Clinical PotpourriImplementation of a risk-stratified opioid weaning protocol in a pediatric intensive care unit☆
Introduction
Opioid infusions are commonly used to manage patients admitted to the pediatric intensive care unit (PICU) [1]. Children with prolonged exposure to opioids frequently develop dependence to these drugs, which may result in symptoms of withdrawal after these medications are weaned or stopped [1], [2]. Additional complications associated with the use of opioids include delirium and opioid-induced bowel dysfunction [3], [4]. In combination, these complications can lead to increased morbidity in critically ill children, including prolonged hospitalization. In addition, there is growing concern that opioids may have a negative effect on long-term neurodevelopmental outcomes of children who have been exposed [5], [6].
Although there is limited clinical evidence of the long-term neurodevelopmental effects of narcotics and sedatives in pediatric patients [7], [8], animal studies have convincingly shown that anesthetics, analgesics, and sedatives, including opioids, have deleterious effects on the developing brain [5], [6]. Therefore, avoiding potentially unnecessary prolonged exposure to opioids could be beneficial in the long-term.
Despite the common use of opioid infusions in the PICU and their associated complications, there is little consensus among critical care practitioners for the ideal sedation management and withdrawal prevention practices [9], [10], [11]. This has led to widely varied drug management practices in the field of pediatric critical care. One approach has been to implement goal-directed sedation protocols; while these protocols have demonstrated decreasing exposure to opioid medications, they have not altogether prevented opioid dependence, necessitating effective weaning guidelines [12]. Other researchers have developed methods for converting continuous opioid infusions to long acting intermittent medications, such as methadone, to minimize the risk of withdrawal [10]. Conversion tables or means of weaning intermittent drugs have also been described [13], [14], [15]. However, a protocol including risk stratification, drug conversion, withdrawal assessment, and weaning of pediatric patients has not been previously described.
The primary objective for this investigation was to study the effectiveness of a comprehensive, risk-stratified opioid weaning protocol at decreasing the opioid drug burden in critically ill children at risk of withdrawal without increasing the amount of withdrawal symptoms. Our hypothesis was that following the implementation of a standardized protocol, children would have a shorter duration of opioid use and, secondarily, a reduction in their hospital length of stay.
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Study design
We conducted a single-center pre- and post-intervention prospective study in the PICU of a large children's hospital between January 2013 and March 2015. The 24-bed multidisciplinary, tertiary PICU serves a mixed population of medical, surgical, trauma, and solid-organ and hematopoietic stem cell transplantation patients. The PICU is staffed by pediatric critical care physicians, nurse practitioners, nurses, pharmacists, pediatric residents, and other support staff. The unit does not provide
Demographics, risk factors, and confounders
One hundred seven critically ill children met the inclusion criteria (68 pre- and 39 post-intervention). The age, weight, gender, primary admitting diagnoses, severity of illness scores on admission, PICU length of stay, and length of mechanical ventilation did not differ between the two groups (Table 1). There was a slightly larger proportion of Hispanic patients in the post-intervention group. The use of adjunct benzodiazepines and clonidine was not different between groups. While the number
Discussion
The primary objective for the current study was to evaluate the effectiveness of a risk-stratified opioid weaning protocol at decreasing the opioid drug burden in critically ill children. As hypothesized, we found that patients in the post-intervention group had fewer days on opioids and decreased total cumulative exposure to opioids without an increase in withdrawal symptoms compared to patients in the pre-intervention group. In addition, there was an associated trend toward a decreased
Conclusion
We successfully implemented a risk-stratified opioid weaning protocol in the PICU of a large children's hospital. The protocol led to a significant reduction in the length of opioid exposure in critically ill children without an increase in withdrawal symptoms nor other adverse outcomes. No difference was observed in the hospital length of stay. External validation of these results in other PICU populations is warranted before this can be generalized as a standard protocol.
Acknowledgements
We would like to acknowledge the large multidisciplinary team who helped create and implement this protocol. Specifically, we would like to acknowledge the nursing staff of the PICU at Children's Hospital Los Angeles led by David Schmidt, CPNP, CCRN. Finally, we want to thank Drs. Susan Turkel and Giovanni Cucchiaro for their insight and guidance.
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Incidence of iatrogenic withdrawal syndrome and associated factors in surgical pediatric intensive care
2023, Archives de PediatrieCitation Excerpt :However, we noted the absence of a standardized protocol for sedation/analgesia withdrawal in our PICU. While current recommendations do not provide specific details on how best to discontinue sedation in PICUs to prevent the occurrence of IWS [16], the use of standardized protocols has been found to be beneficial [30]. Finally, the WAT-1 score was not designed for children with neurological impairments.
Strategies for the management and prevention of withdrawal syndrome in critically ill pediatric patients: a systematic review
2023, Revista Brasileira de Terapia IntensivaStandardized Scoring Tool and Weaning Guideline to Reduce Opioids in Critically Ill Neonates
2022, Pediatric Quality and Safety
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This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Authors' sources of financial support include: None relevant to this study. The authors have no conflict of interest to declare.