Log in | Register

Feasibility of sedation and analgesia interruption following cannulation in neonates on extracorporeal membrane oxygenationOpen access

E. D. Wildschut| M. N. Hanekamp| N. J. Vet| R. J. Houmes| M. J. Ahsman| R. A. A. Mathot| S. N. de Wildt| D. Tibboel
Pediatric Original
Volume 36, Issue 9 / September , 2010

Pages 1587 - 1591

Abstract

Purpose

In most extracorporeal membrane oxygenation (ECMO) centers patients are heavily sedated to prevent accidental decannulation and bleeding complications. In ventilated adults not on ECMO, daily sedation interruption protocols improve short- and long-term outcome. This study aims to evaluate safety and feasibility of sedation interruption following cannulation in neonates on ECMO.

Methods

Prospective observational study in 20 neonates (0.17–5.8 days of age) admitted for ECMO treatment. Midazolam (n = 20) and morphine (n = 18) infusions were discontinued within 30 min after cannulation. Pain and sedation were regularly assessed using COMFORT-B and visual analog scale (VAS) scores. Midazolam and/or morphine were restarted and titrated according to protocolized treatment algorithms.

Results

Median (interquartile range, IQR) time without any sedatives was 10.3 h (5.0–24.1 h). Median interruption duration for midazolam was 16.5 h (6.6–29.6 h), and for morphine was 11.2 h (6.7–39.4 h). During this period no accidental extubations, decannulations or bleeding complications occurred.

Conclusions

This is the first study to show that interruption of sedatives and analgesics following cannulation in neonates on ECMO is safe and feasible. Interruption times are 2–3 times longer than reported for adult ICU patients not on ECMO. Further trials are needed to substantiate these findings and evaluate short- and long-term outcomes.

Keywords

References

  1. Fonsmark L, Rasmussen YH, Carl P (1999) Occurrence of withdrawal in critically ill sedated children. Crit Care Med 27:196–199
    • View reference on publisher's website
    • View reference on PubMed
  2. Ista E, van Dijk M, Gamel C, Tibboel D, de Hoog M (2008) Withdrawal symptoms in critically ill children after long-term administration of sedatives and/or analgesics: a first evaluation. Crit Care Med 36:2427–2432
    • View reference on publisher's website
    • View reference on PubMed
  3. Suresh S, Anand KJ (2001) Opioid tolerance in neonates: a state-of-the-art review. Paediatr Anaesth 11:511–521
    • View reference on publisher's website
    • View reference on PubMed
  4. Hughes J, Gill A, Leach HJ, Nunn AJ, Billingham I, Ratcliffe J, Thornington R, Choonara I (1994) A prospective study of the adverse effects of midazolam on withdrawal in critically ill children. Acta Paediatr 83:1194–1199
    • View reference on PubMed
  5. Ista E, van Dijk M, Gamel C, Tibboel D, de Hoog M (2007) Withdrawal symptoms in children after long-term administration of sedatives and/or analgesics: a literature review. “Assessment remains troublesome”. Intensive Care Med 33:1396–1406
  6. Playfor S, Jenkins I, Boyles C, Choonara I, Davies G, Haywood T, Hinson G, Mayer A, Morton N, Ralph T, Wolf A (2006) Consensus guidelines on sedation and analgesia in critically ill children. Intensive Care Med 32:1125–1136
  7. Prins S, van Dijk M, Tibboel D (2006) Sedation and analgesia in the PICU: many questions remain. Intensive Care Med 32:1103–1105
  8. Kress JP, Pohlman AS, O’Connor MF, Hall JB (2000) Daily interruption of sedative infusions in critically ill patients undergoing mechanical ventilation. N Engl J Med 342:1471–1477
    • View reference on publisher's website
    • View reference on PubMed
  9. Strom T, Martinussen T, Toft P (2010) A protocol of no sedation for critically ill patients receiving mechanical ventilation: a randomised trial. Lancet 375:475–480
    • View reference on publisher's website
    • View reference on PubMed
  10. Carson SS, Kress JP, Rodgers JE, Vinayak A, Campbell-Bright S, Levitt J, Bourdet S, Ivanova A, Henderson AG, Pohlman A, Chang L, Rich PB, Hall J (2006) A randomized trial of intermittent lorazepam versus propofol with daily interruption in mechanically ventilated patients. Crit Care Med 34:1326–1332
    • View reference on publisher's website
    • View reference on PubMed
  11. Kress JP, Gehlbach B, Lacy M, Pliskin N, Pohlman AS, Hall JB (2003) The long-term psychological effects of daily sedative interruption on critically ill patients. Am J Respir Crit Care Med 168:1457–1461
    • View reference on publisher's website
    • View reference on PubMed
  12. Mehta S, Burry L, Martinez-Motta JC, Stewart TE, Hallett D, McDonald E, Clarke F, Macdonald R, Granton J, Matte A, Wong C, Suri A, Cook DJ (2008) A randomized trial of daily awakening in critically ill patients managed with a sedation protocol: a pilot trial. Crit Care Med 36:2092–2099
    • View reference on publisher's website
    • View reference on PubMed
  13. Jayashree M, Gupta VK, Singhi S (2007) Randomized controlled trial of interrupted versus continuous sedative infusions in ventilated children—a pilot study. Pediatr Crit Care Med 8:A182
  14. Heesen G, Verlaat C, Pickkers P (2007) Effects of daily interruption of sedatives in critically ill children. Pediatr Crit Care Med 8:A182
  15. Bouwmeester NJ, Hop WC, van Dijk M, Anand KJ, van den Anker JN, Tibboel D (2003) Postoperative pain in the neonate: age-related differences in morphine requirements and metabolism. Intensive Care Med 29:2009–2015
  16. van Dijk M, de Boer JB, Koot HM, Tibboel D, Passchier J, Duivenvoorden HJ (2000) The reliability and validity of the COMFORT scale as a postoperative pain instrument in 0 to 3-year-old infants. Pain 84:367–377
    • View reference on publisher's website
    • View reference on PubMed
  17. Ista E, van Dijk M, Tibboel D, de Hoog M (2005) Assessment of sedation levels in pediatric intensive care patients can be improved by using the COMFORT “behavior” scale. Pediatr Crit Care Med 6:58–63
    • View reference on publisher's website
    • View reference on PubMed
  18. Ahsman MJ, Hanekamp M, Wildschut ED, Tibboel D, Mathot RAA (2010) Population pharmacokinetics of midazolam and metabolites during venoarterial extracorporeal membrane oxygenation in neonates. Clin Pharmacokinet 49(6):407–419
    • View reference on publisher's website
    • View reference on PubMed
  19. Mulla H, Lawson G, Peek GJ, Firmin RK, Upton DR (2003) Plasma concentrations of midazolam in neonates receiving extracorporeal membrane oxygenation. ASAIO J 49:41–47
    • View reference on publisher's website
    • View reference on PubMed
  20. de Wildt SN, de Hoog M, Vinks AA, Joosten KF, van Dijk M, van den Anker JN (2005) Pharmacodynamics of midazolam in pediatric intensive care patients. Ther Drug Monit 27:98–102
    • View reference on publisher's website
    • View reference on PubMed

Sign In

Connect with ICM

Top 5 Articles Editors Picks Supplement