Practices of assessment of pain, sedation, iatrogenic withdrawal syndrome, and delirium in European paediatric intensive care units: A secondary analysis of the European Prevalence of Acute Rehab for Kids in the paediatric intensive care unit study.

BACKGROUND: Analgosedation is standard practice to ensure comfort and safety of critically ill children in paediatric intensive care units (PICUs). However, a significant number of children develop iatrogenic withdrawal syndrome or delirium with these drugs. The European Society of Paediatric and Neonatal Intensive Care published a position statement in 2016, but how successfully its recommendations have been implemented is unknown. OBJECTIVES: Following were the objectives of this study: (i) to describe assessment practices (prevalence, measurement instruments, and frequency) for pain, sedation, iatrogenic withdrawal syndrome and delirium; (ii) to assess how practices meet the position statement; and (iii) to identify organisational factors associated with the use of recommendations for pain and sedation assessment. METHOD: A secondary analysis of prospectively collected data from the multicentre prevalence study (European Prevalence of Acute Rehab for Kids in the PICU) conducted in 38 PICUs, across 15 European countries in 2018. Data from 453 children were analysed. RESULTS: Of the 38 PICUs, 97% assessed pain, 89% sedation, 82% withdrawal, and 42% delirium. These four symptoms were mainly assessed and documented by the Face, Legs, Activity, Cry, Consolability scale (39%) and Numerical Rating Scale (24%) every 8, 4, or 2 h for pain; the COMFORT-B (45%) and COMFORT (24%) scales every 8 or 2 h for sedation; the Sophia Observation withdrawal Scale (37%) and Withdrawal Assessment Tool-1 (32%) scales every 8 or 4 h for withdrawal and the Cornell Assessment Pediatric-Delirium (18%) and Sophia Observation Withdrawal Symptoms-Pediatric Delirium (16%) scales every 12 or 8 h for delirium. Concordance with the position statement recommendations was low to moderate (13-69%). Adherence to recommendations were influenced by the variables of nurse-to-patient ratio, type of hospital, and the number of PICU beds. CONCLUSION: Based on prospectively collected data, there was variability in pain and sedation assessment practices and a lack of adherence with recommendations in the EU, particularly for delirium. These findings highlight the need for more proactive dissemination, and investigation of barriers and implementation strategies to improve evidence-based assessment practices.

Auricular Acupressure Adjunct Treatment for Opioid Tapering: A Randomized Pilot Feasibility Study.

PURPOSE: Opioid medications are necessary in the treatment of critically ill infants; however. prolonged use may lead to withdrawal syndrome. The purpose of this study was to assess feasibility of delivering an acupressure protocol for the treatment of iatrogenic withdrawal in a pediatric cardiac intensive care unit as well as impact and acceptance of acupressure as an adjunct treatment. DESIGN: Randomized pilot feasibility trial. METHODS: Acupressure stickers were applied and rotated to one ear every 1-3 days until withdrawal symptoms improved. RESULTS: There were no serious adverse events, with only one reported incident of skin irritation. Recruiting benchmarks were exceeded. Weaning phases were significantly shorter in the acupressure group (medians 6.0 vs 22.0 respectively, p = .025, d = 0.90) and the control group used skin-to-skin contact as a comfort measure significantly more than the acupressure group (42.9% vs 6.3%, p = .18). Acupressure was accepted by parents, with an overall 96.2% rating their experience as positive, as measured by the Parent Client Satisfaction Questionnaire. The majority of health care providers (n = 19) were supportive, with 71.9% agreeing or completely agreeing acupressure is an acceptable adjunct for the treatment of withdrawal symptoms; 26.8% were neutral, as measured by the Acceptability of Intervention Measure, Intervention Appropriateness Measure, and Feasibility of Intervention Measure. CONCLUSIONS: Acupressure was found to be safe, feasible, and accepted by health care providers in a pediatric cardiac intensive care setting. CLINICAL IMPLICATIONS: These findings support future research with larger sample sizes to improve clinical treatment of infants physically dependent on sedative medications.

Impact of Intravenous Methadone Dosing Schedule on Iatrogenic Withdrawal Syndrome in a Pediatric Intensive Care Unit.

