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Patterns of Sedation Weaning in Critically Ill Children Recovering From Acute Respiratory Failure
Kaitlin M Best1, Lisa A Asaro, Linda S Franck
11University of Pennsylvania, Philadelphia, PA. 2Department of Cardiology, Boston Children's Hospital, Boston, MA. 3Department of Family Health Care Nursing, University of California, San Francisco, CA. 4Department of Pediatrics, Harvard Medical School, Boston, MA. 5Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA. 6Department of Family and Community Health in the School of Nursing, and the Department of Anesthesia and Critical Care Medicine in the Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA. 7Critical Care/Cardiovascular Nursing Program, Boston Children's Hospital, Boston, MA.
Insights
Pediatric critical care patients often experience intermittent sedation weaning, linked to higher opioid/sedative doses and withdrawal symptoms. This highlights the need for better weaning strategies to prevent iatrogenic withdrawal syndrome.
Area of Science:
- Pediatric Critical Care Medicine
- Pharmacology
- Clinical Nursing
Background:
- Sedation weaning in pediatric intensive care units (PICUs) is complex.
- Understanding weaning patterns is crucial for managing withdrawal symptoms.
- Iatrogenic withdrawal syndrome (IWS) is a significant concern in critically ill children.
Purpose of the Study:
- To characterize sedation weaning patterns in children recovering from critical illness.
- To identify factors associated with different weaning patterns.
- To inform future research on weaning strategies.
Main Methods:
- Descriptive secondary analysis of prospectively collected data from 22 US PICUs.
- Included 145 mechanically ventilated children (2 weeks–17 years) with prolonged opioid exposure.
- Compared patients with intermittent weaning (≥20% opioid dose increase) versus steady weaning.
Main Results:
- 46% of patients (66/145) exhibited intermittent weaning.
- Intermittently weaned patients received higher opioid/benzodiazepine doses and had greater sedative tolerance.
- Intermittently weaned patients showed a higher incidence of withdrawal symptoms (85% vs 46%).
Conclusions:
- Sedative administration practices vary significantly during weaning in pediatric critical care.
- A novel methodology for describing weaning patterns in at-risk children was developed.
- Findings may guide future research to prevent iatrogenic withdrawal syndrome.
Objective:
To characterize sedation weaning patterns in typical practice settings among children recovering from critical illness.
Design:
A descriptive secondary analysis of data that were prospectively collected during the prerandomization phase (January to July 2009) of a clinical trial of sedation management.
Setting:
Twenty-two PICUs across the United States.
Patients:
The sample included 145 patients, aged 2 weeks to 17 years, mechanically ventilated for acute respiratory failure who received at least five consecutive days of opioid exposure.
Interventions:
None.
Measurements And Main Results:
Group comparisons were made between patients with an intermittent weaning pattern, defined as a 20% or greater increase in daily opioid dose after the start of weaning, and the remaining patients defined as having a steady weaning pattern. Demographic and clinical characteristics, tolerance to sedatives, and iatrogenic withdrawal symptoms were evaluated. Sixty-six patients (46%) were intermittently weaned; 79 patients were steadily weaned. Prior to weaning, intermittently weaned patients received higher peak and cumulative doses and longer exposures to opioids and benzodiazepines, demonstrated more sedative tolerance (58% vs 41%), and received more chloral hydrate and barbiturates compared with steadily weaned patients. During weaning, intermittently weaned patients assessed for withdrawal had a higher incidence of Withdrawal Assessment Tool-version 1 scores of greater than or equal to 3 (85% vs 46%) and received more sedative classes compared with steadily weaned patients.
Conclusions:
This study characterizes sedative administration practices for pediatric patients prior to and during weaning from sedation after critical illness. It provides a novel methodology for describing weaning in an at-risk pediatric population that may be helpful in future research on weaning strategies to prevent iatrogenic withdrawal syndrome.
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