In the pediatric cardiac intensive care unit (ICU), a specific sedation weaning guideline significantly decreased total methadone exposure among infants, as well as decreased withdrawal scores and length of stay, according to research presented at the National Association of Pediatric Nurse Practitioners (NAPNAP) National Conference on Pediatric Health Care held March 15 to 18, 2023, in Orlando, Florida.
Opioids and sedatives are necessary postoperative care components in the pediatric cardiac ICU. These medications, however, can have negative side effects such as withdrawal, delirium, increased time on ventilation, and increased length of stay in hospitals, making cessation an important and delicate process.
Danielle Wood, DNP, CPNP-AC, and colleagues from Duke University Hospital implemented a sedation-weaning guideline for children in the pediatric ICU. Prior to the standardized guideline, the use of methadone during opioid infusion cessation varied widely between providers. The protocol initiated methadone every 6 hours 24 to 48 hours prior to anticipated extubation in infants (aged <12 months) at moderate or high risk of withdrawal symptoms and to begin weaning opioid (fentanyl) infusions after the third and fourth methadone doses. The weaning protocol is shown in the Table.
Continue Reading
Table. Sedation Weaning Protocol for Pediatric Cardiac ICU By Withdrawal Risk Status
| Time Point | Moderate Riska | High Riskb |
| 24-48 hr before extubation | • Initiate methadone every 6 hours • Obtain WAT score every 12 hours and prn | • Initiate methadone every 6 hours • Obtain WAT score every 12 hours and prn |
| 1 hr after third methadone dose | • Wean opioid (fentanyl) infusion by 50%c | • Wean opioid (fentanyl) infusion by 50%c |
| 1 hr after fourth methadone dose | • Wean opioid (fentanyl) infusion by 50% • Discontinue opioid infusion before extubation | • Wean opioid (fentanyl) infusion by 50% • Discontinue opioid infusion before extubation |
| 24 hours after extubation | • Wean methadone dose by 20% daily • Use rescue dosing if WAT ≥4 • Continue wean if <3 rescue doses given in previous 24 hr • Begin to wean frequency when dose reaches 0.04 mg/kg | • Wean methadone dose by 20% every other day • Use rescue dosing if WAT ≥4 • Continue wean if <3 rescue doses given in previous 24 hr • Begin to wean frequency when dose reaches 0.04 mg/kg |
| Goal | • Methadone wean in 5-7 days | • Methadone wean in 10-14 days |
b Continuous opioid infusion for 8 days or more
c All patients initially received fentanyl infusions; some were transitioned to morphine and/or dilaudid if they were exposed to fentanyl for a prolonged period.
WAT, Withdrawal Assessment Tool
Source: Wood et al.
The researchers compared outcomes from the 12 months before (n=46) and after protocol implementation (n=48). The pre- and postprotocol groups had similar exposure rates to fentanyl (100% vs 100%), morphine (20% vs 8.3%), and hydromorphone (2.2% vs 0%) and they received opioid infusions for similar durations of time (mean, 9.75 vs 8.69 days), respectively.
The proportion of patients who were exposed to methadone prior to extubation increased from 91% preprotocol to 100% postprotocol and more patients received methadone at any time during hospitalization after the protocol (100%) compared with before (96%).
Key Outcomes
The weaning protocol was associated with significant decreases in inpatient wean duration from extubation (from 17.9-13.6 days; P =.035) and total duration of inpatient methadone exposure (from 23.9-17.0 days; P =.023).
A greater proportion of patients in the postintervention group met the inpatient wean goal (33% vs 17%) and fewer were discharged to home on methadone (38% vs 50%) compared with the preprotocol group, respectively. Among patients discharged home on methadone, the outpatient wean time decreased by 7 days using the protocol, from 15.2 days to 7.9 days (P =.0080). The total inpatient and outpatient methadone exposure decreased from 30.1 days to 19.9 days (P =.015) following protocol implementation.
Overall, the length of stay in the pediatric cardiac ICU decreased by 5 days and total hospital stay decreased by 8 days after the protocol implementation.
Intervention Lowers Withdrawal Symptom Severity
“The frequency of elevated WAT [Withdrawal Assessment Tool] scores decreased postintervention,” explained Dr Wood. “The frequency of WAT scores of 4 or greater in our preintervention group was 29.8±34 and post-intervention was 12.2±14 (P =.0021). We did not follow pain scores specifically in this study, but the patients did not experience more discomfort associated with withdrawal due to this intervention.” Parent-reported outcomes were not assessed in this study.
The study authors concluded that the weaning protocol for weaning pediatric patients using methadone decreased total wean duration and exposure to methadone. These findings may not be generalizable for other pediatric cardiac ICUs, they noted.
Visit Clinical Advisor’s meetings section for more coverage of NAPNAP 2023.
Source
Wood D, King C, Koo J, et al. Implementation of sedation titration and weaning guidelines in a pediatric cardiac ICU. Presented at: NAPNAP National Conference; March 15-18, 2023; Orlando, FL.
