Opioids in the Pediatric and Neonatal ICU: Proposal for Tapering Off
DOI:
https://doi.org/10.17533/udea.iatreia.253Keywords:
Acute Pain, Analgesics, Opioid, Drug Tapering, Intensive Care Units, Pediatric, Iatrogenic Disease, Intensive Care Units, Neonatal, Substance Withdrawal SyndromeAbstract
Opioids are considered one of the mainstays of pain treatment. However, they are not exempted from potential risks, such as withdrawal caused by their rapid decline or abrupt cessation. It is usual to observe a high number of withdrawal cases in clinical practice, especially in special populations such as children and in critically ill patients.
Considering the clinical importance of opioids and the permanent search to minimize secondary events related to their use, this update was carried out to review the existing proposals in the literature and suggest a didactic way to perform opioid tapering in pediatric and neonatal population in intensive care units. As a result, the “DESSMONTE” strategy arises, which is an acrostic in Spanish that allows guidance on the eight essential steps for an organized and predictable weaning protocol in critically ill pediatric patients. The strategy is flexible, which would allow it to be adapted to different clinical scenarios.
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(1) Duceppe MA, Perreault MM, Frenette AJ, Burry LD, Rico P, Lavoie A, et al. Frequency, risk factors and symptomatology of iatrogenic withdrawal from opioids and benzodiazepines in critically Ill neonates, children and adults: A systematic review of clinical studies. J Clin Pharm Ther [Internet]. 2019;44(2):148-56. https://doi.org/10.1111/jcpt.12787
(2) Chiu AW, Contreras S, Mehta S, Korman J, Perreault MM, Williamson DR, et al. Iatrogenic Opioid Withdrawal in Critically Ill Patients: A Review of Assessment Tools and Management. Ann Pharmacother [Internet]. 2017;51(12):1099-111. https://doi.org/10.1177/1060028017724538
(3) Fisher D, Grap MJ, Younger JB, Ameringer S, Elswick RK. Opioid withdrawal signs and symptoms in children: frequency and determinants. Heart Lung [Internet]. 2013;42(6):407-13. https://doi.org/10.1016/j.hrtlng.2013.07.008
(4) Katz R, Kelly HW, Hsi A. Prospective study on the occurrence of withdrawal in critically ill children who receive fentanyl by continuous infusion. Crit Care Med [Internet]. 1994;22(5):763-7. https://doi.org/10.1097/00003246-199405000-00009
(5) Abdouni R, Reyburn-Orne T, Youssef TH, Haddad IY, Gerkin RD. Impact of a Standardized Treatment Guideline for Pediatric Iatrogenic Opioid Dependence: A Quality Improvement Initiative. J Pediatr Pharmacol Ther [Internet]. 2016;21(1):54-65. https://doi.org/10.5863/1551-6776-21.1.54
(6) Srinivasan V, Pung D, O'Neill SP. Conversion from prolonged intravenous fentanyl infusion to enteral methadone in critically ill children. World J Clin Pediatr [Internet]. 2017;6(2):110-117. https://doi.org/10.5409/wjcp.v6.i2.110
(7) Tobias JD. Tolerance, withdrawal, and physical dependency after long-term sedation and analgesia of children in the pediatric intensive care unit. Crit Care Med [Internet]. 2000;28(6):2122-32. https://doi.org/10.1097/00003246-200006000-00079
(8) Avila-Alzate JA, Gomez-Salgado J, Romero-Martin M, Martinez-Isasi S, Navarro-Abal Y, Fernandez-Garcia D. Assessment and treatment of the withdrawal syndrome in paediatric intensive care units: Systematic review. Medicine (Baltimore) [Internet]. 2020;99(5):e18502. https://doi.org/10.1097/MD.0000000000018502
(9) Fernández-Carrión F, Gaboli M, González-Celador R, Gómez de Quero-Masia P, Fernández-de Miguel S, Murga-Herrera V, et al. Withdrawal syndrome in the pediatric intensive care unit. Incidence and risk factors. Med Intensiva [Internet]. 2013;37(2):67-74. https://doi.org/10.1016/j.medine.2012.02.010
(10) Massachusetts General Hospital. Strategies for Weaning Analgesia & Sedation. The General Hospital Corporation; 2020.
