Dexmedetomidine Opioid Sparing Effect in Mechanically Ventilated Children (DOSE): Trial of Fentanyl versus Fentanyl

Objectives This article observes the mean daily dose of fentanyl required for adequate sedation in critically ill, mechanically ventilated children randomized to receive dexmedetomidine or placebo.Methods We conducted Dexmedetomidine Opioid Sparing Effect in Mechanically Ventilated Children (DOSE), a multicenter, double-blind, randomized, placebo-controlled, dose-escalating trial. We enrolled children aged 35 weeks postmenstrual to 17 years (inclusive) admitted across 13 pediatric multidisciplinary and cardiac intensive care units. Adequate sedation was based on a State Behavioral Score and Richmond Agitation-Sedation Scale of -1 or lower. Only the first two dexmedetomidine dosing cohorts opened for enrollment, due to early trial closure during the coronavirus 2019 pandemic. Thirty children were randomized over 13 months and included in the analyses.Results Demographic and baseline characteristics were not different between dexmedetomidine and placebo cohorts. Similarly, mean daily fentanyl use was not different, using an unadjusted mixed regression model that considered treatment, time, and a treatment-by-time interaction. Adverse events and safety events of special interest were not different between cohorts.Conclusion The DOSE trial revealed that dexmedetomidine added to fentanyl does not impact safety and may not spare fentanyl use in critically ill children, although the trial did not meet its recruitment goals, due to early closure during the coronavirus 2019 pandemic. More rigorous inpatient pediatric trials like DOSE that study critically ill, mechanically ventilated children are needed. Despite the many obstacles faced, the DOSE trial presents challenges from which the greater research community can learn and use to optimize future therapeutic trials in children.

Focus on laryngeal disease in the cat

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Communicable diseases

Chapter 5 looks at defining communicable diseases and understanding and the impact on both animal and human health and how vital it is for veterinary nurses. This chapter does this in a clear and systematic way. It considers both emerging communicable diseases (such as COVID-19) and re-emerging diseases that reappear after a period of absence and the factors that contribute to this. © CAB International 2023. All rights reserved.

Use of buprenorphine microdosing for opiate dependence in the pediatric intensive care unit

INTRODUCTION: Iatrogenic opioid dependence is a common development when long-term sedation is required. Associated with increased length of stay and increased morbidity from withdrawal, and delirium. Buprenorphine (BPN) is a high-affinity partial mu receptor agonist with a long duration of action and indicated for both analgesia and opioid use disorder. BPN has favorable properties compared to full agonists including fewer side effects, less tolerance, and is easier to wean. The transition from full opioid agonist to buprenorphine requires a washout period to avoid precipitated withdrawal. We describe the use of BPN in 2 PICU patients using a novel method of induction called micro-dosing to simplify sedation and opioid weaning regimens. Micro-dosing, where small doses of BPN are initiated before full agonists had been stopped, allowing BPN accumulation at the receptor without precipitated withdrawal. Microinduction is considered for patients requiring high doses of opiates and at risk of withdrawal but unable to stop full agonists. DESCRIPTION: Case 1: 24 year old with global developmental delay, admitted for respiratory failure with COVID infection. Required 3-weeks sedation and attempts to wean unsuccessful. BPN was initiated over 4 days (150 mcg, 300 mcg, 1 mg, 2 mg) each dose given at 6-hour increments;the dose increased every 4 doses. Opiate agonist discontinued on day 4. They required an increase of their BPN dose two days later to 4 mg. Sedation requirements and symptoms then improved after BPN initiation. The weaning phase was completed over 9 days and did not require rescue dosing. Case 2: 13-month-old, 24-weeks premature, BPD, tracheostomy, ventilator dependence, failing sedation weans underwent micro-induction of 12.5 mcg, 30 mcg, 75 mcg, 300 mcg, 600 mcg, 1 mg, each dose given at 6-hour increments, the dose increased every 4 doses. Adjuvant medications were discontinued and weaned. She remained on full agonists concomitantly with BPN for analgesia but later tolerated weaning. DISCUSSION: BPN benefits of decreased withdrawal risk, fewer side effects, and fewer medication days can benefit the PICU population. BPN initiation in this novel way can simplify opiate weaning and lead to an improved treatment course and recovery. Further research is needed to investigate BPN in comparison to current sedation methods.

Update on feline infectious peritonitis

Background: Feline coronavirus (FCoV) infection in cats is common, usually only causing mild intestinal signs, such as diarrhoea. It is highly infectious and found worldwide. A sequela of FCoV infection, feline infectious peritonitis (FIP), is a common cause of death in young cats, occurring in up to 10 per cent of cats infected with FCoV. Although suspicion of FIP is frequent in sick, particularly young, cats, obtaining a definitive diagnosis using non- or minimally-invasive approaches is difficult. Aim of the article: This article provides an update regarding diagnosing cases of FIP and guidance on current treatment recommendations.