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Association of Obesity With Sedative Dosing, Sedative Response, and Clinical Outcomes in Mechanically Ventilated
Shan L Ward1, Onella S Dawkins-Henry2, Lisa A Asaro2
1Department of Pediatrics, Division of Critical Care, UCSF Benioff Children's Hospitals, San Francisco and Oakland, CA.
Insights
Obesity in pediatric patients receiving mechanical ventilation led to higher opiate doses and worse outcomes, especially with protocolized sedation. These weight-based differences were not seen in usual care, highlighting the need for tailored dosing strategies.
Area of Science:
- Pediatric critical care medicine
- Pharmacology and pharmacokinetics
- Clinical outcomes research
Background:
- Obesity is a growing concern in pediatric populations.
- Understanding its impact on critically ill children is crucial for optimizing care.
- Mechanically ventilated children often require analgesics and sedatives.
Purpose of the Study:
- To investigate how obesity affects analgesic and sedative use in mechanically ventilated children.
- To determine the impact of obesity on iatrogenic withdrawal syndrome (IWS) rates and clinical outcomes.
- To assess the effectiveness of a nurse-implemented sedation protocol in children with and without obesity.
Main Methods:
- Secondary analysis of the Randomized Evaluation of Sedation Titration for Respiratory Failure (RESTORE) trial.
- Inclusion of 31 U.S. pediatric intensive care units (PICUs).
- Categorization of children aged 1-17 years into groups with or without obesity.
Main Results:
- Obesity was present in 22% of patients and led to higher cumulative opiate doses, despite similar weight-based dosing.
- Protocolized sedation in obese children resulted in higher opiate doses, inadequate sedation, longer mechanical ventilation, and increased mortality compared to non-obese counterparts.
- These weight-based differences were not observed in the usual care group.
Conclusions:
- Obesity significantly impacts medication exposure and clinical outcomes in mechanically ventilated children, particularly under protocolized sedation.
- Current dosing strategies may be inadequate for obese pediatric patients, necessitating adjustments based on body habitus.
- Further research is needed to refine medication dosing and improve outcomes for children with obesity in critical care settings.
Objectives:
This study aimed to investigate the impact of obesity on the use of analgesics and sedatives, rates of iatrogenic withdrawal syndrome (IWS), and outcomes in mechanically ventilated pediatric patients. Additionally, it sought to assess whether a nurse-implemented sedation protocol would be equally effective for children with and without obesity.
Design:
Secondary analysis of the Randomized Evaluation of Sedation Titration for Respiratory Failure (RESTORE) pediatric multicenter clinical trial.
Setting:
Thirty-one U.S. PICUs.
Patients:
Children 1-17 years old, categorized as with or without obesity according to World Health Organization and Centers for Disease Control and Prevention criteria.
Interventions:
None.
Measurements And Main Results:
The study assessed various factors including medication exposure, adequacy of pain and sedation management, IWS rates, and clinical outcomes. Obesity occurred in 22% of patients. Obesity did not influence choice of opiate, but it led to extended exposure to these medications. There were no differences in dosing per kilogram of admission weight, resulting in significantly higher daily and cumulative doses in those with obesity. In the protocolized sedation arm, patients with obesity received significantly higher median opiate doses compared with the nonobesity protocolized sedation group. IWS rates did not differ; however, protocolized sedation obesity patients experienced more instances of inadequate sedation, longer time to extubation readiness, longer duration of mechanical ventilation and PICU stay, and higher 28-day in-hospital mortality than the protocolized sedation nonobesity group. These weight-based differences were not noted in the usual care arm.
Conclusions:
This study underscores the significance of accounting for body habitus when selecting and dosing opiates in children with acute respiratory failure. Obesity had substantial impact on medication exposure and clinical outcomes, particularly within a structured, protocolized sedation regimen. Further research is warranted to explore the intricate relationship between medication dosing and clinical outcomes in children with obesity.
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