Pediatrics: Pediatrics |

Risk Factors of Opioid/Benzodiazepines-Induced Withdrawal Syndrome in Critically Ill Hispanic Children FREE TO VIEW

Kristie Rodriguez-Otero, MD; Anabel Puig-Ramos, PhD; Samuel Pabon-Rivera; Carlos Lopez-Ortiz, BS; Kevin Rodriguez-Santos; Reichel Rodriguez, RN; Maria Gomez; Lianet Mamposo, MD; Maria Villar-Prados, MD; Ricardo Garcia de Jesus, MD
Author and Funding Information

UPR-School of Medicine, Carolina, PR

Copyright 2016, American College of Chest Physicians. All Rights Reserved.

Chest. 2016;150(4_S):966A. doi:10.1016/j.chest.2016.08.1069
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SESSION TYPE: Original Investigation Poster

PRESENTED ON: Wednesday, October 26, 2016 at 01:30 PM - 02:30 PM

PURPOSE: Patients in the Pediatric Intensive Care Unit (PICU) typically receive prolonged sedation and analgesia as pain management and to facilitate intensive care therapies. Those patients are at risk to develop iatrogenic withdrawal syndrome (IWS) when medications are suddenly stop or weaned too quickly. We investigated the incidence and risks factors of IWS in critically ill children that were admitted to PICU, and assessed validity of the Withdrawal Assessment tool (WAT-1) in children exposed to opioids and benzodiazepines for 3 days or more.

METHODS: In this prospective observational study, we collected data from medical charts and the Withdrawal Assessment Tool Version 1 (WAT-1) to assessed for signs of withdrawal from patients admitted to PICU at a tertiary academic hospital in Puerto Rico that met inclusion criteria. All children admitted who receive sedation and analgesia by continuous infusions or bolus for more than 3 days was included in the study. Patients with cerebral palsy, chronic use of opioids or benzodiazepines, oncology patients and status epilepticus were excluded. Once the opioid/benzodiazepines weaning started, we used the WAT-1 instrument for 72 hours twice a day to assessed IWS. Data was expressed as percentiles or medians ± SD when appropriate. Mann-Whitney U test were used for comparison between No IWS vs IWS patients.

RESULTS: From 400 newly admissions to PICU, 25 patients met inclusion criteria. An incidence of 60% of opioid/benzodiazepines IWS was observed, with 50 % of the patients showing withdrawal signs within the first 14 days of admission. Younger patients (median = 24 months ± 86) and females (58%) were more prone to develop withdrawal. Our study revealed that CNS/Trauma and Postsurgical patients have the highest incidence of withdrawal signs (50% vs 33% respectively), followed by respiratory problems (25%). 84% of our study population were on mechanical ventilation support with a 2.4% of them had Ventilator Associated Pneumonia. Patients with IWS had prolonged mechanical ventilation support as compared to controls (p = 0.02). The cumulative dose and maximum peak dose of opioid/benzodiazepine drip was higher in patients with IWS (average dose of 0.2mg/kg/hr for benzodiazepine and 2mcg/kg/hr of opioid).

CONCLUSIONS: Incidence of IWS in our population was higher from those reported in the literature. This difference could be explained by the lack of a standardized opiod/benzodiazepines weaning protocol as well as a behavioral scale to measure level of sedation and analgesia to avoid overtreatment in our patients. Also our Unit lacks a protocol that measures delirium symptoms that can be easily confused with withdrawal. Postsurgical patients and CNS/Trauma patient have the highest incidence of withdrawal due to higher doses and prolonged therapy to provide adequate pain control and CNS protection. Prolonged mechanical ventilation support, requires prolong therapy and therefore increased the risk for IWS.

CLINICAL IMPLICATIONS: A standardized weaning protocol is needed to adequately prevent and lower the risk for IWS. Increase awareness among physicians to early identify delirium signs versus IWS. Adequately measure level of sedation to avoid overtreatment with opioids and benzodiazepines.

DISCLOSURE: The following authors have nothing to disclose: Kristie Rodriguez-Otero, Anabel Puig-Ramos, Samuel Pabon-Rivera, Carlos Lopez-Ortiz, Kevin Rodriguez-Santos, Reichel Rodriguez, Maria Gomez, Lianet Mamposo, Maria Villar-Prados, Ricardo Garcia de Jesus

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