OBJECTIVE: To compare median Sophia Observation withdrawal Symptoms scale (SOS) scores between -intravenous methadone dosing scheduled every 6 hours or every 8 hours for iatrogenic withdrawal -syndrome (IWS). METHODS: This single-center, retrospective chart review evaluated patients aged 4 weeks through 18 years treated with intravenous methadone for IWS. Children admitted to the pediatric intensive care unit (PICU) of a tertiary care children's hospital between August 2017 and July 2021 and treated for IWS for at least 48 hours were eligible for inclusion. Methadone dosing schedules were compared, with a primary outcome of median Sophia Observation withdrawal Symptoms (SOS) score during the first 24 hours after cessation of continuous fentanyl infusion. Secondary outcomes included PICU and general pediatric unit lengths of stay, extubation failure rates, and mortality. RESULTS: Twenty patients met inclusion criteria, with 9 in the 6-hour dosing group. There was no difference in median SOS score, extubation failure, length of stay, or mortality between the 2 groups. CONCLUSIONS: During the first 24 hours after cessation of continuous fentanyl, there appears to be no -difference in IWS severity, as determined by bedside nurse scoring, between patients treated with -intravenous methadone every 6 hours compared with every 8 hours.

A systematic review of clinical practice guidelines and recommendations for the management of pain, sedation, delirium and iatrogenic withdrawal syndrome in pediatric intensive care.

Introduction: This systematic review aimed to evaluate the quality of clinical practice guidelines (CPGs) and recommendations for managing pain, sedation, delirium, and iatrogenic withdrawal syndrome in pediatric intensive care (PICU). The objectives included evaluating the quality of recommendations, synthesizing recommendations, harmonizing the strength of the recommendation (SoR) and the certainty of evidence (CoE), and assessing the relevance of supporting evidence. Methods: A comprehensive search in four electronic databases (Medline, Embase.com, CINAHL and JBI EBP Database), 9 guideline repositories, and 13 professional societies was conducted to identify CPGs published from January 2010 to the end of May 2023 in any language. The quality of CPGs and recommendations was assessed using the AGREE II and AGREE-REX instruments. Thematic analysis was used to synthesize recommendations, and the GRADE SoR and CoE harmonization method was used to interpret the credibility of summary recommendations. Results: A total of 18 CPGs and 170 recommendations were identified. Most CPGs were of medium-quality, and three were classified as high. A total of 30 summary recommendations were synthesized across each condition, focused on common management approaches. There was inconsistency in the SoRs and CoE for summary recommendations, those for assessment showed the highest consistency, the remaining were conditional, inconsistent, inconclusive, and lacked support from evidence. Conclusion: This systematic review provides an overview of the quality of CPGs for these four conditions in the PICU. While three CPGs achieved high-quality ratings, the overall findings reveal gaps in the evidence base of recommendations, patient and family involvement, and resources for implementation. The findings highlight the need for more rigorous and evidence-based approaches in the development and reporting of CPGs to enhance their trustworthiness. Further research is necessary to enhance the quality of recommendations for this setting. The results of this review can provide a valuable foundation for future CPG development. Systematic Review Registration: https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=274364, PROSPERO (CRD42021274364).

Effectiveness, quality and implementation of pain, sedation, delirium, and iatrogenic withdrawal syndrome algorithms in pediatric intensive care: a systematic review and meta-analysis.

Background: Pain, sedation, delirium, and iatrogenic withdrawal syndrome are conditions that often coexist, algorithms can be used to assist healthcare professionals in decision making. However, a comprehensive review is lacking. This systematic review aimed to assess the effectiveness, quality, and implementation of algorithms for the management of pain, sedation, delirium, and iatrogenic withdrawal syndrome in all pediatric intensive care settings. Methods: A literature search was conducted on November 29, 2022, in PubMed, Embase, CINAHL and Cochrane Library, ProQuest Dissertations & Theses, and Google Scholar to identify algorithms implemented in pediatric intensive care and published since 2005. Three reviewers independently screened the records for inclusion, verified and extracted data. Included studies were assessed for risk of bias using the JBI checklists, and algorithm quality was assessed using the PROFILE tool (higher % = higher quality). Meta-analyses were performed to compare algorithms to usual care on various outcomes (length of stay, duration and cumulative dose of analgesics and sedatives, length of mechanical ventilation, and incidence of withdrawal). Results: From 6,779 records, 32 studies, including 28 algorithms, were included. The majority of algorithms (68%) focused on sedation in combination with other conditions. Risk of bias was low in 28 studies. The average overall quality score of the algorithm was 54%, with 11 (39%) scoring as high quality. Four algorithms used clinical practice guidelines during development. The use of algorithms was found to be effective in reducing length of stay (intensive care and hospital), length of mechanical ventilation, duration of analgesic and sedative medications, cumulative dose of analgesics and sedatives, and incidence of withdrawal. Implementation strategies included education and distribution of materials (95%). Supportive determinants of algorithm implementation included leadership support and buy-in, staff training, and integration into electronic health records. The fidelity to algorithm varied from 8.2% to 100%. Conclusions: The review suggests that algorithm-based management of pain, sedation and withdrawal is more effective than usual care in pediatric intensive care settings. There is a need for more rigorous use of evidence in the development of algorithms and the provision of details on the implementation process. Systematic Review Registration: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021276053, PROSPERO [CRD42021276053].

