Effects of Clonidine on Withdrawal From Long-term Dexmedetomidine in the Pediatric Patient

Abstract

OBJECTIVE: To compare withdrawal symptoms among pediatric intensive care patients receiving clonidine to those not receiving clonidine while being weaned from long-term dexmedetomidine. METHODS: This retrospective analysis evaluated Withdrawal Assessment Tool-1 (WAT-1) scores and hemodynamic parameters in pediatric patients on dexmedetomidine for 5 days or longer between January 1, 2009, and December 31, 2012. The primary objective was to compare withdrawal symptoms based on the number of elevated WAT-1 scores among patients on clonidine to those not on clonidine, while being weaned from long-term dexmedetomidine. The secondary objective was to describe withdrawal symptoms associated with long-term dexmedetomidine use. RESULTS: Nineteen patients (median age, 1.5 years; interquartile range [IQR], 0.67–3.3) received 20 treatment courses of dexmedetomidine for at least 5 days. Clonidine was received by patients during 12 of the treatment courses. The patients in the clonidine group had an average of 0.8 (range, 0–6) elevated WAT-1 scores 24 hours post wean compared to an average of 3.2 (0–8) elevated WAT-1 scores in the no clonidine group (p = 0.49). There were no significant difierences between prewean and postwean systolic or diastolic blood pressures among the 2 groups. The average heart rate during the postwean period was 112 beats per minute (bpm) (range, 88.5–151.5) in the clonidine group compared to 138.4 bpm (range, 117.8–168.3) in the no clonidine group (p = 0.003). In the clonidine group, the mean change in heart rate postwean compared to prewean was an increase of 3.6 bpm (range, −39.6 to 47.5), compared to a mean increase of 29.9 bpm (range, 5.5–74.7) in the no clonidine group (p = 0.042). CONCLUSIONS: There was no difierence in WAT-1 scores between groups, with the clonidine group displaying a trend towards fewer elevated WAT-1 scores during the 24 hours post dexmedetomidine wean. Patients who received clonidine had significantly lower heart rates than the no clonidine group.

Iatrogenic Opioid Withdrawal in Critically Ill Patients: A Review of Assessment Tools and Management

“…49 Since then, the WAT-1 has been used in a number of studies evaluating the frequency of medication withdrawal, in various strategies to prevent opioid and sedation withdrawal and in the safe use of dexmedetomidine. 18,50-53…”

Effects of a Clonidine Taper on Dexmedetomidine Use and Withdrawal in Adult Critically Ill Patients—A Pilot Study

“…No studies have evaluated clonidine’s impact on dexmedetomidine withdrawal symptoms in adult patients. Lardieri et al ( 26 ) used the WAT-1 assessment to evaluate the effect of clonidine on dexmedetomidine withdrawal in pediatric patients. They found no difference in WAT-1 scores between groups, although patients in the clonidine group displayed a trend toward fewer elevated WAT-1 scores while weaning from dexmedetomidine.…”

“…The five withdrawal symptoms evaluated were as follows: (1) agitation as per a RASS greater than +1, (2) delirium as per a positive Confusion Assessment Method for the ICU assessment, (3) withdrawal as per a Withdrawal Assessment Tool Version 1 (WAT-1) score greater than 2, (4) tachycardia defined as heart rate (HR) greater than 90 beats per minute (beats/min), and (5) hypertension defined as systolic blood pressure (SBP) greater than 140 mm Hg or mean arterial pressure greater than 90 mm Hg. Although the WAT-1 ( Appendix C , Supplemental Digital Content 3, http://links.lww.com/CCX/A393 ) is only validated to evaluate opioid and benzodiazepine withdrawal in pediatric patients, it includes several hypersympathetic symptoms that overlap with dexmedetomidine withdrawal in adult patients and has been successfully used to evaluate dexmedetomidine withdrawal in pediatric studies ( 17 , 21 , 26 , 32 , 33 ). Secondary outcomes included incidence of individual withdrawal symptoms, incidence of pain (as defined by a Numerical Pain Rating Scale ≥ 4 for patients able to self-report or a Critical Care Pain Observation Tool ≥ 3 for those who were not), oral morphine equivalents (OMEs) administered during the wean period (calculated based on our institutional standard equivalency chart for all opiates, described in Appendix D , Supplemental Digital Content 4, http://links.lww.com/CCX/A394 ), use of concomitant propofol, antipsychotics, benzodiazepines, and ketamine during the wean period, average daily dexmedetomidine infusion rate throughout the total infusion duration, time to successful dexmedetomidine discontinuation, difference in drug cost using average wholesale price, time to transfer out of the ICU, and incidence of hypotension (SBP < 90 mm Hg) or bradycardia (HR < 60 beats/min) at any time during the wean period.…”

Dexmedetomidine Use in a Tertiary Care NICU: A Descriptive Study

“…10 Clonidine, an oral α-2 agonist, can provide an oral option to dexmedetomidine and has been utilized to minimize rebound tachycardia and agitation from dexmedeomidine withdrawal in PICU patients. 11…”

“…6,7,9,10,15,16 There are concerns of rebound tachycardia and hypertension, or agitation associated with abrupt discontinuation, but data are variable owing to concomitant sedative/analgesics and lack of a validated assessment tool. 4,6,11,17,18…”