Prolonged Dexmedetomidine Infusion and Drug Withdrawal In Critically Ill Children

OBJECTIVE To characterise the incidence, symptoms and risk factors for withdrawal associated with prolonged dexmedetomidine infusion in paediatric critically ill patients. METHODS Retrospective chart review in the paediatric intensive care unit and the cardiac critical care unit of a single tertiary children's hospital. Patients up to 18 years old, who received dexmedetomidine for longer than 48 hours were included. RESULTS A total of 52 patients accounted for 68 unique dexmedetomidine treatment courses of more than 48 hours. We identified 24 separate episodes of withdrawal in the 68 dexmedetomidine courses (incidence 35%). Of these episodes 38% occurred in patients who were weaned from dexmedetomidine alone while the remaining occurred in patients who had concurrent weans of opioids and/or benzodiazepines. Most common symptoms were agitation, fever, vomiting/retching, loose stools and decreased sleep. The symptoms occurred during the latter part of the wean or after discontinuation of dexmedetomidine. A cumulative dose of dexmedetomidine of 107 mcg/kg prior to initiation of wean was more likely associated with withdrawal (this equates to a dexmedetomidine infusion running at 1 mcg/kg/hr over 4 days). Duration of opioid use was an additional risk factor for withdrawal. The use of clonidine, as a transition from dexmedetomidine, did not protect against withdrawal (p = 1). CONCLUSIONS A withdrawal syndrome may occur after prolonged infusion of dexmedetomidine. As all our patients were also exposed to opioids this may be affected by the duration of opioid use. We identified a cumulative dose of 107 micrograms/kg of dexmedetomidine beyond which withdrawal symptoms were more likely (which equates to 4 days of use at a dose of 1 mcg/kg/hr). A protocol for weaning should be considered in this circumstance.

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Faculty Opinions recommendation of Tolerance and withdrawal from prolonged opioid use in critically ill children.

Faculty Opinions – Post-Publication Peer Review of the Biomedical Literature ◽

10.3410/f.3185961.2872062 ◽

2010 ◽

Author(s):

Saskia de Wildt ◽

Nienke Vet

Keyword(s):

Critically Ill ◽

Critically Ill Children ◽

Opioid Use

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Extended Duration Ketamine Infusions in Critically Ill Children: A Case Report and Review of the Literature

Journal of Pediatric Intensive Care ◽

10.1055/s-0040-1713144 ◽

2020 ◽

Author(s):

Eszter Moore ◽

Rebecca Mayes ◽

Maura Harkin ◽

Jamie L. Miller ◽

Peter N. Johnson

Keyword(s):

Case Report ◽

Critically Ill ◽

Withdrawal Symptoms ◽

Critically Ill Children ◽

Second Line ◽

Review Of The Literature ◽

Aspartate Receptor ◽

Variable Duration ◽

Extended Duration ◽

Dexmedetomidine Infusion

AbstractKetamine is an N-methyl-D-aspartate receptor antagonist that has been used as an adjunct analgesic and sedative in critically ill children. Previous reports noted that ketamine has been used for a variable duration of 12 to 408 hours for this indication. We report on the use of ketamine infusions for >720 hours as a second-line sedative in addition to an opioid and dexmedetomidine infusion in a 2-month old and 17-month old. The purpose of this case report and review of the literature is to highlight the prolonged ketamine exposure of these two patients and to provide awareness to clinicians on the potential of withdrawal with extended ketamine administration. These children were started on initials doses of 5 and 15 µg/kg/min and titrated to peak doses of 20 and 25 µg/kg/min, respectively. They were continued for a total of 987 and 792 hours, respectively. No adverse events were noted during the ketamine infusions. One patient developed possible withdrawal symptoms 17 hours after ketamine discontinuation despite tapering of the infusion. These symptoms resolved with administration of as needed intravenous opioids and benzodiazepines, and the agitation normalized within 24 hours after ketamine discontinuation. Clinicians should consider tapering ketamine infusions in children receiving >72 hours of a continuous infusion by 5 µg/kg/min every 8 to 12 hours. Patients should be monitored for potential withdrawal symptoms including anxiety, allodynia, hyperalgesia, sweating, and drowsiness.