Implementation of an algorithm for tapering analgosedation reduces iatrogenic withdrawal syndrome in pediatric intensive care.

BACKGROUND: Proper analgosedation is a cornerstone in the treatment of critically ill patients in Pediatric Intensive Care Units (PICUs). Medications, such as fentanyl, morphine, and midazolam, are essential to safe and respectful care. The use of these medications over time may lead to side effects such as iatrogenic withdrawal syndrome (IWS) in the tapering phase. The aim of the study was to test an algorithm for tapering analgosedation to reduce the prevalence of IWS in two Norwegian PICUs at Oslo University Hospital. METHODS: A cohort of mechanically ventilated patients from newborn to 18 years with continuous infusions of opioids and benzodiazepines for 5 days or more were included consecutively from May 2016 to December 2021. A pre- and posttest design, with an intervention phase using an algorithm for tapering analgosedation after the pretest, was used. The ICU staffs were trained in using the algorithm after the pretest. The primary outcome was a reduction in IWS. The Withdrawal Assessment Tool-1 (WAT-1) was used to identify IWS. A WAT-1 score ≥3 indicates IWS. RESULTS: We included 80 children, 40 in the baseline group, and 40 in the intervention group. Age and diagnosis did not differ between the groups. The prevalence of IWS was 95% versus 52.5% in the baseline group versus the intervention group, and the peak WAT-1 median was 5.0 (IQR 4-6.8) versus 3.0 (IQR 2.0-6.0) (p = .012). Based on SUM WAT-1 ≥ 3, which describes the burden over time better, we demonstrated a reduction of IWS, from a median of 15.5 (IQR 8.25-39) to a median of 3 (IQR 0-20) (p = <.001). CONCLUSION: We suggest using an algorithm for tapering analgosedation in PICUs since the prevalence of IWS was significantly lower in the intervention group in our study.

Assessment and management of iatrogenic withdrawal syndrome and delirium in pediatric intensive care units across Europe: An ESPNIC survey.

INTRODUCTION: Analgesia and sedation are essential for the care of children in the pediatric intensive care unit (PICU); however, when prolonged, they may be associated with iatrogenic withdrawal syndrome (IWS) and delirium. We sought to evaluate current practices on IWS and delirium assessment and management (including non-pharmacologic strategies as early mobilization) and to investigate associations between the presence of an analgosedation protocol and IWS and delirium monitoring, analgosedation weaning, and early mobilization. METHODS: We conducted a multicenter cross-sectional survey-based study collecting data from one experienced physician or nurse per PICU in Europe from January to April 2021. We then investigated differences among PICUs that did or did not follow an analgosedation protocol. RESULTS: Among 357 PICUs, 215 (60%) responded across 27 countries. IWS was systematically monitored with a validated scale in 62% of PICUs, mostly using the Withdrawal Assessment Tool-1 (53%). The main first-line treatment for IWS was a rescue bolus with interruption of weaning (41%). Delirium was systematically monitored in 58% of PICUs, mostly with the Cornell Assessment of Pediatric Delirium scale (48%) and the Sophia Observation Scale for Pediatric Delirium (34%). The main reported first-line treatment for delirium was dexmedetomidine (45%) or antipsychotic drugs (40%). Seventy-one percent of PICUs reported to follow an analgosedation protocol. Multivariate analyses adjusted for PICU characteristics showed that PICUs using a protocol were significantly more likely to systematically monitor IWS (odds ratio [OR] 1.92, 95% confidence interval [CI] 1.01-3.67) and delirium (OR 2.00, 95% CI 1.07-3.72), use a protocol for analgosedation weaning (OR 6.38, 95% CI 3.20-12.71) and promote mobilization (OR 3.38, 95% CI 1.63-7.03). CONCLUSIONS: Monitoring and management of IWS and delirium are highly variable among European PICUs. The use of an analgosedation protocol was associated with an increased likelihood of monitoring IWS and delirium, performing a structured analgosedation weaning and promoting mobilization. Education on this topic and interprofessional collaborations are highly needed to help reduce the burden of analgosedation-associated adverse outcomes.

