“Difficult to Sedate”: Successful Implementation of a Benzodiazepine-Sparing Analgosedation-Protocol in Mechanically Ventilated Children

Abstract

We sought to evaluate the success rate of a benzodiazepine-sparing analgosedation protocol (ASP) in mechanically ventilated children and determine the effect of compliance with ASP on in-hospital outcome measures. In this single center study from a quaternary pediatric intensive care unit, our objective was to evaluate the ASP protocol, which included opiate and dexmedetomidine infusions and was used as first-line sedation for all intubated patients. In this study we included 424 patients. Sixty-nine percent (n = 293) were successfully sedated with the ASP. Thirty-one percent (n = 131) deviated from the ASP and received benzodiazepine infusions. Children sedated with the ASP had decrease in opiate withdrawal (OR 0.16, 0.08–0.32), decreased duration of mechanical ventilation (adjusted mean duration 1.81 vs. 3.39 days, p = 0.018), and decreased PICU length of stay (adjusted mean 3.15 vs. 4.7 days, p = 0.011), when compared to the cohort of children who received continuous benzodiazepine infusions. Using ASP, we report that 69% of mechanically ventilated children were successfully managed with no requirement for continuous benzodiazepine infusions. The 69% who were successfully managed with ASP included infants, severely ill patients, and children with chromosomal disorders and developmental disabilities. Use of ASP was associated with decreased need for methadone use, decreased duration of mechanical ventilation, and decreased ICU and hospital length of stay.

Modified ABCDEF-Bundles for Critically Ill Pediatric Patients - What Could They Look Like?

“…Regular spontaneous awakening and breathing trials with pause in all sedation have been successful in reducing time on mechanical ventilation, length of PICU-stay and cumulative dosis of sedatives ( 45 ), but have not been proven effective in terms of short-term health related quality of life ( 48 ). Instead, compared to use of standardized sedation protocols with continuous reduction in sedation ( 40 , 49 ), Vet et al ( 50 ) showed daily sedation interruption in addition to protocolized sedation to increase mortality in critically ill children when compared to those under protocolized sedation only. There were no added benefits for clinical outcome in the combined group.…”

The LiberAction Project: Implementation of a Pediatric Liberation Bundle to Screen Delirium, Reduce Benzodiazepine Sedation, and Provide Early Mobilization in a Human Resource-Limited Pediatric Intensive Care Unit

“…In our unit, before the implementation of the LiberAction, delirium screening was never performed, early mobilization was not protocolized and sedation was mainly based on benzodiazepine, therefore, an extensive educational process of all PICU staff was needed to address important knowledge gaps ( 15 ). Compared with other similar quality improvement projects ( 12 , 15 , 21 , 33 ), our educational process was relatively short (8 months), however, this time was sufficient to implement simultaneously all the three components of the PICU liberation bundle and achieve good results in terms of bundle adherence and patients' safety. These good achievements were possible mainly for two reasons: (a) the “ in situ training” performed at the McMaster PICU in 2019 and (b) the limited number of PICU staff to be educated and trained.…”

“…Benzodiazepines have been the mainstay of pediatric sedation for many decades, however, in recent years a causal and temporal relationship was demonstrated between benzodiazepine exposure and delirium development ( 21 , 29 ). The LiberAction project successfully implemented a benzodiazepine sparing sedation protocol.…”

“…A benzodiazepine-sparing protocol and guidelines to wean patients sedated for more than 5 days were developed and adopted in the post-implementation period ( Supplementary Figures 2 , 3 ). Dexmedetomidine was introduced as first sedative agent in order to reduce the daily dose of benzodiazepines ( 21 , 29 ). Sedation goals were arbitrarily set according to the COMFORT B scale for sedation and to the Nurse Reported Scale Visual Analogic Pain Scale (NRVAS) for pain ( 3 , 27 ) during the morning round according to the patient's needs.…”

“…This bundle -has been also referred to as ICU-based rehabilitation (11), as that rationale for this intervention is to prevent ICU-acquired morbidities, improve functional recovery and reduce p-PICS. Pediatric specific data are emerging (12,13) on the feasibility and safety of PICU-based rehabilitation (12,14,15) and several PICUs are currently starting to implement the "A-F" bundle, adopting assessment screening tools for delirium, optimizing daily sedation and assessing patient readiness for mobilization (15)(16)(17)(18)(19)(20)(21). However, pragmatic data on how to implement this bundle, especially in limited resource PICU are scarce; further, since this bundle requires the adoption of several interventions, including environmental changes and investments, prioritization of clinical interventions is crucial for success where both human and physical resources are limited.…”