Implementation of a Risk-Stratified Opioid and Benzodiazepine Weaning Protocol in a Pediatric Cardiac ICU.

OBJECTIVES: Opioids and benzodiazepines are commonly used to provide analgesia and sedation for critically ill children with cardiac disease. These medications have been associated with adverse effects including delirium, dependence, withdrawal, bowel dysfunction, and potential neurodevelopmental abnormalities. Our objective was to implement a risk-stratified opioid and benzodiazepine weaning protocol to reduce the exposure to opioids and benzodiazepines in pediatric patients with cardiac disease. DESIGN: A prospective pre- and postinterventional study. PATIENTS: Critically ill patients less than or equal to 21 years old with acquired or congenital cardiac disease exposed to greater than or equal to 7 days of scheduled opioids ± scheduled benzodiazepines between January 2013 and February 2015. SETTING: A 24-bed pediatric cardiac ICU and 21-bed cardiovascular acute ward of an urban stand-alone children's hospital. INTERVENTION: We implemented an evidence-based opioid and benzodiazepine weaning protocol using educational and quality improvement methodology. MEASUREMENTS AND MAIN RESULTS: One-hundred nineteen critically ill children met the inclusion criteria (64 post intervention, 55 pre intervention). Demographics and risk factors did not differ between groups. Patients in the postintervention period had shorter duration of opioids (19.0 vs 30.0 d; p < 0.01) and duration of benzodiazepines (5.3 vs 22.7 d; p < 0.01). Despite the shorter duration of wean, there was a decrease in withdrawal occurrence (% Withdrawal Assessment Tool score ≥ 4, 4.9% vs 14.1%; p < 0.01). There was an 8-day reduction in hospital length of stay (34 vs 42 d; p < 0.01). There was a decrease in clonidine use (14% vs 32%; p = 0.02) and no change in dexmedetomidine exposure (59% vs 75%; p = 0.08) in the postintervention period. CONCLUSIONS: We implemented a risk-stratified opioid and benzodiazepine weaning protocol for critically ill cardiac children that resulted in reduction in opioid and benzodiazepine duration and dose exposure, a decrease in symptoms of withdrawal, and a reduction in hospital length of stay.

Length of Stay and Hospital Revisit After Bacterial Tracheostomy-Associated Respiratory Tract Infection Hospitalizations.

OBJECTIVES: To identify factors associated with longer length of stay (LOS) and higher 30-day hospital revisit rates for children hospitalized with bacterial tracheostomy-associated respiratory tract infections (bTARTIs). METHODS: This was a multicenter, retrospective cohort study using administrative data from the Pediatric Health Information System database between 2007 and 2014 of patients 30 days to 17 years old with a principal discharge diagnosis of bTARTI or a principal discharge diagnosis of bTARTI symptoms with a secondary diagnosis of bTARTI. Primary outcomes of LOS (in days) and 30-day all-cause revisit rates (inpatient, observation, or emergency department visit) were analyzed by using a 3-level hierarchical regression model (discharges within patients within hospital). RESULTS: We included 3715 unique patients and 7355 discharges. The median LOS was 4 days (interquartile range: 3-8 days), and the 30-day revisit rate was 30.5%. Compared with children 1 to 4 years old, children aged 30 days to 12 months had both longer LOS (adjusted length of stay [aLOS] = +0.9 days; 95% confidence interval [CI]: 0.6 to 1.3) and increased hospital revisit risk (adjusted odds ratio [aOR] = 1.5; 95% CI: 1.3 to 1.7). Other factors associated with longer LOS included public insurance (aLOS = +0.5 days; 95% CI: 0.2 to 0.8), 3 or more complex chronic conditions (CCCs), mechanical ventilation (acute or chronic), and empirical anti-Pseudomonas aeruginosa antibiotics (aLOS = +0.6 days; 95% CI: 0.3 to 0.9). Other factors associated with 30-day revisit included 4 or more CCCs (aOR = 1.3; 95% CI: 1.1 to 1.6) and chronic ventilator dependency (aOR = 1.1; 95% CI: 1.0 to 1.3). CONCLUSIONS: Ventilator-dependent patients <12 months old with at least 4 CCCs are at highest risk for both longer LOS and 30-day revisit after discharge for bTARTIs. They may benefit from bTARTI prevention strategies and intensive care coordination while hospitalized.

Implementation of a risk-stratified opioid weaning protocol in a pediatric intensive care unit.

PURPOSE: Opioids are important in the care of critically ill children. However, their use is associated with complications including delirium, dependence, withdrawal, and bowel dysfunction. Our aim was to implement a risk-stratified opioid weaning protocol to reduce the duration of opioids without increasing the incidence of withdrawal. METHODS: A pre- and post-interventional prospective study was undertaken in a large children's hospital pediatric ICU where we implemented a risk-stratified opioid weaning protocol. Patients were included if exposed to ≥7days of scheduled opioids. The primary outcome was duration of opioids and secondary outcome was hospital LOS. RESULTS: One hundred seven critically ill children met the inclusion criteria (68 pre-, 39 post-intervention). Demographics, risk factors, and confounders did not differ between groups. Patients in the post-intervention group had shorter duration of opioids (17 vs. 22.5days, p=0.01) and opioid wean (12 vs. 18days, p=0.01). Despite the shorter duration of opioid wean, there was no increase in withdrawal incidence. There was no difference in the LOS (29 vs. 33days, p=0.06). CONCLUSIONS: We implemented a risk-stratified opioid weaning protocol for critically ill children that resulted in reduction in opioid exposure without an increase in withdrawal. There was no difference in the LOS.

Multicenter study of viral etiology and relapse in hospitalized children with bronchiolitis.

BACKGROUND: It is unclear whether the infectious etiology of severe bronchiolitis affects short-term outcomes, such as posthospitalization relapse. We tested the hypothesis that children hospitalized with rhinovirus (RV) bronchiolitis, either as a sole pathogen or in combination with respiratory syncytial virus (RSV), are at increased risk of relapse. METHODS: We performed a 16-center, prospective cohort study of hospitalized children age <2 years with bronchiolitis. During the winters of 2007-2010, researchers collected clinical data and nasopharyngeal aspirates from study participants; the aspirates were tested using real-time polymerase chain reaction. The primary outcome was bronchiolitis relapse (urgent bronchiolitis visit or scheduled visit at which additions to the bronchiolitis medications were made) during the 2 weeks after hospital discharge. RESULTS: Among 1836 enrolled children with 2-week, follow-up data, the median age was 4 months and 60% were male. Overall, 48% had sole RSV infection, 8% had sole RV infection, and 13% had RSV/RV coinfection. Compared with children with sole RSV infection, and adjusting for 10 demographic and clinical characteristics and clustering of patients within hospitals, children with sole RV infection did not differ in their likelihood of relapse (odds ratio: 0.99; 95% confidence interval: 0.52-1.90; P = 0.98), whereas those with RSV/RV coinfection were more likely to have relapse (odds ratio: 1.54; 95% confidence interval: 1.03-2.30; P = 0.03). CONCLUSIONS: In this prospective, multicenter, multiyear study of children hospitalized with bronchiolitis, we found that RSV/RV coinfection was independently associated with a higher likelihood of bronchiolitis relapse. Present data support the concept that the infectious etiology of severe bronchiolitis affects short-term outcomes.