Iatrogenic withdrawal syndrome frequently occurs in paediatric intensive care without algorithm for tapering of analgosedation.

BACKGROUND: Analgesics and sedatives are key elements to reduce physiological and psychological stress associated with treatment in paediatric intensive care. Prolonged drug use may induce tolerance and development of iatrogenic withdrawal syndrome (IWS) during the tapering phase. Our primary aim was to describe the prevalence of IWS among critically ill ventilated patients in two Norwegian paediatric intensive care units (PICUs), and secondary to investigate what motivated bedside nurses to administer additional drug doses. METHODS: Mechanically ventilated patients (n = 40) from newborn to eighteen years of age, with continuous infusions of opioids and benzodiazepines for 5 days or more, were included consecutively from May 2016 to June 2018. By using Withdrawal Assessment Tool-1 (WAT-1) twice daily we recorded the prevalence of IWS. Additionally, we recorded signs and symptoms that led bedside nurses to administration extra bolus medication. RESULTS: Peak WAT-1 score indicated an IWS prevalence of 95% in this selected group. The first days of the tapering phase were most critical for IWS. The most frequent symptoms triggering administration of additional bolus doses were agitation/restlessness, and thiopental and propofol were the bolus drugs used most frequently. CONCLUSIONS: IWS affected 95% of the children having received infusions of opioids and benzodiazepines for 5 days or more in PICUs without a tapering protocol for these drugs. This calls for implementation and testing of such weaning protocols.

Promoção do conforto ao cliente pediátrico: intervenções de enfermagem à criança com síndrome de abstinência iatrogénica / Promotion of comfort to pediatric clients: nursing interventions for children with iatrogenic withdrawal syndrome

A hospitalização é uma situação causadora de ansiedade, stress e disrupção do decorrer normal do dia-a-dia da pessoa, afetando em especial a criança e a sua família, podendo condicionar o seu desenvolvimento harmonioso. Em situações de doença crítica há a necessidade de internamento em cuidados intensivos, onde técnicas e procedimentos especializados e diferenciados, frequentemente invasivos e dolorosos, sujeitam a criança e família a experiências difíceis de lidar e superar. No sentido de minimizar a dor, a ansiedade, o stress e o sofrimento associados aos cuidados intensivos e aos procedimentos realizados são utilizadas estratégias nãofarmacológicas e farmacológicas, sendo a sedoanalgesia a estratégia farmacológica mais frequentemente utilizada. Contudo, a sua utilização não é isenta de risco, havendo evidência de que doses elevadas de opióides e benzodiazepinas, o seu uso prolongado e descontinuação abrupta estão associados a eventos adversos em particular a Síndroma de Abstinência Iatrogénica. Procurando entender a ocorrência desta síndroma, a sua prevenção e tratamento, e identificar a intervenção do enfermeiro na criança, jovem e família no contexto desta síndroma, bem como desenvolver competências de Enfermeiro Especialista de Enfermagem de Saúde Infantil e Pediátrica, foi delineado um projeto de aprendizagem enfatizando a reflexão na ação e a reflexão crítica sobre as situações e práticas nos diversos contextos de estágio. Por forma a desenvolver conhecimentos e capacidades ao nível de mestrado, elaborou-se um projeto de investigação sobre a temática em estudo, a ser concluído após término deste percurso formativo, integrado na Unidade de Investigação da Escola Superior de Enfermagem de Lisboa. O resultado deste conjunto de atividades é exposto neste relatório onde se apresentam a pertinência da temática escolhida, a filosofia de cuidar em enfermagem pediátrica enquadrando a intervenção e aplicando a teoria do conforto de Kolcaba, as competências desenvolvidas ao longo de todo o percurso relacionando-as com as atividades realizadas e as limitações encontradas, e por último os projetos de desenvolvimento futuros bem como as considerações finais de todo o processo.