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Thrombotic events in critically ill children with myocarditis

Cardiology in the Young ◽

10.1017/s1047951113001145 ◽

2013 ◽

Vol 24 (5) ◽

pp. 840-847 ◽

Cited By ~ 2

Author(s):

Kimberly Y. Lin ◽

Basavaraj Kerur ◽

Char M. Witmer ◽

Lauren A. Beslow ◽

Daniel J. Licht ◽

...

Keyword(s):

Dilated Cardiomyopathy ◽

Critically Ill ◽

Acute Decompensated Heart Failure ◽

Anticoagulation Therapy ◽

Retrospective Chart Review ◽

Decompensated Heart Failure ◽

Critically Ill Children ◽

Circulatory Support ◽

Multiple Risk Factors ◽

High Clinical Suspicion

AbstractBackground: Children with myocarditis have multiple risk factors for thrombotic events, yet the role of antithrombotic therapy is unclear in this population. We hypothesised that thrombotic events in critically ill children with myocarditis are common and that children with myocarditis are at higher risk for thrombotic events than children with non-inflammatory dilated cardiomyopathy. Methods: This is a retrospective chart review of all children presenting to a single centre cardiac intensive care unit with myocarditis from 1995 to 2008. A comparison group of children with dilated cardiomyopathy was also examined. Antithrombotic regimens were recorded. The primary outcome of thrombotic events included intracardiac clots and any thromboembolic events. Results: Out of 45 cases with myocarditis, 40% were biopsy-proven, 24% viral polymerase chain reaction-supported, and 36% diagnosed based on high clinical suspicion. There were two (4.4%) thrombotic events in the myocarditis group and three (6.7%) in the dilated cardiomyopathy group (p = 1.0). Neither the use of any antiplatelet or anticoagulation therapy, use of intravenous immune globulin, presence of any arrhythmia, nor need for mechanical circulatory support were predictive of thrombotic events in the myocarditis, dilated cardiomyopathy, or combined groups. Conclusions: Thrombotic events in critically ill children with myocarditis and dilated cardiomyopathy occurred in 6% of the combined cohort. There was no difference in thrombotic events between inflammatory and non-inflammatory cardiomyopathy groups, suggesting that the decision to use antithrombotic prophylaxis should be based on factors other than the underlying aetiology of a child's acute decompensated heart failure.

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

Journal of Pediatric Intensive Care ◽

10.1055/s-0041-1726091 ◽

2021 ◽

Author(s):

Mara F. Crabtree ◽

Cheryl L. Sargel ◽

Colleen P. Cloyd ◽

Joseph D. Tobias ◽

Mahmoud Abdel-Rasoul ◽

...

Keyword(s):

Continuous Infusion ◽

Critically Ill ◽

Pediatric Intensive Care ◽

Withdrawal Symptoms ◽

Critically Ill Children ◽

Or Management ◽

Single Center Study ◽

Dexmedetomidine Infusion ◽

Center Study ◽

Sedative Agents

AbstractThe aim of the current study is to evaluate the use of an enteral clonidine transition for the prevention or management of dexmedetomidine withdrawal symptoms in critically ill children not exposed to other continuous infusion sedative agents. A retrospective, single-center study was conducted in patients ≤ 18 years of age admitted to the pediatric intensive care unit who received a continuous infusion of dexmedetomidine for ≥ 24 hours and who were prescribed enteral clonidine within 72 hours of dexmedetomidine discontinuation. Predefined withdrawal terminology was established to assess for hypertension, tachycardia, agitation, tremors, and decreased sleep. A total of 105 patients were included and received enteral clonidine for prevention or management of dexmedetomidine withdrawal symptoms, with 13 patients (12.4%) requiring a taper modification to manage withdrawal symptoms. The median duration of dexmedetomidine infusion was 120.5 hours (95.5, 143.5) and median peak infusion rate was 1 µg/kg/h (1, 1.2). A higher cumulative dexmedetomidine dose of 119.2 µg/kg (96.6, 154.9) and duration of 142.9 hours (122.6, 158.3) were noted in patients who required a taper modification. Risk factors for dexmedetomidine withdrawal such as dexmedetomidine duration and cumulative dose may help predict patients at the highest risk of withdrawal that would benefit from an enteral clonidine taper to prevent dexmedetomidine withdrawal symptoms. An enteral clonidine taper can be effective in the prevention and management of dexmedetomidine withdrawal symptoms.

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