Reducing Exposure to Opioid and Benzodiazepine Medications for Pediatric Cardiac Intensive Care Patients: A Quality Improvement Project*

Donnellan, Amy; Sawyer, Jaclyn E.; Peach, Anne; Staveski, Sandra; Nelson, David P.; Pratap, Jayant Nick

doi:10.1097/pcc.0000000000001870

Cited by 20 publications

(14 citation statements)

References 13 publications

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“…21 To this end, new sedation protocols, focused on benzodiazepine-sparing strategies, have been implemented in the PICU. 22 As a benzodiazepine-sparing strategy, this study used a delayed initiation of continuous infusion and an early association of adjuvant therapies. Recent treatment guidelines 5,6 favor the use of dexmedetomidine, leaving benzodiazepines as a second-line option.…”

Section: Discussionmentioning

confidence: 99%

Impact of the implementation of a sedation and analgesia protocol in a pediatric intensive care unit

et al. 2023

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Introduction.Adequate sedation and analgesia is essential in the management of patients requiring mechanical ventilation (MV). The implementation of protocols and their monitoring is recommended; mixed results on adherence and impact have been reported. Objectives.To assess the impact of the implementation of a sedation and analgesia protocol on the use of benzodiazepines, opioids, and evolution in the pediatric intensive care unit (PICU) in patients requiring MV for more than 72 hours.Methods. Before-and-after, uncontrolled study in the PICU of a children's hospital. The study was developed in 3 stages: pre-intervention for situational diagnosis (from April to September 2019), intervention, and post-intervention for implementation of a sedation and analgesia protocol, education on use, and monitoring of adherence and impact (from October 2019 to October 2021).Results. A total of 99 and 92 patients were included in the study in the pre-and post-intervention stages, respectively. Patients had a more severe condition, were younger, and had a lower weight in the preintervention period. After adjusting for severity and age, the group comparison in the post-intervention stage showed a reduction in days of continuous infusion of opioids (6 ± 5.2 versus 7.6-5.8, p = 0.018) and days of continuous infusion of benzodiazepines (3.3 ± 3.5 versus 7.6 ± 6.8, p = 0.001). No significant differences were observed in days of MV and total days of benzodiazepine use. Conclusion.The implementation of a sedation and analgesia protocol resulted in a reduction in the use of continuous infusion of drugs.

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Section: Discussionmentioning

confidence: 99%

Impact of the implementation of a sedation and analgesia protocol in a pediatric intensive care unit

et al. 2023

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“…Several studies have examined the impact of SA regimens on clinical outcomes in critically ill infants and children over the past decade (Table 1) (5)(6)(7)(8)(9)(10)(11)(12)(13)(14)(15)(16). Most of these studies were single-center studies conducted in tertiary or quaternary PICUs, i.e., a mix of cardiac, medical, and surgical patients.…”

Section: Sedation and Analgesia Regimens In The Pediatric Intensive C...mentioning

confidence: 99%

“…Furthermore, although a number of studies have demonstrated safety in using dexmedetomidine as a primary sedative agent, the adoption of dexmedetomidine as a primary sedative in pediatric critical care is still lagging (6,(24)(25)(26). Of the 11 studies reviewed above, only three (27%) utilized dexmedetomidine as a first-line sedative agent (6,8,13).…”

Section: Challenges With Implementation Of Sedation and Analgesia Reg...mentioning

confidence: 99%

Implementation Science in Pediatric Critical Care – Sedation and Analgesia Practices as a Case Study

