Long-term Dexmedetomidine in Critically Ill Children
Long-term Dexmedetomidine in Critically Ill Children
Objective To determine whether long-term dexmedetomidine dosing is associated with lower opioid and benzodiazepine use without risk of significant hemodynamic changes and/or withdrawal.
Design Retrospective, observational study.
Setting PICU, cardiovascular ICU, and neonatal ICU in a single, tertiary care, academic children's hospital.
Subjects We included all patients less than or equal to 21 years old, who received dexmedetomidine for greater than or equal to 72 hours from December 2008 to December 2010 resulting in a 98-subject cohort.
Interventions None.
Measurement and Main Results The median duration of dexmedetomidine use was 141 hours. A decrease in systolic blood pressure and heart rate was seen after initiation of dexmedetomidine. After dexmedetomidine was discontinued, systolic blood pressure was statistically significantly higher than baseline. Similarly, heart rate showed a significant increase from baseline following discontinuation of dexmedetomidine. Starting dexmedetomidine was not associated with a significant difference in the dosing of opiates or benzodiazepines. Comfort scores were significantly lower at 2 and 72 hours of dexmedetomidine infusion. After stopping dexmedetomidine, the comfort score for patients at 1 hour was statistically higher than for patients at cessation of the infusion. Thirty percent of patients who were taken off dexmedetomidine, whether weaned or abruptly stopped, had withdrawal symptoms and scores recorded with agitation, tremor, and decreased sleep being most prominent.
Conclusions Hemodynamic effects of dexmedetomidine did not limit long-term use in this diverse population. After the addition of dexmedetomidine, opioid and benzodiazepine doses did not significantly escalate, and patients were more comfortable as evidenced by decreasing comfort scores. Withdrawal from dexmedetomidine may be an issue and manifests as agitation, tremors, and decreased sleep.
Sedation in the PICU is vital for patient comfort and to facilitate care delivery. The use of dexmedetomidine hydrochloride (Precedex; Hospira, Lake Forest, IL), a selective α2-adrenoreceptor agonist, has increased in pediatrics as an adjunct to traditional sedation regimens and has become increasingly used as a primary sedative. The therapeutic effects of dexmedetomidine are mediated throughout the CNS: with the sedative and anxiolytic effects resulting from its activity in the locus ceruleus and the analgesic effects from the dorsal horn of the spinal cord. These actions result in sedation, anxiolysis, and analgesia coupled with minimal concern for respiratory depression. Becasue of its sympatholytic activity, the most significant adverse reactions associated with dexmedetomidine use are hypotension and bradycardia.
Despite its popularity in the pediatric population, dexmedetomidine only has Food and Drug Administration approval for use in adults for up to 24 hours. Most data concerning pediatric use of dexmedetomidine remain centered on the use for less than 72 hours. There are few reports and case studies with small subject numbers describing the safety of dexmedetomidine with average use longer than 72 hours, and fewer that highlights possible withdrawal and rebound symptoms.
Our original dexmedetomidine policy at Seattle Children's Hospital, Seattle, WA, limited its use to 24 hours. As comfort increased with the use of the drug and its known side effects, the use expanded beyond these confines. This shift in clinical practice and experience with agitation after discontinuation of dexmedetomidine infusions prompted us to design this study to describe the hemodynamic variables, comfort scores, opioid and benzodiazepine use, and withdrawal symptoms during initiation, after 72 hours of use and up to 48 hours after discontinuation of dexmedetomidine.
Abstract and Introduction
Abstract
Objective To determine whether long-term dexmedetomidine dosing is associated with lower opioid and benzodiazepine use without risk of significant hemodynamic changes and/or withdrawal.
Design Retrospective, observational study.
Setting PICU, cardiovascular ICU, and neonatal ICU in a single, tertiary care, academic children's hospital.
Subjects We included all patients less than or equal to 21 years old, who received dexmedetomidine for greater than or equal to 72 hours from December 2008 to December 2010 resulting in a 98-subject cohort.
Interventions None.
Measurement and Main Results The median duration of dexmedetomidine use was 141 hours. A decrease in systolic blood pressure and heart rate was seen after initiation of dexmedetomidine. After dexmedetomidine was discontinued, systolic blood pressure was statistically significantly higher than baseline. Similarly, heart rate showed a significant increase from baseline following discontinuation of dexmedetomidine. Starting dexmedetomidine was not associated with a significant difference in the dosing of opiates or benzodiazepines. Comfort scores were significantly lower at 2 and 72 hours of dexmedetomidine infusion. After stopping dexmedetomidine, the comfort score for patients at 1 hour was statistically higher than for patients at cessation of the infusion. Thirty percent of patients who were taken off dexmedetomidine, whether weaned or abruptly stopped, had withdrawal symptoms and scores recorded with agitation, tremor, and decreased sleep being most prominent.
Conclusions Hemodynamic effects of dexmedetomidine did not limit long-term use in this diverse population. After the addition of dexmedetomidine, opioid and benzodiazepine doses did not significantly escalate, and patients were more comfortable as evidenced by decreasing comfort scores. Withdrawal from dexmedetomidine may be an issue and manifests as agitation, tremors, and decreased sleep.
Introduction
Sedation in the PICU is vital for patient comfort and to facilitate care delivery. The use of dexmedetomidine hydrochloride (Precedex; Hospira, Lake Forest, IL), a selective α2-adrenoreceptor agonist, has increased in pediatrics as an adjunct to traditional sedation regimens and has become increasingly used as a primary sedative. The therapeutic effects of dexmedetomidine are mediated throughout the CNS: with the sedative and anxiolytic effects resulting from its activity in the locus ceruleus and the analgesic effects from the dorsal horn of the spinal cord. These actions result in sedation, anxiolysis, and analgesia coupled with minimal concern for respiratory depression. Becasue of its sympatholytic activity, the most significant adverse reactions associated with dexmedetomidine use are hypotension and bradycardia.
Despite its popularity in the pediatric population, dexmedetomidine only has Food and Drug Administration approval for use in adults for up to 24 hours. Most data concerning pediatric use of dexmedetomidine remain centered on the use for less than 72 hours. There are few reports and case studies with small subject numbers describing the safety of dexmedetomidine with average use longer than 72 hours, and fewer that highlights possible withdrawal and rebound symptoms.
Our original dexmedetomidine policy at Seattle Children's Hospital, Seattle, WA, limited its use to 24 hours. As comfort increased with the use of the drug and its known side effects, the use expanded beyond these confines. This shift in clinical practice and experience with agitation after discontinuation of dexmedetomidine infusions prompted us to design this study to describe the hemodynamic variables, comfort scores, opioid and benzodiazepine use, and withdrawal symptoms during initiation, after 72 hours of use and up to 48 hours after discontinuation of dexmedetomidine.
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