Opioid Analgesia in Mechanically Ventilated Children

Anand, K.J.S.; Clark, Amy; Willson, Douglas F.; Berger, John; Meert, Kathleen L.; Zimmerman, Jerry J.; Harrison, Rick; Carcillo, Joseph A.; Newth, Christopher J. L.; Bisping, Stephanie; Holubkov, Richard; Dean, J. Michael; Nicholson, Carol

doi:10.1097/pcc.0b013e318253c80e

Cited by 76 publications

(29 citation statements)

References 50 publications

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“…Emerging evidence has shown that when used as an infusion it is more favorable than fentanyl with regard to need for dose escalation, incidence of withdrawal, and length of hospital stay. (31, 32) Opioid tolerance and withdrawal pose major challenges for all providers in the PICU, and the predilection for fentanyl may be a trend that needs further evaluation through a randomized controlled trial.…”

Section: Discussionmentioning

confidence: 99%

Sedation, Sleep Promotion, and Delirium Screening Practices in the Care of Mechanically Ventilated Children

Kudchadkar

Yaster

Punjabi

2014

Critical Care Medicine

195

183

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Objective To examine pediatric intensivist sedation management, sleep promotion, and delirium screening practices for intubated and mechanically ventilated children. Design An international, online survey of questions regarding sedative and analgesic medication choices and availability, sedation protocols, sleep optimization, and delirium recognition and treatment. Setting Member societies of the World Federation of Pediatric Intensive and Critical Care Societies were asked to send the survey to their mailing lists; responses were collected from July 2012 to January 2013. Interventions Survey Measurements and Main Results The survey was completed by 341 respondents, the majority of whom were from North America (70%). Twenty-seven percent of respondents reported having written sedation protocols. Most respondents worked in pediatric intensive care units (PICUs) with sedation scoring systems (70%), although only 42% of those with access to scoring systems reported routine daily use for goal-directed sedation management. The State Behavioral Scale was the most commonly used scoring system in North America (22%), with the COMFORT score more prevalent in all other countries (39%). The most commonly used sedation regimen for intubated children was a combination of opioid and benzodiazepine (72%). Most intensivists chose fentanyl as their first-line opioid (66%) and midazolam as their first-line benzodiazepine (86%), and prefer to administer these medications as continuous infusions. Propofol and dexmedetomidine were the most commonly restricted medications in PICUs internationally. Use of earplugs, eye masks, noise reduction, and lighting optimization for sleep promotion was uncommon. Delirium screening was not practiced in 71% of respondent’s PICUs, and only 2% reported routine screening at least twice a day. Conclusions The results highlight the heterogeneity in sedation practices among intensivists who care for critically ill children, as well as a paucity of sleep promotion and delirium screening in PICUs worldwide.

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Section: Discussionmentioning

confidence: 99%

Sedation, Sleep Promotion, and Delirium Screening Practices in the Care of Mechanically Ventilated Children

Kudchadkar

Yaster

Punjabi

2014

Critical Care Medicine

195

183

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“…For example, a recent study found that the primary outcome of doubling of daily medication dose (tolerance) was more likely to occur with infusions lasting >7 days. 43 …”

Section: Discussionmentioning

confidence: 99%

Risk Factors Associated With Iatrogenic Opioid and Benzodiazepine Withdrawal in Critically Ill Pediatric Patients