Hospitalization is a situation that causes anxiety, stress and disruption of the person's normal day-to-day life, affecting especially the child and his family, eventually conditioning their harmonious development. When critical illness occurs, admission to intensive care is needed, where specialized and differentiated techniques and procedures, often invasive and painful, turn the child and family´s experience harder to deal with and overcome. To minimize pain, discomfort, and suffering associated with intensive care and the procedures needed non-pharmacological and pharmacological strategies are frequently used, with sedoanalgesia being the most frequent pharmacological strategy. However, its use is not without risk, and there is evidence that high dose of opioids and benzodiazepines, its prolonged use and abrupt discontinuation, can lead to the occurrence of adverse events mainly the Iatrogenic Withdrawal Syndrome. Searching to understand the occurrence of this syndrome, how it can be prevented or treated, and to identify the interventions of the paediatric nurse to the child and family in the context of this syndrome, as well as to develop skills for acquiring the title of Specialist Nurse in Child and Paediatric Health Nursing, a learning project was outlined, emphasising the reflection in action and critical thinking processes regarding the experiences and nursing practices occurring in the diverse clinical practice contexts. In order to develop knowledge and skills at master's level, a research project on the subject under study was elaborated, to be concluded after the end of this formative path, integrated in the Escola Superior de Enfermagem de Lisboa Research Unit. The result of this set of activities is exposed in this report, presenting the relevance of the chosen theme, the philosophy of paediatric nursing care framing the intervention and applying Kolcaba's theory of comfort, the skills developed throughout the entire formative path relating them with the activities carried out and the limitations found, and finally the future development projects as well as the final considerations of the entire process.

Opioid and Benzodiazepine Iatrogenic Withdrawal Syndrome in Patients in the Intensive Care Unit.

Iatrogenic withdrawal syndrome is an increasingly recognized issue among adult patients in the intensive care unit. The prolonged use of opioids and benzodiazepines during the intensive care unit stay and preexisting disorders associated with their use put patients at risk of developing iatrogenic withdrawal syndrome. Although research to date is scant regarding iatrogenic withdrawal syndrome in adult patients in the intensive care unit, it is important to recognize and adequately manage iatrogenic withdrawal syndrome in order to prevent possible negative outcomes during and after a patient's intensive care unit stay. This article discusses in depth 8 studies of iatrogenic withdrawal syndrome among adult patients in the intensive care unit. It also addresses important aspects of opioid and benzodiazepine iatrogenic withdrawal syndrome, including prevalence, risk factors, and assessment and considers its prevention and management.

Parent's experiences of their child's withdrawal syndrome: a driver for reciprocal nurse-parent partnership in withdrawal assessment.

Withdrawal assessment in critically ill children is complicated by the reliance on non-specific behaviours and compounded when the child's typical behaviours are unknown. The existing approach to withdrawal assessment assumes that nurses elicit the parents' view of the child's behaviours. OBJECTIVE AND RESEARCH METHODOLOGY: This qualitative study explored parents' perspectives of their child's withdrawal and preferences for involvement and participation in withdrawal assessment. Parents of eleven children were interviewed after their child had completed sedation weaning during recovery from critical illness. Data were analysed using thematic analysis. SETTING: A large children's hospital in the Northwest of England. FINDINGS: Parents experienced varying degrees of partnership in the context of withdrawal assessment and identified information deficits which contributed to their distress of parenting a child with withdrawal syndrome. Most parents were eager to participate in withdrawal assessment and reported instances where their knowledge enabled a personalised interpretation of their child's behaviours. Reflecting on the reciprocal nature of the information deficits resulted in the development of a model for nurse-parent collaboration in withdrawal assessment. CONCLUSION: Facilitating nurse-parent collaboration in withdrawal assessment may have reciprocal benefits by moderating parental stress and aiding the assessment and management of withdrawal syndrome.

Validation of the SOS-PD scale for assessment of pediatric delirium: a multicenter study.

