Evidence indicates that opioid infusions are commonly used to manage patients admitted to the pediatric intensive care unit (PICU). However, children with prolonged exposure to opioids frequently develop complications, including delirium, dependence, withdrawal, and bowel dysfunction.

With previous studies yielding little consensus among critical care practitioners for the ideal sedation management and withdrawal prevention practices for this patient population, L. Nelson Sanchez-Pinto, MD, MBI, and colleagues conducted a study—published in the Journal of Critical Care—that aimed to help reduce the duration of opioid use without increasing the incidence of withdrawal through the use of a opioid-weaning protocol developed by the study team.

“We use a lot of opioids in children during their critical illness, and even though they are necessary and useful, they can also have detrimental effects,” Dr. Sanchez-Pinto says. “There are concerns that opioids can increase the risk for delirium, prolong the use of mechanical ventilation, slow the gut motility and increase feeding intolerance, and other complications that can add to the burden of the critical illness for which they were prescribed in the first place. There is also some evidence from animal studies that opioids can affect brain development, something that is particularly important in our patient population. The goal should always be to use the minimum amount necessary.”

The process of weaning down off medications traditionally has been performed at the physician’s discretion. Dr. Sanchez-Pinto and colleagues observed that many of these weaning courses were long, possibly exposing children to unnecessary opioid side effects.

 

Pre- vs. Post-Intervention

The researchers conducted a pre- versus post-interventional prospective study of a risk-stratified opioid-weaning protocol in a large children’s hospital pediatric ICU. Participants were patients exposed to 7 or more days of scheduled opioids. The primary outcome was duration of opioids, and the secondary outcome was hospital length of stay (LOS).

“Our algorithm was risk-stratified, which means that based on the child’s baseline risk of withdrawal (based on the length of exposure to opioids), he or she would be classified into one of several risk groups,” Dr. Sanchez-Pinto says. “Each group then had an algorithm for the weaning schedule length, types and amounts of weaning opioids to be used, and criteria to slow down the wean if excessive withdrawal was noted.”

Patients treated during the post-intervention group had shorter duration of opioids (17 vs. 22.5 days) and opioid wean (12 vs. 18 days; Table). Despite the shorter duration of opioid wean, no increase in withdrawal incidence was observed when compared with the pre-intervention period. Length of stay was similar among patients treated during both periods (29 vs. 33 days).

“The decrease in opioid duration was due to the opioid weaning phase being significantly shorter,” says Dr. Sanchez-Pinto. “The time on opioids prior to weaning and the length of time between end of opioids and discharge was about the same during both the pre- and post-intervention periods.”

 

More Research Needed

Dr. Sanchez-Pinto stresses that physicians can actually shorten opioid weaning without adverse effects, thereby reducing the complications of opioid use. He adds, “I would like to see more standardization for PICU processes like this one. Standardization seems to be associated with better outcomes for our patients, and it is not that hard to achieve with buy-in from staff and physicians.”

References

Sanchez-Pinto L, Nelson L, Lieu P, et al. Implementation of a risk-stratified opioid weaning protocol in a pediatric intensive care unit. J Crit Care. 2017; 43, 214-219. Available at: http://www.jccjournal.org/article/S0883-9441(17)30278-2/fulltext