Implementation of a Risk-Stratified Opioid and Benzodiazepine Weaning Protocol in a Pediatric Cardiac ICU

Abstract

Objectives: Opioids and benzodiazepines are commonly used to provide analgesia and sedation for critically ill children with cardiac disease. These medications have been associated with adverse effects including delirium, dependence, withdrawal, bowel dysfunction, and potential neurodevelopmental abnormalities. Our objective was to implement a risk-stratified opioid and benzodiazepine weaning protocol to reduce the exposure to opioids and benzodiazepines in pediatric patients with cardiac disease. Design: A prospective pre- and postinterventional study. Patients: Critically ill patients less than or equal to 21 years old with acquired or congenital cardiac disease exposed to greater than or equal to 7 days of scheduled opioids ± scheduled benzodiazepines between January 2013 and February 2015. Setting: A 24-bed pediatric cardiac ICU and 21-bed cardiovascular acute ward of an urban stand-alone children’s hospital. Intervention: We implemented an evidence-based opioid and benzodiazepine weaning protocol using educational and quality improvement methodology. Measurements and Main Results: One-hundred nineteen critically ill children met the inclusion criteria (64 post intervention, 55 pre intervention). Demographics and risk factors did not differ between groups. Patients in the postintervention period had shorter duration of opioids (19.0 vs 30.0 d; p < 0.01) and duration of benzodiazepines (5.3 vs 22.7 d; p < 0.01). Despite the shorter duration of wean, there was a decrease in withdrawal occurrence (% Withdrawal Assessment Tool score ≥ 4, 4.9% vs 14.1%; p < 0.01). There was an 8-day reduction in hospital length of stay (34 vs 42 d; p < 0.01). There was a decrease in clonidine use (14% vs 32%; p = 0.02) and no change in dexmedetomidine exposure (59% vs 75%; p = 0.08) in the postintervention period. Conclusions: We implemented a risk-stratified opioid and benzodiazepine weaning protocol for critically ill cardiac children that resulted in reduction in opioid and benzodiazepine duration and dose exposure, a decrease in symptoms of withdrawal, and a reduction in hospital length of stay.

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].…”

“…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].…”

“…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.…”

“…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. One study involved incorporation of the protocol's order sets in electronic health records [40].…”