BACKGROUNDS: Reports of increasing incidence rates of delirium in critically ill children are reason for concern. We evaluated the measurement properties of the pediatric delirium component (PD-scale) of the Sophia Observation Withdrawal Symptoms scale Pediatric Delirium scale (SOS-PD scale). METHODS: In a multicenter prospective observational study in four Dutch pediatric ICUs (PICUs), patients aged ≥ 3 months and admitted for ≥ 48 h were assessed with the PD-scale thrice daily. Criterion validity was assessed: if the PD-scale score was ≥ 4, a child psychiatrist clinically assessed the presence or absence of PD according to the Diagnostic and statistical manual of mental disorders (DSM)-IV. In addition, the child psychiatrist assessed a randomly selected group to establish the false-negative rate. The construct validity was assessed by calculating the Pearson coefficient (rp) for correlation between the PD-scale and Cornell Assessment Pediatric Delirium (CAP-D) scores. Interrater reliability was determined by comparing paired nurse-researcher PD-scale assessments and calculating the intraclass correlation coefficient (ICC). RESULTS: Four hundred eighty-five patients with a median age of 27.0 months (IQR 8-102) were included, of whom 48 patients were diagnosed with delirium by the child psychiatrist. The PD-scale had overall sensitivity of 92.3% and specificity of 96.5% compared to the psychiatrist diagnosis for a cutoff score ≥4 points. The rp between the PD-scale and the CAP-D was 0.89 (CI 95%, 0.82-0.93; p < 0.001). The ICC of 75 paired nurse-researcher observations was 0.99 (95% CI, 0.98-0.99). CONCLUSIONS: The PD-scale has good reliability and validity for early screening of PD in critically ill children. It can be validly and reliably used by nurses to this aim.

Sophia Observation withdrawal Symptoms-Paediatric Delirium scale: A tool for early screening of delirium in the PICU.

BACKGROUND: Delirium in critically ill children is a severe neuropsychiatric disorder which has gained increased attention from clinicians. Early identification of delirium is essential for successful management. The Sophia Observation withdrawal Symptoms-Paediatric Delirium (SOS-PD) scale was developed to detect Paediatric Delirium (PD) at an early stage. OBJECTIVE: The aim of this study was to determine the measurement properties of the PD component of the SOS-PD scale in critically ill children. METHODS: A prospective, observational study was performed in patients aged 3 months or older and admitted for more than 48h. These patients were assessed with the SOS-PD scale three times a day. If the SOS-PD total score was 4 or higher in two consecutive observations, the child psychiatrist was consulted to assess the diagnosis of PD using the Diagnostic and Statistical Manual-IV criteria as the "gold standard". The child psychiatrist was blinded to outcomes of the SOS-PD. The interrater reliability of the SOS-PD between the care-giving nurse and a researcher was calculated with the intraclass correlation coefficient (ICC). RESULTS: A total of 2088 assessments were performed in 146 children (median age 49 months; IQR 13-140). The ICC of 16 paired nurse-researcher observations was 0.90 (95% CI 0.70-0.96). We compared 63 diagnoses of the child psychiatrist versus SOS-PD assessments in 14 patients, in 13 of whom the diagnosis of PD was confirmed. The sensitivity was 96.8% (95% CI 80.4-99.5%) and the specificity was 92.0% (95% CI 59.7-98.9%). CONCLUSIONS: The SOS-PD scale shows promising validity for early screening of PD. Further evidence should be obtained from an international multicentre study.

Opioid-associated iatrogenic withdrawal in critically ill adult patients: a multicenter prospective observational study.

BACKGROUND: Opioids and benzodiazepines are frequently used in the intensive care unit (ICU). Regular use and prolonged exposure to opioids in ICU patients followed by abrupt tapering or cessation may lead to iatrogenic withdrawal syndrome (IWS). IWS is well described in pediatrics, but no prospective study has evaluated this syndrome in adult ICU patients. The objective of this study was to determine the incidence of IWS caused by opioids in a critically ill adult population. This multicenter prospective cohort study was conducted at two level-1 trauma ICUs between February 2015 and September 2015 and included 54 critically ill patients. Participants were eligible if they were 18 years and older, mechanically ventilated and had received more than 72 h of regular intermittent or continuous intravenous infusion of opioids. For each enrolled patient and per each opioid weaning episode, presence of IWS was assessed by a qualified ICU physician or senior resident according to the 5th edition of Diagnostic and Statistical Manual of Mental Disorders criteria for opioid withdrawal. RESULTS: The population consisted mostly of males (74.1%) with a median age of 50 years (25th-75th percentile 38.2-64.5). The median ICU admission APACHE II score was 22 (25th-75th percentile 12.0-28.2). The overall incidence of IWS was 16.7% (95% CI 6-27). The median cumulative opioid dose prior to weaning was higher in patients with IWS (245.7 vs. 169.4 mcg/kg, fentanyl equivalent). Patients with IWS were also exposed to opioids for a longer period of time as compared to patients without IWS (median 151 vs. 125 h). However, these results were not statistically significant. CONCLUSIONS: IWS was occasionally observed in this very specific population of mechanically ventilated, critically ill ICU patients. Further studies are needed to confirm these preliminary results and identify risk factors.