Evaluation of an Enteral Clonidine Taper following Prolonged Dexmedetomidine Exposure in Critically Ill Children

Abstract

The aim of the current study is to evaluate the use of an enteral clonidine transition for the prevention or management of dexmedetomidine withdrawal symptoms in critically ill children not exposed to other continuous infusion sedative agents. A retrospective, single-center study was conducted in patients ≤ 18 years of age admitted to the pediatric intensive care unit who received a continuous infusion of dexmedetomidine for ≥ 24 hours and who were prescribed enteral clonidine within 72 hours of dexmedetomidine discontinuation. Predefined withdrawal terminology was established to assess for hypertension, tachycardia, agitation, tremors, and decreased sleep. A total of 105 patients were included and received enteral clonidine for prevention or management of dexmedetomidine withdrawal symptoms, with 13 patients (12.4%) requiring a taper modification to manage withdrawal symptoms. The median duration of dexmedetomidine infusion was 120.5 hours (95.5, 143.5) and median peak infusion rate was 1 µg/kg/h (1, 1.2). A higher cumulative dexmedetomidine dose of 119.2 µg/kg (96.6, 154.9) and duration of 142.9 hours (122.6, 158.3) were noted in patients who required a taper modification. Risk factors for dexmedetomidine withdrawal such as dexmedetomidine duration and cumulative dose may help predict patients at the highest risk of withdrawal that would benefit from an enteral clonidine taper to prevent dexmedetomidine withdrawal symptoms. An enteral clonidine taper can be effective in the prevention and management of dexmedetomidine withdrawal symptoms.

Dexmedetomidine Withdrawal Syndrome in Children in the PICU: Systematic Review and Meta-Analysis

“…Therefore, data gathered from cohorts exposed to only dexmedetomidine or weaned from dexmedetomidine alone are highly valuable for identifying signs and risk factors for dexmedetomidine withdrawal without the confounding effects of opioid or benzodiazepine exposure and/or their concomitant weaning. In the five cohorts without opioid or benzodiazepine exposure or with dexmedetomidine weaning alone (15, 23), withdrawal signs of hypertension, and tachycardia and agitation were still observed, thus supporting the presence of a withdrawal syndrome attributable to dexmedetomidine. While sedation regimens with dexmedetomidine alone may not always be feasible, future studies investigating dexmedetomidine withdrawal must control for these important potential confounding factors in their design or analysis.…”

“…Only 11 of the 23 studies provided recommendations on the usage of clonidine in patients being weaned from dexmedetomidine. Of these 11 studies, six reported decreased tachycardia, hypertension, and/or agitation with clonidine use (12, 15, 20, 21, 23, 24). Four studies, comprising a total of 304 patients undergoing dexmedetomidine tapering without clonidine, and 97 patients undergoing dexmedetomidine tapering with concomitant clonidine, directly compared rates of dexmedetomidine withdrawal signs between these two strategies (11, 12, 20, 23).…”

“…Two studies reported statistically shorter LOS in the dexmedetomidine taper alone cohort compared with dexmedetomidine taper with clonidine (11, 23). Another study found shorter LOS in patients transitioned to clonidine after dexmedetomidine discontinuation compared with those patients transitioned to clonidine before dexmedetomidine was stopped (15).…”

“…Six of the 23 studies identified risk factors for dexmedetomidine withdrawal. The most identified risk factors were duration of dexmedetomidine infusion and cumulative dexmedetomidine dose (9, 15, 18, 24, 28). There were no significant correlations between dexmedetomidine exposure variables and withdrawal signs.…”

“…Of the 498 publications identified by the literature search, 23 studies were included (Appendix 1, http://links.lww.com/PCC/C439) (6–28). Included studies were published between 2008 and 2022.…”