, Department of Medical, Surgical and Experimental Sciences, Sassari University Hospital, University of Sassari, Sassari, Italy
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Abstract
PURPOSE OF REVIEW Delirium is a frequent complication of serious medical illness in children. The purpose of this review is to highlight recent data on the epidemiology and outcomes related to pediatric delirium, and discuss prevention strategies. RECENT FINDINGS Delirium rates in the pediatric ICU are greater than 25%. Delirium in children is associated with prolonged mechanical ventilation and hospital length of stay, increased costs, and excess mortality. Pediatric delirium may affect postdischarge cognition and quality of life. Recent initiatives targeting universal screening, early mobilization, and minimization of benzodiazepine-based sedation have shown reduction in delirium prevalence. SUMMARY Widespread screening is needed in critically ill children to detect and mitigate delirium. The identification of modifiable risk factors has provided an opportunity for delirium prevention. Large-scale longitudinal studies are needed to investigate the long-term sequelae of delirium in children.
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Mahmoud M, Barbi E, Mason KP. Dexmedetomidine: What's New for Pediatrics? A Narrative Review. J Clin Med 2020; 9:E2724. [PMID: 32846947 DOI: 10.3390/jcm9092724] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 07/17/2020] [Accepted: 07/28/2020] [Indexed: 02/07/2023] Open
Abstract
Over the past few years, despite the lack of approved pediatric labelling, dexmedetomidine’s (DEX) use has become more prevalent in pediatric clinical practice as well as in research trials. Its respiratory-sparing effects and bioavailability by various routes are only some of the valued features of DEX. In recent years the potential organ-protective effects of DEX, with the possibility for preserving neurocognitive function, has put it in the forefront of clinical and bench research. This comprehensive review focused on the pediatric literature but presents relevant, supporting adult and animal studies in order to detail the recent growing body of literature around the pharmacology, end-organ effects, organ-protective effects, alternative routes of administration, synergetic effects, and clinical applications, with considerations for the future.
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Daverio M, Sperotto F, Zanetto L, Coscini N, Frigo AC, Mondardini MC, Amigoni A. Dexmedetomidine for Prolonged Sedation in the PICU: A Systematic Review and Meta-Analysis. Pediatr Crit Care Med 2020; 21:e467-74. [PMID: 32453924 DOI: 10.1097/PCC.0000000000002325] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVES We aimed to systematically describe the use of dexmedetomidine as a treatment regimen for prolonged sedation in children and perform a meta-analysis of its safety profile. DATA SOURCES PubMed, EMBASE, Cochrane Library, Scopus, Web of Science, ClinicalTrials.gov, and CINAHL were searched from inception to November 30, 2018. STUDY SELECTION We included studies involving hospitalized critically ill patients less than or equal to 18 years old receiving dexmedetomidine for prolonged infusion (≥ 24 hr). DATA EXTRACTION Data extraction included study characteristics, patient demographics, modality of dexmedetomidine use, associated analgesia and sedation details, comfort and withdrawal evaluation scales, withdrawal symptoms, and side effects. DATA SYNTHESIS Literature search identified 32 studies, including a total of 3,267 patients. Most of the studies were monocentric (91%) and retrospective (88%); one was a randomized trial. Minimum and maximum infusion dosages varied from 0.1-0.5 µg/kg/hr to 0.3-2.5 µg/kg/hr, respectively. The mean/median duration range was 25-540 hours. The use of a loading bolus was reported in eight studies (25%) (range, 0.5-1 µg/kg), the mode of weaning in 11 (34%), and the weaning time in six of 11 (55%; range, 9-96 hr). The pooled prevalence of bradycardia was 2.6% (n = 10 studies; 14/387 patients; 95% CI, 0.3-7.3; I = 75%), the pooled prevalence incidence of bradycardia was 2.6% (n = 10 studies; 14/387 patients; 95% CI, 0.3-7.3; I = 75%), the pooled incidence of hypotension was 6.1% (n = 8 studies; 19/304 patients; 95% CI, 0.8-15.9; I = 84%). Three studies (9%) reported side effects' onset time which in all cases was within 12 hours of the infusion starting. CONCLUSIONS High-quality data on dexmedetomidine use for prolonged sedation and a consensus on correct dosing and weaning protocols in children are currently missing. Infusion of dexmedetomidine can be considered relatively safe in pediatrics even when longer than 24 hours.
