Analgesia and Sedation Protocol for Mechanically Ventilated Postsurgical Children Reduces Benzodiazepines and Withdrawal Symptoms—But Not in All Patients

Abstract

We demonstrated recently that the implementation of a nurse-driven analgesia and sedation protocol (pediatric analgesia and sedation protocol [pASP]) for mechanically ventilated nonpostsurgical patients reduces the total dose of benzodiazepines and the withdrawal symptoms significantly. It has not been investigated if these results can also be expected in the group of patients undergoing surgery. To evaluate the effects of the pASP in mechanically ventilated postsurgical children regarding drug dosage, duration of mechanical ventilation, length of stay, and rate of withdrawal symptoms. This is a two-phase prospective observational control study. The preimplementation group was managed by the physician's order and the postimplementation group was managed with the pASP including COMFORT-B, nurse interpretation of sedation, and Sophia observation withdrawal symptoms scale scoring. One hundred and sixteen patients were included before and one hundred and ten patients after implementation. The pASP had no effect on length of pediatric intensive care unit stay or duration of mechanical ventilation. The protocol reduced total (5.0 mg/kg [0.5-58.0] vs 4.0 mg/kg [0.0-47.0]; = 0.021) and daily doses (4.4 mg/kg/d [1.1-33.9] vs 2.9 mg/kg/d [0.0-9.9]; < 0.001) of benzodiazepines significantly. No difference was observed in total and daily doses of opioids (5.0 mg/kg [0.1-67.0] vs 3.0 mg/kg [0.1-71.0]; = 0.81) and (0.7 mg/kg/d [0.0-7.0] vs. 0.8 mg/kg/d [0.0-3.7]; = 0.35), respectively. Rate of withdrawal symptoms was significantly lower after implementation (35.3 vs 20.0%; = 0.01), but not in patients after solid organ transplantation or oncological patients. The nurse-driven analgesia and sedation protocol is an effective procedure to reduce the total doses of benzodiazepines and occurrence of withdrawal symptoms in postsurgical children, which are naïve to opioids or benzodiazepines.

Strategies for the Prevention and Treatment of Iatrogenic Withdrawal from Opioids and Benzodiazepines in Critically Ill Neonates, Children and Adults: A Systematic Review of Clinical Studies

“…Of the 13 studies, 10 were NRSI [31][32][33][34][35][36][37][38][39][40], and 3 were randomised controlled trials (RCTs) [41][42][43] (Table 1). Nine studies were conducted in North American ICUs [31,33,34,[37][38][39][40][41][42] and 12 were single-centre studies [43].…”

“…Heterogeneity was found in the type of patients included (Table 1). Only two studies involved adult patients [35,43], while the rest involved neonatal and paediatric patients [31][32][33][34][36][37][38][39][40][41][42]. Nine studies included only patients at risk of IWS based on opioid and/or benzodiazepine exposure of at least 5 days in six studies [32,33,[40][41][42][43] and at least 7 days in three studies [31,37,38].…”

“…Nine studies included only patients at risk of IWS based on opioid and/or benzodiazepine exposure of at least 5 days in six studies [32,33,[40][41][42][43] and at least 7 days in three studies [31,37,38]. Other studies included patients based on previous experience of IWS [35,41], exposure to treatment for IWS [34,39], or use of mechanical ventilation for ≥ 24 h [36]. One of the studies included both patients at risk of IWS (pre-emptive enrolment) and patients experiencing IWS (rescue enrolment) [41].…”

“…Interventions and comparators described were heterogeneous (Table 1) and may be broadly categorised in two main categories: multifaceted protocolised care targeting IWS (n = 8) as compared to usual practices [31,33,34,[36][37][38][39][40] or interventions focusing on individual aspects of IWS management (n = 5) [32,35,[41][42][43] (see Table 2 for a detailed description of interventions). Multifaceted protocolised care included more than one implementation component (e.g.…”

“…Individual interventions involved using a specific drug for IWS (clonidine or methadone) against placebo in two studies, both of which were conducted in adult patients [35,43]; or testing various dosages [42], routes of administration [32] or durations of tapering [41], in three studies, all of which were conducted in the paediatric/neonatal setting. Studies involving multifaceted protocolised care were all conducted in paediatric/neonatal populations [31,33,34,[36][37][38][39][40]. Task shift to nurses (n = 5) [31,34,36,38,40] or pharmacists (n = 3) [34,37,39] (vs physician-managed standard of care) was an element of most of these interventions.…”