Management of Opioid and Sedative Weaning in Pediatric Congenital Heart Disease Patients

Abstract

Background: Opioid and sedative medications are commonly used to treat pediatric patients with congenital heart disease; however, their use is not without adverse effects. Symptoms of withdrawal can occur if the medications are discontinued abruptly or weaned too quickly. Objective: The aim of this study was to understand and describe the current management of opioid and sedative weaning in pediatric congenital heart disease patients in freestanding children’s hospitals across the United States. Methods: A Web-based survey of pediatric congenital heart centers was conducted. Survey participants were recruited from the Consortium of Congenital Cardiac Care–Measurement of Nursing Practice. Quantitative data were summarized using frequency and proportions. Qualitative data were summarized using content analysis. Results: Twelve sites participated in the survey (44% response rate). Methadone was used as a weaning medication at 100% of participating sites, lorazepam at 83% of sites, and clonidine at 75% of sites. Seventy-five percent of sites reported using a clinical assessment tool to monitor withdrawal symptoms. Twenty-five percent of sites used a standardized clinical pathway when weaning opioid and sedative medications. Eighty-three percent of sites will consider discharging a patient to complete the medication wean at home. Discussion: Weaning practices varied across sites. While some similarities were observed among sites, substantial practice variation exists. The majority of sites used a clinical assessment tool to assess for withdrawal symptoms. Few sites reported using a standardized approach to weaning patients. Discharging patients to complete an opioid or sedative wean at home was common practice. Opportunities exist for the development of weaning practice guidelines.

Individualized Family-Centered Developmental Care for Infants With Congenital Heart Disease in the Intensive Care Unit

“…36 A core activity of the C4-MNP is to establish the current state of specific pediatric cardiovascular nursing practices, identify variation, and develop recommendations to standardize practice across participating programs. 37 Established in 2011, the consortium includes nurses, advanced practice nurses, administrators, and scientists. 36,38…”

Pharmacological Strategies for Decreasing Opioid Therapy and Management of Side Effects from Chronic Use

“…In a recent survey of pediatric healthcare providers, only 27% of respondents utilized a written protocol for opioid tapering, 22% consulted a pain management team regarding weaning of opioids, and the majority seldom or never consulted a pharmacist [15]. In another survey of pediatric congenital heart disease centers, only 25% of sites used a standardized clinical pathway when weaning opioid medications [16]. In the RESTORE study—a randomized controlled multicenter study of protocolized sedation of 1225 pediatric patients—Curley et al demonstrated that the use of protocolized weaning of opioid medication was associated with shorter durations of opioid treatment (9 vs. 10 days, p = 0.01), and more study days spent in the calm and awake states (86% vs. 75%, p = 0.004) [14].…”

International quality improvement initiatives

“…11 The C4-MNP has developed evidenced-based nurse-sensitive measures to use for assessment and improvement in nursing practice across the 31 collaborative paediatric cardiovascular programmes. [11][12][13] The Pediatric Cardiac Critical Care Consortium (PC 4 ; pc4quality.org) is a quality collaborative dedicated to improving care and outcomes for children and adults with critical congenital cardiovascular disease. 14 Started in 2009 with funding from the National Institutes of Health, PC 4 began with the launch of its clinical database.…”