The Impact of a Clonidine Transition Protocol on Dexmedetomidine Withdrawal in Critically Ill Pediatric Patients

Abstract

OBJECTIVES This study describes our experience with a clonidine transition protocol to prevent dexmedetomidine (DEX) withdrawal in critically ill pediatric patients. METHODS Retrospective review of electronic medical records of patients in the pediatric intensive care unit of a single tertiary children's hospital. All patients up to 19 years of age, who received concomitant DEX infusion and enteral clonidine between June 1, 2016, and May 31, 2018, were included. RESULTS Two of 24 encounters had DEX restarted for withdrawal (8.3%). Five of 14 encounters who were transitioned to clonidine 2 mcg/kg every 6 hours required an increased dose, and 1 of 10 encounters transitioned to clonidine 4 mcg/kg every 6 hours required an increased dose (36% vs 10%, p = 0.21). For encounters with clonidine dose increases, 5 of 6 had improvements in Withdrawal Assessment Tool-1 (WAT-1) scores. Of these 5 encounters, 4 had decreasing or stable opioid and sedative requirements and 1 was transitioned to methadone. No encounters required discontinuation of clonidine owing to adverse events. Two of 24 encounters met our safety endpoint. One received a fluid bolus during the clonidine transition with no change in clonidine dosing, while the other had clonidine dose decreased for asymptomatic bradycardia. CONCLUSIONS The 24 encounters in our retrospective study add to the limited literature available to describe dosing, initiation time, and duration of clonidine to prevent withdrawal from DEX in critically ill pediatric patients. Further research is needed to clarify the optimal dosing and duration of clonidine to prevent DEX withdrawal in pediatric patients.

The use of Dexmedetomidine in preterm infants: a single academic center experience.

“…11,12,20 It has been suggested that Dex's prolonged infusions may be associated with rebound tachycardia, hypertension, and withdrawal symptoms with rapid discontinuation. 21 There was no report of rebound hypertension in this cohort, but due to these possible withdrawal and rebound symptoms, a slow wean approach should be considered for a patient on long term Dex therapy (more than 5 days). In this study, 9 (9%) of the infants received Clonidine because they did not tolerate a rapid wean of the drip.…”

Evaluation of an Enteral Clonidine Taper following Prolonged Dexmedetomidine Exposure in Critically Ill Children

“…Previous studies have relied on the Withdrawal Assessment Tool (WAT-1), a scoring system developed and validated to monitor for the development of iatrogenic opioid and benzodiazepine withdrawal, to identify the development of central α 2 -adrenergic agonist withdrawal. 10,[12][13][14]17,18,21 The WAT-1 is a 12-point scale scoring system, which includes tremor and agitation in its criteria, but the tool is not Clonidine for Prolonged Dexmedetomdine in Critically Ill Children Crabtree et al…”

“…To the knowledge of the study team, there is only one pediatric study outside of this institution that has described an enteral clonidine dosing strategy to prevent dexmedetomidine withdrawal. 18 Liu et al found that five patients (35.7%) who received an initial enteral clonidine dose of 2 µg/kg/dose every 6 hours (8 µg/kg/day) required a clonidine dose increase compared with one patient (10%) in the group of patients who received an initial dose of 4 µg/kg/dose every 6 hours (16 µg/kg/day). 18 However, the study by Liu et al along with other previous studies have not excluded patients with exposure to other continuous infusion sedative agents, and thus can influence findings as it relates specifically to dexmedetomidine exposure and withdrawal symptoms.…”

“…Additionally, there is significant variation in current conversion practices with clonidine dosing ranging from 1.4 to 18 µg/kg/day, divided at differing frequencies. 11,13,[16][17][18] This study aims to describe the use of an enteral clonidine transition for the prevention and management of dexmedetomidine withdrawal in critically ill children not exposed to other continuous infusion sedative agents. Secondary outcomes seek to describe the characteristics of dexmedetomidine exposure associated with a need for a clonidine taper modification and to describe the prevalence of dexmedetomidine withdrawal symptoms.…”

“…Additionally, there is significant variation in current conversion practices with clonidine dosing ranging from 1.4 to 18 µg/kg/day, divided at differing frequencies. 11 13 16 17 18…”