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Sperotto F, Mondardini MC, Dell'Oste C, Vitale F, Ferrario S, Lapi M, Ferrero F, Dusio MP, Rossetti E, Daverio M, Amigoni A; Pediatric Neurological Protection and Drugs (PeNPAD) Study Group of the Italian Society of Neonatal and Pediatric Anesthesia and Intensive Care (SARNePI). Efficacy and Safety of Dexmedetomidine for Prolonged Sedation in the PICU: A Prospective Multicenter Study (PROSDEX). Pediatr Crit Care Med 2020; 21:625-36. [PMID: 32224830 DOI: 10.1097/PCC.0000000000002350] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
OBJECTIVES We sought to evaluate dexmedetomidine efficacy in assuring comfort and sparing conventional drugs when used for prolonged sedation (≥24 hr) in critically ill patients, by using validated clinical scores while systematically collecting drug dosages. We also evaluated the safety profile of dexmedetomidine and the risk factors associated with adverse events. DESIGN Observational prospective study. SETTING Nine tertiary-care PICUs. PATIENTS Patients less than 18 years who received dexmedetomidine for greater than or equal to 24 hours between January 2016 and December 2017. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS One-hundred sixty-three patients (median age, 13 mo; interquartile range, 4-71 mo) were enrolled. The main indication for dexmedetomidine use was as an adjuvant for drug-sparing (42%). Twenty-three patients (14%) received dexmedetomidine as monotherapy. Seven percent of patients received a loading dose. The median infusion duration was 108 hours (interquartile range, 60-168 hr), with dosages between 0.4 (interquartile range, 0.3-0.5) and 0.8 µg/kg/hr (interquartile range, 0.6-1.2 µg/kg/hr). At 24 hours of dexmedetomidine infusion, values of COMFORT-B Scale (n = 114), Withdrawal Assessment Tool-1 (n = 43) and Cornell Assessment of Pediatric Delirum (n = 6) were significantly decreased compared with values registered immediately pre dexmedetomidine (p < 0.001, p < 0.001, p = 0.027). Dosages/kg/hr of benzodiazepines, opioids, propofol, and ketamine were also significantly decreased (p < 0.001, p < 0.001, p = 0.001, p = 0.027). The infusion was weaned off in 85% of patients, over a median time of 36 hours (interquartile range, 12-48 hr), and abruptly discontinued in 15% of them. Thirty-seven percent of patients showed hemodynamic changes, and 9% displayed hemodynamic adverse events that required intervention (dose reduction in 79% of cases). A multivariate logistic regression model showed that a loading dose (odds ratio, 4.8; CI, 1.2-18.7) and dosages greater than 1.2 µg/kg/hr (odds ratio, 5.4; CI, 1.9-15.2) increased the odds of hemodynamic changes. CONCLUSIONS Dexmedetomidine used for prolonged sedation assures comfort, spares use of other sedation drugs, and helps to attenuate withdrawal syndrome and delirium symptoms. Adverse events are mainly hemodynamic and are reversible following dose reduction. A loading dose and higher infusion dosages are independent risk factors for hemodynamic adverse events.
