Implementation of a risk-stratified opioid weaning protocol in a pediatric intensive care unit

Sanchez-Pinto, L. Nelson; Nelson, Lara; Lieu, Phuong; Koh, Joyce; Rodgers, John W.; Larson, Krichelle A.; Huson, Jennifer; Amirnovin, Rambod

doi:10.1016/j.jcrc.2017.08.049

Cited by 26 publications

(68 citation statements)

References 18 publications

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“…Nonetheless, preventing or effectively treating withdrawal syndrome might reduce the number of subsequent readmissions. Proposed measures for doing so include better selection of analgesics, implementation of nurse‐driven analgesic and sedation protocols, and administration of opioid‐weaning treatments and massage therapy . Although further studies are needed, multidisciplinary team approaches may reduce the incidence of withdrawal syndrome and, consequently, readmission.…”

Section: Discussionmentioning

confidence: 99%

Incidence and risk factors for readmission to a paediatric intensive care unit

Konishi

Hatachi

Ikebe

et al. 2019

Nursing in Critical Care

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Background: Unscheduled readmission to a paediatric intensive care unit can lead to unfavourable patient outcomes. Therefore, determining the incidence and risk factors is important. Previous studies on such readmissions have only focused on the first 48 hours after discharge and described the relative risk factors as unmodifiable.Aim: To identify the incidence and risk factors of unscheduled readmission to a paediatric intensive care unit within 7 days of discharge.Design: This was a retrospective observational study.Methods: Our study population comprised consecutive patients admitted to the paediatric intensive care unit of our tertiary hospital in Japan in 2012 to 2016. We determined the incidence of unscheduled readmission to the unit within 7 days of discharge and identified potential risk factors using multivariable logistic regression analysis.Results: Among the 2432 admissions (1472 patients), 60 admissions (2.5%, 44 patients) were followed by ≥1 unscheduled readmission. The median time to readmission was 3.5 days. The most common causes for readmission were respiratory issues and cardiovascular symptoms. The significant risk factors for readmission within 7 days of discharge were unscheduled initial admission (odds ratio [OR]: 3.02; 95% confidence interval [CI:] 1.45-6.31), admission from a general ward (OR: 5.13; 95% CI: 1.75-15.0), and withdrawal syndrome during the initial stay (OR: 3.95; 95%

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Section: Discussionmentioning

confidence: 99%

Incidence and risk factors for readmission to a paediatric intensive care unit

Konishi

Hatachi

Ikebe

et al. 2019

Nursing in Critical Care

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“…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].…”

Section: Study Characteristicsmentioning

confidence: 99%

“…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]. 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].…”

Section: Study Characteristicsmentioning

confidence: 99%

“…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.…”

Section: Interventions and Comparatorsmentioning

confidence: 99%

“…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.…”

Section: Interventions and Comparatorsmentioning

confidence: 99%

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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

Sneyers

Duceppe

Frenette

et al. 2020

Drugs

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Background Critically ill patients are at high risk of iatrogenic withdrawal syndrome (IWS), due to exposure to high doses or prolonged periods of opioids and benzodiazepines. Purpose To examine pharmacological management strategies designed to prevent and/or treat IWS from opioids and/or benzodiazepines in critically ill neonates, children and adults. Methods We included non-randomised studies of interventions (NRSI) and randomised controlled trials (RCTs), reporting on interventions to prevent or manage IWS in critically ill neonatal, paediatric and adult patients. Database searching included: PubMed, CINAHL, Embase, Cochrane databases, TRIP, CMA Infobase and NICE evidence. Additional grey literature was examined. Study selection and data extraction were performed in duplicate. Data collected included: population, definition of opioid, benzodiazepine or mixed IWS, its assessment and management (drug or strategy, route of administration, dosage and titration), previous drug exposures and outcomes measures. Methodological quality assessment was performed by two independent reviewers using the Cochrane risk of bias tool for RCTs and the ROBINS-I tool for NRSI. A qualitative synthesis of the results is provided. For the subset of studies evaluating multifaceted protocolised care, we meta-analysed results for 4 outcomes and examined the quality of evidence using GRADE post hoc. Results Thirteen studies were eligible, including 10 NRSI and 3 RCTs; 11 of these included neonatal and paediatric patients exclusively. Eight studies evaluated multifaceted protocolised interventions, while 5 evaluated individual components of IWS management (e.g. clonidine or methadone at varying dosages, routes of administration and duration of tapering). IWS was measured using an appropriate tool in 6 studies. Ten studies reported upon occurrence of IWS, showing significant reductions (n = 4) or no differences (n = 6). Interventions failed to impact duration of mechanical ventilation, ICU length of stay, and adverse effects. Impact on opioid and/or benzodiazepine total doses and duration showed no differences in 4 studies, while 3 showed opioid and benzodiazepine cumulative doses were significantly reduced by 20-35% and 32-66%, and treatment durations by 1.5-11 and 19 days, respectively. Variable effects on intervention drug exposures were found. Weaning durations were reduced by 6-12 days (n = 4) for opioids and/or methadone and by 13 days (n = 1) for benzodiazepines. In contrast, two studies using interventions centred on transition to enteral routes or longer tapering durations found significant increases in intervention drug exposures. Interventions had overall non-significant effects on additional drug requirements (except for one study). Included studies were at high risk of bias, relating to selection, detection and reporting bias. Conclusion Interventions for IWS management fail to impact duration of mechanical ventilation or ICU length of stay, while effect on occurrence of IWS and drug exposures is inconsistent. Heterogeneity in...

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Maternal and iatrogenic neonatal opioid withdrawal syndrome: Differences and similarities in recognition, management, and consequences

Isaac

Hoogen

Habib

et al. 2021

J of Neuroscience Research

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Opioids are potent analgesics, and have been used for their psychoactive properties for centuries. Chronic and widespread opioid use, however, has significant individual and societal implications. In 2015, over two million Americans struggled with opioid use disorder (Hedegaard et al., 2020). Among this population are pregnant women, contributing to a surge in in utero opioid exposure from both prescription and illicit opioid use (Haight et al., 2018), and adverse neonatal outcomes. The incidence of neonatal opioid withdrawal syndrome (NOWS), or neonatal abstinence syndrome (NAS),

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Implementation of a risk-stratified opioid weaning protocol in a pediatric intensive care unit

Cited by 26 publications

References 18 publications

Incidence and risk factors for readmission to a paediatric intensive care unit

Incidence and risk factors for readmission to a paediatric intensive care unit

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

Maternal and iatrogenic neonatal opioid withdrawal syndrome: Differences and similarities in recognition, management, and consequences

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