Implementation of an algorithm for tapering analgosedation reduces iatrogenic withdrawal syndrome in pediatric intensive care.

BACKGROUND: Proper analgosedation is a cornerstone in the treatment of critically ill patients in Pediatric Intensive Care Units (PICUs). Medications, such as fentanyl, morphine, and midazolam, are essential to safe and respectful care. The use of these medications over time may lead to side effects such as iatrogenic withdrawal syndrome (IWS) in the tapering phase. The aim of the study was to test an algorithm for tapering analgosedation to reduce the prevalence of IWS in two Norwegian PICUs at Oslo University Hospital. METHODS: A cohort of mechanically ventilated patients from newborn to 18 years with continuous infusions of opioids and benzodiazepines for 5 days or more were included consecutively from May 2016 to December 2021. A pre- and posttest design, with an intervention phase using an algorithm for tapering analgosedation after the pretest, was used. The ICU staffs were trained in using the algorithm after the pretest. The primary outcome was a reduction in IWS. The Withdrawal Assessment Tool-1 (WAT-1) was used to identify IWS. A WAT-1 score ≥3 indicates IWS. RESULTS: We included 80 children, 40 in the baseline group, and 40 in the intervention group. Age and diagnosis did not differ between the groups. The prevalence of IWS was 95% versus 52.5% in the baseline group versus the intervention group, and the peak WAT-1 median was 5.0 (IQR 4-6.8) versus 3.0 (IQR 2.0-6.0) (p = .012). Based on SUM WAT-1 ≥ 3, which describes the burden over time better, we demonstrated a reduction of IWS, from a median of 15.5 (IQR 8.25-39) to a median of 3 (IQR 0-20) (p = <.001). CONCLUSION: We suggest using an algorithm for tapering analgosedation in PICUs since the prevalence of IWS was significantly lower in the intervention group in our study.

Iatrogenic withdrawal syndrome frequently occurs in paediatric intensive care without algorithm for tapering of analgosedation.

BACKGROUND: Analgesics and sedatives are key elements to reduce physiological and psychological stress associated with treatment in paediatric intensive care. Prolonged drug use may induce tolerance and development of iatrogenic withdrawal syndrome (IWS) during the tapering phase. Our primary aim was to describe the prevalence of IWS among critically ill ventilated patients in two Norwegian paediatric intensive care units (PICUs), and secondary to investigate what motivated bedside nurses to administer additional drug doses. METHODS: Mechanically ventilated patients (n = 40) from newborn to eighteen years of age, with continuous infusions of opioids and benzodiazepines for 5 days or more, were included consecutively from May 2016 to June 2018. By using Withdrawal Assessment Tool-1 (WAT-1) twice daily we recorded the prevalence of IWS. Additionally, we recorded signs and symptoms that led bedside nurses to administration extra bolus medication. RESULTS: Peak WAT-1 score indicated an IWS prevalence of 95% in this selected group. The first days of the tapering phase were most critical for IWS. The most frequent symptoms triggering administration of additional bolus doses were agitation/restlessness, and thiopental and propofol were the bolus drugs used most frequently. CONCLUSIONS: IWS affected 95% of the children having received infusions of opioids and benzodiazepines for 5 days or more in PICUs without a tapering protocol for these drugs. This calls for implementation and testing of such weaning protocols.

Indirect calorimetry reveals that better monitoring of nutrition therapy in pediatric intensive care is needed.

BACKGROUND: Monitoring nutrition therapy is essential in the care of critically ill children, but the risk of nutrition failure seems to remain. The aims of the present study were to examine the prevalence of underfeeding, adequate feeding, and overfeeding in mechanically ventilated children and to identify barriers to the delivery of nutrition support. MATERIALS AND METHODS: Children aged 0-14 years who fulfilled the criteria for indirect calorimetry were enrolled in this prospective, observational study and were studied for up to 5 consecutive days. Actual energy intake was recorded and compared with the required energy intake (measured energy expenditure plus 10%); energy intake was classified as underfeeding (<90% of required energy intake), adequate feeding (90%-110%), or overfeeding (>110%). The reasons for interruptions to enteral and parenteral nutrition were recorded. RESULTS: In total, 104 calorimetric measurements for 140 total days were recorded for 30 mechanically ventilated children. Underfeeding, adequate feeding, and overfeeding occurred on 21.2%, 18.3%, and 60.5% of the 104 measurement days, respectively. There was considerable variability in the measured energy expenditure between children (median, 37.2 kcal/kg/d; range, 16.81-66.38 kcal/kg/d), but the variation within each child was small. Respiratory quotient had low sensitivity of 21% and 27% for detecting underfeeding and overfeeding, respectively. Fasting for procedures was the most frequent barrier that led to interrupted nutrition support. CONCLUSION: The high percentage of children (~61%) who were overfed emphasizes the need to measure energy needs by using indirect calorimetry.