title: Analgesia and Sedation Protocol for Mechanically Ventilated Postsurgical Children Reduces Benzodiazepines and Withdrawal Symptoms-But Not in All Patients.
abstract: BackgroundWe demonstrated recently that the implementation of a nurse-driven analgesia and sedation protocol (pediatric analgesia and sedation protocol [pASP]) for mechanically ventilated nonpostsurgical patients reduces the total dose of benzodiazepines and the withdrawal symptoms significantly. It has not been investigated if these results can also be expected in the group of patients undergoing surgery.ObjectivesTo evaluate the effects of the pASP in mechanically ventilated postsurgical children regarding drug dosage, duration of mechanical ventilation, length of stay, and rate of withdrawal symptoms.MethodsThis is a two-phase prospective observational control study. The preimplementation group was managed by the physician's order and the postimplementation group was managed with the pASP including COMFORT-B, nurse interpretation of sedation, and Sophia observation withdrawal symptoms scale scoring.Measurements and Main ResultsOne hundred and sixteen patients were included before and one hundred and ten patients after implementation. The pASP had no effect on length of pediatric intensive care unit stay or duration of mechanical ventilation. The protocol reduced total (5.0 mg/kg [0.5-58.0] vs 4.0 mg/kg [0.0-47.0];p= 0.021) and daily doses (4.4 mg/kg/d [1.1-33.9] vs 2.9 mg/kg/d [0.0-9.9];p< 0.001) of benzodiazepines significantly. No difference was observed in total and daily doses of opioids (5.0 mg/kg [0.1-67.0] vs 3.0 mg/kg [0.1-71.0];p= 0.81) and (0.7 mg/kg/d [0.0-7.0] vs. 0.8 mg/kg/d [0.0-3.7];p= 0.35), respectively. Rate of withdrawal symptoms was significantly lower after implementation (35.3 vs 20.0%;p= 0.01), but not in patients after solid organ transplantation or oncological patients.ConclusionThe nurse-driven analgesia and sedation protocol is an effective procedure to reduce the total doses of benzodiazepines and occurrence of withdrawal symptoms in postsurgical children, which are naïve to opioids or benzodiazepines.
authors.affiliation: Department of Pediatric Cardiology, Pulmonology and Pediatric Intensive Care Medicine, University Children's Hospital Tübingen, Tübingen, Germany.
authors.forename: Felix
authors.initials: F
authors.lastname: Neunhoeffer
authors.affiliation: Department of Pediatric Surgery, University Hospital Giessen/Marburg, Marburg, Germany.
authors.forename: Guido
authors.initials: G
authors.lastname: Seitz
authors.affiliation: Department of Pediatric Surgery and Pediatric Urology, University Children's Hospital Tübingen, Tübingen, Germany.
authors.forename: Andreas
authors.initials: A
authors.lastname: Schmidt
authors.affiliation: Department of Pediatric Cardiology, Pulmology and Pediatric Intensive Care Medicine, University Children's Hospital Tübingen, Tübingen, Germany.
authors.forename: Hanna
authors.initials: H
authors.lastname: Renk
authors.affiliation: Department of Pediatric Cardiology, Pulmology and Pediatric Intensive Care Medicine, University Children's Hospital Tübingen, Tübingen, Germany.
authors.forename: Matthias
authors.initials: M
authors.lastname: Kumpf
authors.affiliation: Department of Anesthesiology and Intensive Care Medicine, University Hospital Tübingen, Tübingen, Germany.
authors.forename: Frank
authors.initials: F
authors.lastname: Fideler
authors.affiliation: Department of Pediatric Cardiology, Pulmonology and Pediatric Intensive Care Medicine, University Children's Hospital Tübingen, Tübingen, Germany.
authors.forename: Martin
authors.initials: M
authors.lastname: Esslinger
authors.affiliation: Department of Pediatric Cardiology, Pulmonology and Pediatric Intensive Care Medicine, University Children's Hospital Tübingen, Tübingen, Germany.
authors.forename: Ines
authors.initials: I
authors.lastname: Gerbig
authors.affiliation: Department of Pediatric Surgery, University Tuebingen, Tuebingen, Germany.
authors.forename: Jörg
authors.initials: J
authors.lastname: Fuchs
authors.affiliation: Department of Pediatric Cardiology, Pulmology and Pediatric Intensive Care Medicine, University Children's Hospital Tübingen, Tübingen, Germany.
authors.forename: Michael
authors.initials: M
authors.lastname: Hofbeck
mesh_terms: D000293:Adolescent; D000701:Analgesics, Opioid / Q000008:administration & dosage* / Q000009:adverse effects; D002648:Child; D002675:Child, Preschool; D002985:Clinical Protocols; D004334:Drug Administration Schedule; D005260:Female; D005283:Fentanyl / Q000008:administration & dosage* / Q000009:adverse effects; D006801:Humans; D006993:Hypnotics and Sedatives / Q000008:administration & dosage* / Q000009:adverse effects; D007223:Infant; D007262:Infusions, Intravenous; D007902:Length of Stay; D008297:Male; D008874:Midazolam / Q000008:administration & dosage* / Q000009:adverse effects; D011182:Postoperative Care / Q000379:methods* / Q000592:standards; D011446:Prospective Studies; D012121:Respiration, Artificial; D013375:Substance Withdrawal Syndrome / Q000517:prevention & control*
chemical_list: D000701:Analgesics, Opioid; D006993:Hypnotics and Sedatives; D008874:Midazolam; D005283:Fentanyl