et al. 2022

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Sedation and analgesia (SA) management is essential practice in the pediatric intensive care unit (PICU). Over the past decade, there has been significant interest in optimal SA management strategy, due to reports of the adverse effects of SA medications and their relationship to ICU delirium. We reviewed 13 studies examining SA practices in the PICU over the past decade for the purposes of reporting the study design, outcomes of interest, SA protocols used, strategies for implementation, and the patient-centered outcomes. We highlighted the paucity of evidence-base for these practices and also described the existing gaps in the intersection of implementation science (IS) and SA protocols in the PICU. Future studies would benefit from a focus on effective implementation strategies to introduce and sustain evidence-based SA protocols, as well as novel quasi-experimental study designs that will help determine their impact on relevant clinical outcomes, such as the occurrence of ICU delirium. Adoption of the available evidence-based practices into routine care in the PICU remains challenging. Using SA practice as an example, we illustrated the need for a structured approach to the implementation science in pediatric critical care. Key components of the successful adoption of evidence-based best practice include the assessment of the local context, both resources and barriers, followed by a context-specific strategy for implementation and a focus on sustainability and integration of the practice into the permanent workflow.

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“…In this study, the children received morphine and midazolam according to an algorithm based on regular pain and distress assessments by the nursing staff. Donnelan et al (23) showed recently that the implementation of an algorithm reduced opioid and benzodiazepine dosing in children after cardiac surgery. More than two thirds of the subjects in our study received midazolam at some point during their intensive care admission, and only half of them needed a midazolam infusion.…”

Section: Optimal Analgosedation After Cardiac Surgerymentioning

confidence: 99%

Section: Optimal Analgosedation After Cardiac Surgerymentioning

confidence: 99%

Sedation With Midazolam After Cardiac Surgery in Children With and Without Down Syndrome: A Pharmacokinetic-Pharmacodynamic Study

Valkenburg

Goulooze

Breatnach

et al. 2020

Pediatric Critical Care Medicine

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To compare the pharmacokinetics and pharmacodynamics of IV midazolam after cardiac surgery between children with and without Down syndrome. DESIGN: Prospective, single-center observational trial. SETTING: PICU in a university-affiliated pediatric teaching hospital.PATIENTS: Twenty-one children with Down syndrome and 17 without, 3-36 months, scheduled for cardiac surgery with cardiopulmonary bypass. INTERVENTIONS:Postoperatively, nurses regularly assessed the children's pain and discomfort with the validated COMFORT-Behavioral scale and Numeric Rating Scale for pain. A loading dose of morphine (100 µg/ kg) was administered after coming off bypass; thereafter, morphine infusion was commenced at 40 µg/kg/hr. Midazolam was started if COMFORT-Behavioral scale score of greater than 16 and Numeric Rating Scale score of less than 4 (suggestive of undersedation). Plasma midazolam and metabolite concentrations were measured for population pharmacokineticand pharmacodynamic analysis using nonlinear mixed effects modeling (NONMEM) (Version VI; GloboMax LLC, Hanover, MD) software. MEASUREMENTS AND MAIN RESULTS:Twenty-six children (72%) required midazolam postoperatively (15 with Down syndrome and 11 without; p = 1.00). Neither the cumulative midazolam dose (p = 0.61) nor the time elapsed before additional sedation was initiated (p = 0.71), statistically significantly differed between children with and without Down syndrome. Population pharmacokinetic and pharmacodynamics analysis revealed no statistically significant differences between the children with and without Down syndrome. Bodyweight was a significant covariate for the clearance of 1-OH-midazolam to 1-OH-glucuronide (p = 0.003). Pharmacodynamic analysis revealed a marginal effect of the midazolam concentration on the COMFORT-Behavioral score. CONCLUSIONS:The majority of children with and without Down syndrome required additional sedation after cardiac surgery. This pharmacokinetic and pharmacodynamic analysis does not provide evidence for different dosing of midazolam in children with Down syndrome after cardiac surgery.

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Reducing Exposure to Opioid and Benzodiazepine Medications for Pediatric Cardiac Intensive Care Patients: A Quality Improvement Project*

Cited by 20 publications

References 13 publications

Impact of the implementation of a sedation and analgesia protocol in a pediatric intensive care unit

Impact of the implementation of a sedation and analgesia protocol in a pediatric intensive care unit

Implementation Science in Pediatric Critical Care – Sedation and Analgesia Practices as a Case Study

Sedation With Midazolam After Cardiac Surgery in Children With and Without Down Syndrome: A Pharmacokinetic-Pharmacodynamic Study

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