Relationship between rate of fentanyl infusion and time to achieve sedation in nonobese and obese critically ill children

Johnson, Peter N.; Skrepnek, Grant H.; Golding, Charles L.; Owora, Arthur H.; Thomas, Amber; Miller, Jamie L.

doi:10.2146/ajhp160230

Cited by 6 publications

(10 citation statements)

References 23 publications

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“…►Table 3 provides a summary of the published studies on dosing, pharmacodynamics, and/or pharmacokinetics of medications listed in the 20 most frequently prescribed continuous infusions in obese children. [18][19][20][21][22][23] Only six studies representing three continuous infusion agents (15.0%) and a total of 115 obese children were identified. All of these studies focused on sedatives and analgesics.…”

Section: Resultsmentioning

confidence: 99%

“…Two of the identified studies from the literature search evaluated dosing and pharmacodynamics. 18,19 Gish et al 18 retrospectively evaluated the number of fentanyl infusion dosage changes in 15 overweight and obese children versus 16 normal-weight controls, with 18 and 16 individual infusions identified. They found a numerical but not a statistically significant difference in the number of dosage changes between the overweight and obese children versus controls, 0.92 AE 0.60 versus 0.69 AE 0.34, p ¼ 0.16.…”

Section: Discussionmentioning

confidence: 99%

“…This study is limited in that it lacked a pharmacodynamic target, such as a validated sedation score. Johnson et al 19 conducted a retrospective study to examine the association between initial fentanyl infusion rate and time to goal sedation, defined as achieving three consecutive State Behavioral Scale scores from 0 to À1, and dosing characteristics among 57 nonobese and 18 obese children. They noted that for every 10 µg/h increase in initial fentanyl dose in nonobese children there was 19% lower odds of achieving goal sedation at any point in time compared with obese children.…”

Section: Discussionmentioning

confidence: 99%

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Prescribing Patterns of Continuous Infusions in Nonobese versus Obese Children Admitted to the Pediatric Intensive Care Unit

Johnson

Stephens

Barker

et al. 2019

J Pediatr Intensive Care

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This retrospective study compared the continuous infusions prescribed for obese and nonobese children. Ninety-five (13.2%) received an infusion. A greater percentage of obese (n = 42/168) versus nonobese (53/552) children received infusions, p < 0.01. No difference was noted in the median number of infusions between the obese and nonobese groups, 2 versus 2, p = 0.975. The top 20 prescribed infusions included ten (50%) for sedation/analgesia or neuromuscular blockade and six (30%) for hemodynamic support. A literature search was performed for these 20 agents to determine pharmacokinetics, pharmacodynamics, and dosing in obese children and revealed six studies evaluating fentanyl (n = 2), midazolam (n = 1), and propofol (n = 3).

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Section: Resultsmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

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Prescribing Patterns of Continuous Infusions in Nonobese versus Obese Children Admitted to the Pediatric Intensive Care Unit

Johnson

Stephens

Barker

et al. 2019

J Pediatr Intensive Care

Self Cite

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“…Fentanyl is safe to use in both hepatic and renal impairment; whereas hydromorphone is safe in renal impairment but should be used cautiously in hepatic impairment, as it is metabolized by the liver to inactive metabolites 9,11 . Another consideration is that fentanyl is a more lipophilic agent and distributes into fatty tissues, giving it a longer half‐life in patients with large fat stores 12 . Neonates are also at particularly high risk for respiratory depression due to immature hepatic enzymes and decreased hypoxic respiratory drive 13 .…”

Section: Discussionmentioning

confidence: 99%

“…9,11 Another consideration is that fentanyl is a more lipophilic agent and distributes into fatty tissues, giving it a longer half-life in patients with large fat stores. 12 Neonates are also at particularly high risk for respiratory depression due to immature hepatic enzymes and decreased hypoxic respiratory drive. 13 Pain control in the pediatric population is a perplexing patient-specific problem, and management has been further complicated due to the national shortages of many of the IV opioid pain management options Despite opioid stewardship efforts at our hospital, no difference in the amount of pain medication, quantified as milligrams of morphine equivalents per kilogram per day, was seen between 2017 and 2018.…”

Section: Diagnoses Categorized As Other Includes Double Inlet Left Vementioning

confidence: 99%

The impact of intravenous opioid shortages on postoperative pain control in a pediatric cardiac intensive care unit

et al. 2020

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Background The national supply of intravenous pain medications has been restricted since 2018 due to shortages. In late 2017, the ongoing shortages combined with the increased demand for alternative formulations resulted in interruptions in the supply of medications. The cascading effect of interruptions in supply caused hospitals to implement restrictive measures to extend the availability of these medications. This study aims to evaluate differences in pain control in postoperative cardiac patients due to intravenous opioid shortage at a standalone pediatric hospital. Method A retrospective chart review of postoperative patients in the cardiac intensive care unit at Children's National Hospital was conducted from January to September 2017 and 2018. The objective of this study is to determine if a difference in postoperative pain scores in the period before and during the national intravenous opioid shortage exists, analyzed by differences in Face, Legs, Activity, Cry, Consolability (FLACC) scores. Results No differences were found in mean FLACC scores for the 140 patients who were evaluated. Patients in 2017 reported faster decline of pain symptoms compared with those in 2018. No differences in baseline characteristics or secondary outcomes were noted. Conclusion Pain management was better controlled immediately postoperatively in 2018 compared with 2017, but the pain was better controlled for the duration of the postoperative period in 2017.

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Dosing Common Medications in Hospitalized Pediatric Patients with Obesity: A Review

Ameer

Weintraub

2020

Obesity

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Medication management in children and adolescents with obesity is challenging because both developmental and pathophysiological changes may impact drug disposition and response. Evidence to date indicates an effect of obesity on drug disposition for certain drugs used in this population. This work identified published studies evaluating drug dosing, pharmacokinetics (PK), and effect in pediatric patients with obesity, focusing on 70 common medications used in a pediatric network of 42 US medical centers. A PubMed search revealed 33 studies providing PK and/or effectiveness data for 23% (16 of 70) of medications, 44% of which have just one study and can be considered exploratory. This work appraising 4 decades of literature shows several promising approaches: greater use of PK models applied to prospective clinical studies, dosing recommendations derived from both PK and safety, and multiyear effectiveness data on drugs for chronic conditions (e.g., asthma). Most studies make dose recommendations but are weakened by retrospective study design, small study populations, and no controls or historic controls. Dosing decisions continue to rely on extrapolating knowledge, including targeting systemic drug exposure typically achieved in adults. Optimal weight‐based dosing strategies vary by drug and warrant prospective, controlled studies incorporating PK and modeling and simulation to complement clinical assessment.

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Relationship between rate of fentanyl infusion and time to achieve sedation in nonobese and obese critically ill children

Abstract: Fentanyl infusion rates in obese and nonobese children varied widely in the time needed to achieve goal sedation. At any given time, initial fentanyl infusion rates were less likely to result in goal sedation in nonobese than in obese children.

Cited by 6 publications

References 23 publications

Prescribing Patterns of Continuous Infusions in Nonobese versus Obese Children Admitted to the Pediatric Intensive Care Unit

Prescribing Patterns of Continuous Infusions in Nonobese versus Obese Children Admitted to the Pediatric Intensive Care Unit

The impact of intravenous opioid shortages on postoperative pain control in a pediatric cardiac intensive care unit

Dosing Common Medications in Hospitalized Pediatric Patients with Obesity: A Review

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