Best

Boullata

Curley³

2015

Pediatric Critical Care Medicine

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Objective Analgesia and sedation are common therapies in pediatric critical care, and rapid titration of these medications is associated with iatrogenic withdrawal syndrome (IWS). We performed a systematic review of the literature to identify all common and salient risk factors associated with IWS and build a conceptual model of IWS risk in critically ill pediatric patients. Data sources Multiple databases, including PubMed/Medline, EMBASE, CINAHL, and the Cochrane Central Registry of Clinical Trials were searched using relevant terms from January 1, 1980 to August 1, 2014. Study selection Articles were included if they were published in English and discussed IWS following either opioid or benzodiazepine therapy in children in acute or intensive care settings. Articles were excluded if subjects were neonates born to opioid- or benzodiazepine-dependent mothers, children diagnosed as substance abusers, or subjects with cancer-related pain; if data about opioid or benzodiazepine treatment were not specified; or if primary data were not reported. Data extraction and synthesis In total 1395 papers were evaluated, 33 of which met the inclusion criteria. To facilitate analysis, all opioid and/or benzodiazepine doses were converted to morphine or midazolam equivalents, respectively. A table of evidence was developed for qualitative analysis of common themes, providing a framework for the construction of a conceptual model. The strongest risk factors associated with IWS include duration of therapy and cumulative dose. Additionally, evidence exists linking patient, process and system factors in the development of IWS. Findings Most papers were prospective observational or interventional studies. Conclusions Given the state of existing evidence, well-designed prospective studies are required to better characterize IWS in critically ill pediatric patients. This review provides data to support the construction of a conceptual model of IWS risk that, if supported, could be useful in guiding future research.

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“…Only a small number of studies have described the development of opioid tolerance in children. Recently, Anand et al [16] reported that the fentanyl dose for analgesia and sedation of mechanically ventilated children had to be doubled in 16% of patients after 7 days of opioid exposure. There are no paediatric studies investigating remifentanil escalations to maintain a defined opioid effect.…”

Section: Discussionmentioning

confidence: 99%

Remifentanil-Induced Tolerance, Withdrawal or Hyperalgesia in Infants: A Randomized Controlled Trial. RAPIP Trial: Remifentanil-Based Analgesia and Sedation of Paediatric Intensive Care Patients

et al. 2013

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Background: Short-acting opioids like remifentanil are suspected of an increased risk for tolerance, withdrawal and opioid-induced hyperalgesia (OIH). These potential adverse effects have never been investigated in neonates. Objectives: To compare remifentanil and fentanyl concerning the incidence of tolerance, withdrawal and OIH. Methods: 23 mechanically ventilated infants received up to 96 h either a remifentanil- or fentanyl-based analgesia and sedation regimen with low-dose midazolam. We compared the required opioid doses and the number of opioid dose adjustments. Following extubation, withdrawal symptoms were assessed by a modification of the Finnegan score. OIH was evaluated by the CHIPPS scale and by testing the threshold of the flexion withdrawal reflex with calibrated von Frey filaments. Results: Remifentanil had to be increased by 24% and fentanyl by 47% to keep the infants adequately sedated during mechanical ventilation. Following extubation, infants revealed no pronounced opioid withdrawal and low average Finnegan scores in both groups. Only 1 infant of the fentanyl group and 1 infant of the remifentanil group required methadone for treatment of withdrawal symptoms. Infants also revealed no signs of OIH and low CHIPPS scores in both groups. The median threshold of the flexion withdrawal reflex was 4.5 g (IQR = 2.3) in the fentanyl group and 2.7 g (IQR = 3.3) in the remifentanil group (p = 0.312), which is within the physiologic range of healthy infants. Conclusions: Remifentanil does not seem to be associated with an increased risk for tolerance, withdrawal or OIH.

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Opioid Analgesia in Mechanically Ventilated Children

Cited by 76 publications

References 50 publications

Sedation, Sleep Promotion, and Delirium Screening Practices in the Care of Mechanically Ventilated Children

Sedation, Sleep Promotion, and Delirium Screening Practices in the Care of Mechanically Ventilated Children

Risk Factors Associated With Iatrogenic Opioid and Benzodiazepine Withdrawal in Critically Ill Pediatric Patients

Remifentanil-Induced Tolerance, Withdrawal or Hyperalgesia in Infants: A Randomized Controlled Trial. RAPIP Trial: Remifentanil-Based Analgesia and Sedation of Paediatric Intensive Care Patients

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