Sedative and Analgesic Drug Rotation Protocol in Critically Ill Children With Prolonged Sedation: Evaluation of Implementation and Efficacy to Reduce Withdrawal Syndrome*

Abstract

Objectives: The first aim of this study was to assess the implementation of a sedative and analgesic drug rotation protocol in a PICU. The second aim was to analyze the incidence of withdrawal syndrome, drug doses, and time of sedative or analgesic drug infusion in children after the implementation of the new protocol. Design: Prospective observational study. Setting: PICU of a tertiary care hospital between June 2012 and June 2016. Patients: All patients between 1 month and 16 years old admitted to the PICU who received continuous IV infusion of sedative or analgesic drugs for more than 4 days were included in the study. Interventions: A sedative and analgesic drug rotation protocol was designed. The level of sedation, analgesia, and withdrawal syndrome were monitored with validated scales. The relationship between compliance with the protocol and the incidence of withdrawal syndrome was studied. Measurements and Main Results: One-hundred pediatric patients were included in the study. The protocol was followed properly in 35% of patients. Sixty-seven percent of the overall cohort presented with withdrawal syndrome. There was a lower incidence rate of withdrawal syndrome (34.3% vs 84.6%; p < 0.001), shorter PICU length of stay (median 16 vs 25 d; p = 0.003), less time of opioid infusion (median 5 vs 7 d for fentanyl; p = 0.004), benzodiazepines (median 5 vs 9 d; p = 0.001), and propofol (median 4 vs 8 d; p = 0.001) in the cohort of children in which the protocol was followed correctly. Conclusions: Our results show that compliance with the drug rotation protocol in critically ill children requiring prolonged sedation may reduce the appearance of withdrawal syndrome without increasing the risk of adverse effects. Furthermore, it may reduce the time of continuous IV infusions for most sedative and analgesic drugs and the length of stay in PICU.

An examination of sedation requirements and practices for mechanically ventilated critically ill patients with COVID-19

“…Given the prolonged duration of mechanical ventilation and sedation for this patient population, it seems plausible that sedation rotation strategies may reduce total dose exposure, thus minimizing development of tolerance and reducing adverse effects. 25 …”

Inhaled sedation with sevoflurane in critically ill children during extracorporeal membrane oxygenation

“…It is based on the use of different combinations of sedative and analgesic drugs, alternating different opioids with nonopioid analgesics and benzodiazepines with nonbenzodiazepine sedatives. The duration of each rotation is 4 days 8 . The patient is clinically monitored with sedation scales and with a Bispectral Index Score (BIS) monitor.…”

Dexmedetomidine and Iatrogenic Withdrawal Syndrome in Critically Ill Children

“…A nurse-driven pediatric sedation protocol can reduce withdrawal symptoms in patients admitted to the PICU, 44,45 and a sedative and analgesic drug rotation protocol can also help to reduce the risk of IWS. 46 Therefore, nurses must fully understand the clinical consequences and potential side effects of sedative and analgesic therapy and the potential risk factors for development of IWS. A better understanding of sedation weaning protocols and risk stratification for IWS can be helpful to nurses in assessing and reducing the risk of IWS in patients admitted to the PICU.…”