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Pediatric Ventilation Liberation: Bundled Extubation Readiness and Analgosedation Pathways Decrease Mechanical
Jeremy M Loberger1, Kristen C Waddell2, Priya Prabhakaran3
1Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama. jloberger@uabmc.edu.
Insights
A new analgosedation approach reduced mechanical ventilation duration in children by 23% and benzodiazepine use by 75%. This quality improvement project in a pediatric ICU showed better outcomes without affecting key safety measures.
Area of Science:
- Pediatric Critical Care Medicine
- Quality Improvement Science
- Pharmacology
Background:
- Mechanical ventilation in children can lead to prolonged intensive care unit (ICU) stays and complications like delirium.
- Previous research suggests analgosedation and readiness testing improve outcomes.
- Standardized protocols are needed to optimize care for ventilated pediatric patients.
Purpose of the Study:
- To decrease the duration of invasive mechanical ventilation in pediatric ICU patients by 25% within 9 months.
- To implement a bundled approach combining benzodiazepine-sparing analgosedation and standardized extubation readiness testing.
- To evaluate the impact of this bundled approach on key clinical outcomes and safety measures.
Main Methods:
- A quality improvement project was conducted in a 24-bed pediatric ICU.
- Inclusion criteria: patients ≤ 18 years old requiring invasive mechanical ventilation.
- A bundled clinical pathway for benzodiazepine-sparing analgosedation and extubation readiness testing was developed and implemented.
Main Results:
- Mean invasive mechanical ventilation duration decreased by 23% (3.95 days to 3.1 days, P=.039).
- Median benzodiazepine dose decreased by 75% (0.4 mg/kg/ventilated day to 0.1 mg/kg/ventilated day, P<.001).
- No significant changes were observed in pediatric ICU length of stay, unplanned extubation rates, extubation failure rates, or delirium incidence.
Conclusions:
- A multidisciplinary, bundled approach to analgosedation and extubation readiness testing effectively reduced mechanical ventilation duration and benzodiazepine exposure.
- The implemented strategy did not negatively impact critical safety outcomes.
- Further evaluation in diverse settings is recommended to confirm external validity and establish best practices.
Background:
Recent studies reported that children on mechanical ventilation who were managed with an analgosedation approach and standardized extubation readiness testing experienced better outcomes, including decreased delirium and invasive mechanical ventilation duration.
Methods:
This was a quality improvement project in a 24-bed pediatric ICU within a single center, including subjects ≤ 18 years old who required invasive mechanical ventilation via an oral or nasal endotracheal tube. The aim was to decrease the invasive mechanical ventilation duration for all the subjects by 25% within 9 months through the development and implementation of bundled benzodiazepine-sparing analgosedation and extubation readiness testing clinical pathways.
Results:
In the pre-implementation cohort, there were 274 encounters, with 253 (92.3%) that met inclusion for ending in an extubation attempt. In the implementation cohort, there were 367 encounters with 332 (90.5%) that ended in an extubation attempt. The mean invasive mechanical ventilation duration decreased by 23% (Pre 3.95 d vs Post 3.1 d; P = .039) after the implementation without a change in the mean pediatric ICU length of stay (Pre 7.5 d vs Post 6.5 d; P = .42). No difference in unplanned extubation (P > .99) or extubation failure rates (P = .67) were demonstrated. Sedation levels as evaluated by the mean State Behavioral Scale were similar (Pre -1.0 vs Post -1.1; P = .09). The median total benzodiazepine dose administered decreased by 75% (Pre 0.4 vs Post 0.1 mg/kg/ventilated day; P < .001). No difference in narcotic withdrawal (Pre 17.8% vs Post 16.4%; P = .65) or with delirium treatment (Pre 5.5% vs Post 8.7%; P = .14) was demonstrated.
Conclusions:
A multidisciplinary, bundled benzodiazepine-sparing analgosedation and extubation readiness testing approach resulted in a reduction in mechanical ventilation duration and benzodiazepine exposure without impacting key balancing measures. External validity needs to be evaluated in similar centers and consensus on best practices developed.
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