Association Between Deep Sedation from Continuous Intravenous Sedatives and Extubation Failures in Mechanically Ventilated Patients in the Pediatric Intensive Care Unit

Abstract

OBJECTIVE The primary objective of this study was to determine whether an association exists between deep sedation from continuous infusion sedatives and extubation failures in mechanically ventilated children. Secondary outcomes evaluated risk factors associated with deep sedation. METHODS This was a retrospective cohort study conducted between January 1, 2009, and October 31, 2012, in the pediatric intensive care unit (PICU) at Duke Children's Hospital. Patients were included in the study if they had been admitted to the PICU, had been mechanically ventilated for ≥48 hours, and had received at least one continuous infusion benzodiazepine and/or opioid infusion for ≥24 hours. Patients were separated into 2 groups: those deeply sedated and those not deeply sedated. Deep sedation was defined as having at least one documented State Behavioral Scale (SBS) of −3 or −2 within 72 hours prior to planned extubation. RESULTS A total of 108 patients were included in the analysis. Both groups were well matched with regard to baseline characteristics. For the primary outcome, there was no difference in extubation failures in those who were deeply sedated compared to those not deeply sedated (14 patients [22.6%] versus 7 patients [15.2%], respectively; p = 0.33). After adjusting for potential risk factors, patients with a higher weight percentile for age (odds ratio [OR] 1.02; 95% confidence interval [CI] 1.00–1.03), lower Glasgow Coma Score (GCS) score prior to intubation (OR 0.85; 95% CI 0.74–0.97), and larger maximum benzodiazepine dose (OR 1.93; 95% CI 1.01–3.71) were associated with greater odds of deep sedation. A higher GCS prior to intubation was significantly associated with increased odds of extubation failure (OR 1.19; 95% CI 1.02–1.39). CONCLUSIONS While there was no statistically significant difference in extubation failures between the 2 groups included in this study, considering the severe consequences of extubation failure, the numerical difference reported may be clinically important.

Operational Definitions Related to Pediatric Ventilator Liberation

“…The articles that were used to inform the definitions are cited in Table 2 . 8 , 9 , 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 49 , 50 , 51 , 52 , 53 During the final voting round, the expert panel agreed on all modified definitions ( e-Table 7 ). Final definitions are shown in Table 2 and reported below.…”

“… Conventional oxygen therapy is defined as the provision of > 0.21 oxygen by any of the following devices applied to a spontaneously breathing patient regardless of presence of humidification: Face mask oxygen delivered via any type of nonocclusive mask Nasal cannula at flow rates less than HFNC rates (see Definition 5) Tracheostomy collar without positive pressure B. Liberation from invasive MV 8 , 9 , 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 53 : A patient is considered to be liberated from invasive MV when: ETT: An ETT is removed and is not re-inserted within 48 h.∗ Tracheostomy tube: Positive pressure ventilation is no longer being delivered through a tracheostomy tube and is not re-initiated within 48 h.∗ This includes application of controlled, assisted, supported, or CPAP modes of positive pressure via a tracheostomy tube for any period during the day/night. ∗Excluding use for temporary procedures ...…”

“… If one of the above NRS modes is re-initiated ≤ 48 h from an attempt to liberate from NRS, it is considered a failed liberation attempt, and the duration of NRS should include the time (≤ 48 h) that the patient was not receiving one of these therapies. E. Total duration of invasive MV 8 , 9 , 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 49 , 50 , 51 , 52 : Time from initiation of invasive MV until successful liberation from invasive MV or death. If invasive MV is resumed > 48 h after an initial attempt to liberate from invasive MV, it is considered a new ventilation course.…”

“…Invasive mechanical ventilation (MV) 5 , 8 , 9 , 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 49 , 50 : Positive pressure ventilation delivered via an artificial airway (ie, endotracheal tube [ETT] or tracheostomy tube) into the trachea.…”

Predictors of Failed Extubation in Mechanically Ventilated Children: Single Center Experience

“…The prolonged use of sedation seems possible to control, or fine tune to achieve more successful smooth extubation. Especially that evidence supports that comfort during MV can be achieved with no or very light sedation, and this is associated with lower incidences of delirium, and shorter length of stay (15), and there is no difference between deeply sedated patients and those not deeply sedated regarding extubation success (16). More research is needed to assess the minimum effective dose, duration, methods of administration whether continuous or interrupted and decrease its empirical unnecessary use as in encephalopathic patients, as it may be of value to decrease the frequency of extubation failure.…”