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Sargel CL, Thompson RZ. Dexmedetomidine: A Multipurpose Tool Which Is Difficult to Analyze. Pediatr Crit Care Med 2020; 21:704-5. [PMID: 32618870 DOI: 10.1097/PCC.0000000000002353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Affiliation(s)
- C R Bailey
- Department of Anaesthesia, Guy's and St, Thomas' NHS Foundation Trust, London, UK
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Affiliation(s)
- Marta Somaini
- Department of Anesthesia, Niguarda Ca'Granda Hospital, Milan, Italy -
| | - Pablo Ingelmo
- Department of Anesthesia, Montreal Children's Hospital, McGill University, Montreal, QC, Canada
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Mondardini MC, Sperotto F, Daverio M, Caramelli F, Gregori D, Caligiuri MF, Vitale F, Cecini MT, Piastra M, Mancino A, Pettenazzo A, Conti G, Amigoni A. 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. Trials 2019; 20:710. [PMID: 31829274 PMCID: PMC6907190 DOI: 10.1186/s13063-019-3793-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2019] [Accepted: 10/10/2019] [Indexed: 11/12/2022] Open
Abstract
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.
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Affiliation(s)
- Maria Cristina Mondardini
- Department of Woman, Child and Urological Diseases, Pediatric Intensive Care Unit, University-Hospital S.Orsola-Malpighi Policlinic, Via Albertoni 15, 40138, Bologna, Italy.
| | - Francesca Sperotto
- Department of Woman's and Child's Health, Pediatric Intensive Care Unit, University-Hospital of Padua, Via Giustiniani 2, 35128, Padua, Italy
| | - Marco Daverio
- Department of Woman's and Child's Health, Pediatric Intensive Care Unit, University-Hospital of Padua, Via Giustiniani 2, 35128, Padua, Italy
| | - Fabio Caramelli
- Department of Woman, Child and Urological Diseases, Pediatric Intensive Care Unit, University-Hospital S.Orsola-Malpighi Policlinic, Via Albertoni 15, 40138, Bologna, Italy
| | - Dario Gregori
- Unit of Biostatistics, Epidemiology and Public Health, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University-Hospital of Padua, Via Loredan18, 35131, Padua, Italy
| | - Maria Francesca Caligiuri
- Department of Woman, Child and Urological Diseases, Pediatric Intensive Care Unit, University-Hospital S.Orsola-Malpighi Policlinic, Via Albertoni 15, 40138, Bologna, Italy
| | - Francesca Vitale
- Department of Anesthesia and Intensive Care, Pediatric Intensive Care Unit and Pediatric Trauma Center, Catholic University of Rome, A Gemelli Policlinic, Largo Agostino Gemelli 8, 00168, Rome, Italy
| | - Maria Teresa Cecini
- Department of Woman, Child and Urological Diseases, Pediatric Intensive Care Unit, University-Hospital S.Orsola-Malpighi Policlinic, Via Albertoni 15, 40138, Bologna, Italy
| | - Marco Piastra
- Department of Anesthesia and Intensive Care, Pediatric Intensive Care Unit and Pediatric Trauma Center, Catholic University of Rome, A Gemelli Policlinic, Largo Agostino Gemelli 8, 00168, Rome, Italy
| | - Aldo Mancino
- Department of Anesthesia and Intensive Care, Pediatric Intensive Care Unit and Pediatric Trauma Center, Catholic University of Rome, A Gemelli Policlinic, Largo Agostino Gemelli 8, 00168, Rome, Italy
| | - Andrea Pettenazzo
- Department of Woman's and Child's Health, Pediatric Intensive Care Unit, University-Hospital of Padua, Via Giustiniani 2, 35128, Padua, Italy
| | - Giorgio Conti
- Department of Anesthesia and Intensive Care, Pediatric Intensive Care Unit and Pediatric Trauma Center, Catholic University of Rome, A Gemelli Policlinic, Largo Agostino Gemelli 8, 00168, Rome, Italy
| | - Angela Amigoni
- Department of Woman's and Child's Health, Pediatric Intensive Care Unit, University-Hospital of Padua, Via Giustiniani 2, 35128, Padua, Italy
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Affiliation(s)
- Cydni Williams
- Department of Pediatric Critical Care Medicine, Oregon Health and Sciences University, Portland, OR, USA
| | - Susan L Bratton
- Unit of Pediatric Critical Care Medicine, Department of Pediatrics, School of Medicine, University of Utah, Salt Lake City, UT, USA -
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