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Sedative Medications for Critically Ill Children during and after Mechanical Ventilation: A Retrospective
Deanna Caldwell1, Jonathan Wong1, Mark Duffett1
1, PharmD, ACPR, RPh, was, at the time of this study, a pharmacy resident at McMaster Children's Hospital, Hamilton, Ontario. She is now with the Department of Pharmacy, London Health Sciences, London, Ontario, BScPharm, PharmD, ACPR, RPh, is with the Department of Pharmacy, McMaster Children's Hospital, Hamilton, Ontario, BSc(Pharm), MSc, PhD, ACPR, RPh, is with the Department of Pediatrics, McMaster University, and the Department of Pediatrics, McMaster Children's Hospital, Hamilton, Ontario.
Insights
Critically ill children often receive prolonged sedation, leading to frequent iatrogenic withdrawal. Optimizing sedative use and withdrawal management is crucial for improving pediatric intensive care unit recovery.
Area of Science:
- Pediatric Critical Care Medicine
- Pharmacology
- Patient Recovery
Background:
- Sedation in critically ill children presents significant challenges.
- Managing iatrogenic withdrawal is vital for safe and effective sedation practices.
Purpose of the Study:
- To characterize sedative medication use in critically ill children.
- To identify the incidence and impact of iatrogenic withdrawal in this population.
Main Methods:
- Retrospective observational study of children receiving sedation and mechanical ventilation for at least 48 hours.
- Data collected from admission to 3 days post-sedation discontinuation.
- Included assessment of iatrogenic withdrawal using the Withdrawal Assessment Tool-1 (WAT-1).
Main Results:
- 67 children received prolonged sedation (median 12 days) with opioids and benzodiazepines.
- 46% received dexmedetomidine; many received sedation post-extubation and after ward transfer.
- 63% showed signs of iatrogenic withdrawal, associated with higher sedative exposure.
Conclusions:
- Critically ill children experience extensive exposure to multiple sedatives, often continuing post-ventilation.
- Iatrogenic withdrawal is common, highlighting a key area for improving pediatric recovery.
- This study underscores the need for improved sedation protocols and withdrawal management strategies.
Background:
Providing safe and effective sedation to critically ill children is challenging. The assessment, prevention, and treatment of symptoms of iatrogenic withdrawal are critical aspects of sedation practice.
Objective:
To describe the use of sedative medications in critically ill children at McMaster Children's Hospital.
Methods:
This retrospective observational study included children admitted over a 12-month period who survived their illness and who received sedation and at least 48 h of invasive ventilation. We collected data from the time of admission to the pediatric intensive care unit to 3 days after discontinuation of sedation.
Results:
We included 67 children. The median age was 1.6 (interquartile range [IQR] 0.2-6.2) years, and respiratory illnesses were the most common reason for admission (41 [61%]). The children received invasive ventilation for a median of 7 (IQR 4-11) days and sedation for a median of 12 (IQR 6-20) days. Sixty-six children (99%) received an opioid, and all received a benzodiazepine, with median cumulative doses of 14 (IQR 5-27) mg/kg morphine equivalents and 15 (IQR 6-32) mg/kg midazolam equivalents. Dexmedetomidine was given to 31 children (46%), for a median of 8 (IQR 4-12) days. Most children (67%) received sedation after extubation (median duration 7 [IQR 4-14] days). In addition, 32 children (48%) continued to receive sedative medications after transfer to the ward, for a median of 6 (IQR 4-13) days. Forty-two children (63%) had at least one Withdrawal Assessment Tool-1 (WAT-1) score indicative of iatrogenic withdrawal. Children who experienced withdrawal were exposed to more opioids and more benzodiazepines, both per day and overall, and for longer periods.
Conclusions:
The children in this study were exposed to multiple sedatives, and many continued to receive these medications for an extended period after discontinuation of mechanical ventilation. Iatrogenic withdrawal was common and represents an important opportunity to improve children's recovery after critical illness.
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