title: Opioid analgesia in mechanically ventilated children: results from the multicenter Measuring Opioid Tolerance Induced by Fentanyl study.
abstract: OBJECTIVE
  To examine the clinical factors associated with increased opioid dose among mechanically ventilated children in the pediatric intensive care unit.
  
  
  METHODS
  Prospective, observational study with 100% accrual of eligible patients.
  
  
  METHODS
  Seven pediatric intensive care units from tertiary-care children's hospitals in the Collaborative Pediatric Critical Care Research Network.
  
  
  METHODS
  Four hundred nineteen children treated with morphine or fentanyl infusions.
  
  
  METHODS
  None.
  
  
  RESULTS
  Data on opioid use, concomitant therapy, demographic and explanatory variables were collected. Significant variability occurred in clinical practices, with up to 100-fold differences in baseline opioid doses, average daily or total doses, or peak infusion rates. Opioid exposure for 7 or 14 days required doubling of the daily opioid dose in 16% patients (95% confidence interval 12%-19%) and 20% patients (95% confidence interval 16%-24%), respectively. Among patients receiving opioids for longer than 3 days (n = 225), this occurred in 28% (95% confidence interval 22%-33%) and 35% (95% confidence interval 29%-41%) by 7 or 14 days, respectively. Doubling of the opioid dose was more likely to occur following opioid infusions for 7 days or longer (odds ratio 7.9, 95% confidence interval 4.3-14.3; p < 0.001) or co-therapy with midazolam (odds ratio 5.6, 95% confidence interval 2.4-12.9; p < 0.001), and it was less likely to occur if morphine was used as the primary opioid (vs. fentanyl) (odds ratio 0.48, 95% confidence interval 0.25-0.92; p = 0.03), for patients receiving higher initial doses (odds ratio 0.96, 95% confidence interval 0.95-0.98; p < 0.001), or if patients had prior pediatric intensive care unit admissions (odds ratio 0.37, 95% confidence interval 0.15-0.89; p = 0.03).
  
  
  CONCLUSIONS
  Mechanically ventilated children require increasing opioid doses, often associated with prolonged opioid exposure or the need for additional sedation. Efforts to reduce prolonged opioid exposure and clinical practice variation may prevent the complications of opioid therapy.
authors.affiliation: Department of Pediatrics, Le Bonheur Children's Hospital, University of Tennessee Health Science Center, Memphis, TN, USA. kanand@uthsc.edu
authors.forename: Kanwaljeet J S
authors.initials: KJ
authors.lastname: Anand
authors.forename: Amy E
authors.initials: AE
authors.lastname: Clark
authors.forename: Douglas F
authors.initials: DF
authors.lastname: Willson
authors.forename: John
authors.initials: J
authors.lastname: Berger
authors.forename: Kathleen L
authors.initials: KL
authors.lastname: Meert
authors.forename: Jerry J
authors.initials: JJ
authors.lastname: Zimmerman
authors.forename: Rick
authors.initials: R
authors.lastname: Harrison
authors.forename: Joseph A
authors.initials: JA
authors.lastname: Carcillo
authors.forename: Christopher J L
authors.initials: CJ
authors.lastname: Newth
authors.forename: Stephanie
authors.initials: S
authors.lastname: Bisping
authors.forename: Richard
authors.initials: R
authors.lastname: Holubkov
authors.forename: J Michael
authors.initials: JM
authors.lastname: Dean
authors.forename: Carol E
authors.initials: CE
authors.lastname: Nicholson
mesh_terms: D000293:Adolescent; D000701:Analgesics, Opioid / Q000008:administration & dosage*; D002648:Child; D002675:Child, Preschool; D016001:Confidence Intervals; D005260:Female; D005283:Fentanyl / Q000008:administration & dosage*; D006801:Humans; D006993:Hypnotics and Sedatives / Q000008:administration & dosage; D007223:Infant; D007231:Infant, Newborn; D015278:Intensive Care Units, Pediatric; D053208:Kaplan-Meier Estimate; D008297:Male; D008874:Midazolam / Q000008:administration & dosage; D009020:Morphine / Q000008:administration & dosage*; D015999:Multivariate Analysis; D016017:Odds Ratio; D011446:Prospective Studies; D012121:Respiration, Artificial / Q000379:methods*; D012737:Sex Factors; D013997:Time Factors
chemical_list: D000701:Analgesics, Opioid; D006993:Hypnotics and Sedatives; D009020:Morphine; D008874:Midazolam; D005283:Fentanyl