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A cost analysis of enterally administered lorazepam in the pediatric intensive care unit
R A Lugo1, E A Chester, J Cash
1University of Utah College of Pharmacy and Department of Pharmacy, Primary Children's Medical Center, Salt Lake City 84112, USA. rlugo@deans.pharm.utah.edu
Insights
Replacing intravenous midazolam with enteral lorazepam in mechanically ventilated children significantly reduces costs. This switch maintains effective sedation while offering substantial financial savings for long-term care.
Area of Science:
- Pediatric Critical Care Medicine
- Pharmacoeconomics
- Pharmacology
Background:
- Continuous sedation is crucial for mechanically ventilated children.
- Intravenous midazolam is commonly used but can be costly for long-term use.
- Enteral lorazepam offers a potential alternative for sustained sedation.
Purpose of the Study:
- To evaluate the cost-effectiveness of switching from intravenous midazolam to enteral lorazepam.
- To assess the efficacy of enteral lorazepam in maintaining sedation levels.
- To quantify the cost savings associated with this therapeutic change.
Main Methods:
- Retrospective review of 30 mechanically ventilated children in a pediatric intensive care unit.
- Analysis of sedation protocols involving transition from midazolam to lorazepam.
- Calculation of projected midazolam costs versus actual expenditures for both agents.
Main Results:
- Enteral lorazepam significantly reduced midazolam administration by a median of 52%.
- Midazolam was successfully discontinued in 80% of patients within 3 days.
- Total cost savings amounted to $42,904, with a projected midazolam cost of $90,771 versus actual combined costs of $47,867.
Conclusions:
- Transitioning to enteral lorazepam is a cost-effective strategy for long-term sedation in critically ill children.
- Enteral lorazepam is convenient, inexpensive, and effective in maintaining adequate sedation.
- This approach offers significant financial benefits without compromising patient care.
Objective:
To determine the cost savings of replacing intravenous midazolam with enterally administered lorazepam in mechanically ventilated children who require long-term continuous sedation.
Design:
Retrospective review of patients treated according to a preestablished pediatric intensive care unit (ICU) sedation protocol.
Setting:
Twenty-six-bed pediatric ICU in a tertiary care children's hospital.
Patients:
The records of 30 mechanically ventilated children were analyzed. The median age was 1.5 yrs and the median weight was 8.0 kg. Patients required continuous sedation for a total of 16 days (median).
Interventions:
According to our pediatric ICU sedation protocol, midazolam infusion was continued until the hourly midazolam requirement was stable for at least 24 hrs. Thereafter, patients with a nasojejunal tube who were likely to require a minimum of three additional days of continuous sedation were transitioned from intravenous midazolam to enterally administered lorazepam. The goal in transitioning therapy was to titrate the lorazepam dose and reduce midazolam administration while maintaining an unchanged level of sedation.
Measurements And Main Results:
The rate of midazolam administration was significantly (p<.05) reduced beginning on day 1 of lorazepam treatment. Midazolam was successfully discontinued in 24 (80%) patients in 3 days (median), and adequate and appropriate sedation was maintained with lorazepam monotherapy. Six patients in whom midazolam could not be discontinued experienced a 52% reduction in the rate of midazolam administration as a result of adding lorazepam. Total projected midazolam utilization was defined as the sum of midazolam administration before initiating lorazepam and the projected midazolam requirement after initiating lorazepam. Projected midazolam cost was calculated as the product of total projected midazolam utilization and midazolam acquisition cost. Actual expenditures for both midazolam and lorazepam were subtracted from the projected midazolam cost to calculate the estimated cost savings. Overall, midazolam utilization (in milligrams) was reduced by 46.7+/-27.6% (median 52). Total projected midazolam cost for the 30 patients was $90,771. The actual cost of midazolam and lorazepam combined was $47,867, resulting in a cost savings of $42,904.
Conclusions:
Transitioning from intravenous midazolam to enterally administered lorazepam in critically ill children who require long-term sedation results in significant cost savings. The oral formulation of lorazepam was convenient to use, inexpensive, and effective in maintaining a continuous and appropriate level of sedation once midazolam was discontinued.