Iatrogenic withdrawal syndrome in the pediatric cardiac intensive care unit: Incidence, risk factors and outcome

Abstract

Objectives Critically ill children and neonates routinely receive opioids and benzodiazepines for analgesia and sedation in the pediatric intensive care unit (PICU). Prolonged opioid therapy often leads to tolerance and is associated with iatrogenic withdrawal syndrome (IWS) when opioids and benzodiazepines are weaned or discontinued. Our aim is to study the incidence, risk factors and outcome of IWS following use of a withdrawal protocol on pediatric patients after cardiac surgery. Methods We prospectively included all postoperative pediatric patients who developed IWS after being assessed by the Withdrawal Assessment Tool (WAT-1) score (WAT-1 ≥3) over 9 months. Unit-based withdrawal management protocol was used. Patients’ outcome was assessed by duration to be completely off opioids & benzodiazepines, duration of ICU and hospital stay. Results 432 patients were admitted during study period. Twenty-five patients (5.8%) developed IWS. The mean age and weight was 15.2 ± 31.4 months and 6.9 ± 7.7 kg respectively. 60% of the patients who developed withdrawal had previous ICU admissions with exposure to sedatives. In the IWS group the mean duration for use of fentanyl and midazolam infusions was 8.6 ± 5.1 & 9.6 ± 6 days respectively. The mean duration for completely stopping opioids and benzodiazepines was 17.2 ± 6.8 days with a mean duration of ventilation of 8.2 ± 6.8 days. The mean ICU and hospital stay for IWS patients was 26.5 ± 21.9 and 31.5 ± 21.1 days respectively. There was statistically significant difference in the mean age, and duration of use of sedatives between the patients who developed IWS and those who did not with P-value of 0.003 and < 0.0001, respectively. Conclusion Withdrawal syndrome after pediatric cardiac surgery prolongs ICU and hospital stay. Our data shows that younger age and longer duration for use of sedatives seem to be risk factors for developing withdrawal syndrome.

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

“…The main finding in the present study was a significant reduction in the incidence and severity of IWS in our PICUs after the implementation of the newly developed algorithm for tapering opioids and benzodiazepines. Compared to other studies 20,21 the incidences of IWS in our study are high, but then we only included patients with infusions of opioids and benzodiazepines for more than ≥5 days. This group of patients is described in earlier research as a risk group for developing IWS 10 .…”

“…One study defined IWS by using a WAT‐1 score ≥4 instead of ≥3 24 . In other studies, the criteria for IWS was two (not one) WAT‐1 ≥ 3 13,20 …”

“…24 In other studies, the criteria for IWS was two (not one) WAT-1 ≥ 3. 13,20 Of course, in the daily clinical use of WAT-1, it is only the present score that is important, however, to use SUM WAT-1 ≥ 3 in our study, has provided the opportunity to observe the burden of IWS over time.…”

“…12 Similar findings are also published by others, with longer duration of analgesics, longer duration of mechanical ventilation, and longer PICU stay. 20,28,29 So, we assume that it is the presence of IWS that increases LOS.…”

Pediatric delirium is associated with increased brain injury marker levels in cardiac surgery patients

“…WAT-1 is also a standard tool for evaluating pediatric IWS and was validated in PICU settings. In PICU settings, oft- used benzodiazepine and opioids are risk factors for IWS 33 , thus we evaluated IWS symptoms after weaning of benzodiazepine and/or opioids for 72 h by using WAT-1 34 . Both tools are recommended by the European Society of Paediatric and Neonatal Intensive Care for clinical evaluation of pain, sedation, withdrawal and delirium assessment in critically ill pediatric patients 35 .…”