Systemwide Change of Sedation Wean Protocol Following Pediatric Laryngotracheal Reconstruction

Abstract

Importance Pediatric laryngotracheal reconstruction (LTR) remains the standard surgical technique for expanding a stenotic airway and necessitates a multidisciplinary team. Sedation wean following LTR is a critical component of perioperative care. We identified variation and communications deficiencies with our sedation wean practice and describe our experience implementing a standardized sedation wean protocol. Objective Standardize and decrease length of sedation wean in pediatric patients undergoing LTR. Design Using Institute for Healthcare Improvement (IHI) methodology, we implemented system-wide change with the goal of improving care based on best practice guidelines. We created a standardized electronic sedation wean communication document and retrospectively examined our experience in 29 consecutive patients who underwent LTR before (n=16, pre-wean group) and after (n=13, post-wean group) wean document implementation. Setting Tertiary care center Participants Pediatric patients undergoing LTR Intervention Implement standardized sedation protocol Main Outcomes Presence of sedation wean document in electronic medical record, length of sedation wean, and need for continued wean after discharge Results The sedation wean document was utilized in 92.3% patients of the post-wean group. With the new process, the mean length of sedation wean was reduced from 16.19 (standard deviation [SD] 11.56) days in pre-wean group to 8.92 (SD 3.37) days in the post-wean group, p<0.05. Fewer patients in the post-wean group required continued wean after discharge, 81.3% vs. 33.3%, p<0.05. Conclusions and Relevance We implemented system-wide process change with the goal of improving care based on best practice guidelines, which significantly decreased the time required for sedation wean following LTR. Our methodological approach may have implications for other heterogeneous patient populations requiring a sedation wean.

Opioid and Benzodiazepine Weaning in Pediatric Patients: Review of Current Literature

“…Researchers 4 showed the efficacy of initiating a 10‐day wean, while other groups also compared the differences between 5‐day and 10‐day wean protocols. A two‐way wean protocol based on duration of infusion (7–14 days and > 14 days) was described . A more aggressive benzodiazepine wean was described by another group and called for a 50% dose decrease every 2 days over 6 days, corresponding to an approximately 18% daily decrease overall .…”

“…Of the studies analyzed, only one study described a home wean, with 60% of the patients being able to complete their methadone wean without difficulty . Another author did not directly address sedation weaning at home; however, the results described a significant decrease in prescribing sedation medications for home wean completion, meaning that fewer sedation medications were prescribed to complete the wean at home (81% in the nonprotocol arm vs 33% in the protocol arm) …”

“…A two-way wean protocol based on duration of infusion (7-14 days and > 14 days) was described. 16 A more aggressive benzodiazepine wean was described by another group and called for a 50% dose decrease every 2 days over 6 days, corresponding to an approximately 18% daily decrease overall. 8 The use of a dosing schedule for wean management was reported, whereas another author stated that the patient was referred to pharmacy services once criteria were met.…”

“…A change from an intravenous (IV) agent to an oral option may also be a part of the weaning process. Some institutions have developed a standardized weaning plan to decrease variation in prescribing among prescribers; however, variabilities in individual protocols and patient response continue to be big confounders …”

“…Some institutions have developed a standardized weaning plan to decrease variation in prescribing among prescribers; however, variabilities in individual protocols and patient response continue to be big confounders. 4,[12][13][14][15][16][17][18][19][20][21] Children are not always able to verbalize their discomfort or pain. Some tools, like the Face, Legs, Activity, Cry, Consolability (FLACC) scale, have been created and validated in children to assess nonverbal pain.…”