(11) Dokken M, Rustoen T, Diep LM, Fagermoen FE, Huse RI, Rosland GA, et al. Iatrogenic withdrawal syndrome frequently occurs in paediatric intensive care without algorithm for tapering of analgosedation. Acta Anaesthesiol Scand [Internet]. 2021;65(7):928-35. https://doi.org/10.1111/aas.13818
(12) Marra A, Ely EW, Pandharipande PP, Patel MB. The ABCDEF Bundle in Critical Care. Crit Care Clin [Internet]. 2017;33(2):225-43. https://doi.org/10.1016/j.ccc.2016.12.005
(13) Walker T, Kudchadkar SR. Pain and Sedation Management: 2018 Update for the Rogers' Textbook of Pediatric Intensive Care. Pediatr Crit Care Med [Internet]. 2019;20(1):54-61. https://doi.org/10.1097/PCC.0000000000001765
(14) Duitama L, Mercado E, Martínez P, Fernández-Sarmiento J. Metadona para tratar el síndrome de abstinencia en cuidado intensivo pediátrico. Acta Colomb Cuid Intensiv [Internet]. 2018;18(1):43-50. https://doi.org/10.1016/j.acci.2017.11.001
(15) Harris J, Ramelet AS, van Dijk M, Pokorna P, Wielenga J, Tume L, et al. Clinical recommendations for pain, sedation, withdrawal and delirium assessment in critically ill infants and children: an ESPNIC position statement for healthcare professionals. Intensive Care Med [Internet]. 2016;42(6):972-86. https://doi.org/10.1007/s00134-016-4344-1
(16) Tobias JD. Tolerance, Dependency, and Withdrawal. In: Zimmerman JJ, Rotta AT, editors. Fuhrman and Zimmerman's Pediatric Critical Care. 6th ed. Philadelphia: Elsevier Health Sciences; 2021.
(17) Amigoni A, Mondardini MC, Vittadello I, Zaglia F, Rossetti E, Vitale F, et al. Withdrawal Assessment Tool-1 Monitoring in PICU: A Multicenter Study on Iatrogenic Withdrawal Syndrome. Pediatr Crit Care Med [Internet]. 2017;18(2):e86-e91. https://doi.org/10.1097/PCC.0000000000001054
(18) Baethge C, Goldbeck-Wood S, Mertens S. SANRA-a scale for the quality assessment of narrative review articles. Res Integr Peer Rev [Internet]. 2019;4:5. https://doi.org/10.1186/s41073-019-0064-8
(19) Dominguez-Omonte CB. Importancia de mnemotecnias, aforismos, proverbios y otros enfoques para el aprendizaje médico. Rev Cient Cienc Méd [Internet]. 2018;21(2). Disponible en: http://www.scielo.org.bo/scielo.php?script=sci_arttext&pid=S1817-74332018000200015
(20) Franck LS, Harris SK, Soetenga DJ, Amling JK, Curley MA. The Withdrawal Assessment Tool-1 (WAT-1): an assessment instrument for monitoring opioid and benzodiazepine withdrawal symptoms in pediatric patients. Pediatr Crit Care Med [Internet]. 2008;9(6):573-80. https://doi.org/10.1097/PCC.0b013e31818c8328
(21) Franck LS, Naughton I, Winter I. Opioid and benzodiazepine withdrawal symptoms in paediatric intensive care patients. Intensive Crit Care Nurs [Internet]. 2004;20(6):344-51. https://doi.org/10.1016/j.iccn.2004.07.008
(22) Ista E, de Hoog M, Tibboel D, Duivenvoorden HJ, van Dijk M. Psychometric evaluation of the Sophia Observation withdrawal symptoms scale in critically ill children. Pediatr Crit Care Med [Internet]. 2013;14(8):761-9. https://doi.org/10.1097/PCC.0b013e31829f5be1
(23) Ista E, van Dijk M, de Hoog M, Tibboel D, Duivenvoorden HJ. Construction of the Sophia Observation withdrawal Symptoms-scale (SOS) for critically ill children. Intensive Care Med [Internet]. 2009;35(6):1075-81. https://doi.org/10.1007/s00134-009-1487-3
(24) Ista E, van Dijk M, Gamel C, Tibboel D, de Hoog M. Withdrawal symptoms in critically ill children after long-term administration of sedatives and/or analgesics: a first evaluation. Crit Care Med [Internet]. 2008;36(8):2427-32. https://doi.org/10.1097/CCM.0b013e318181600d
(25) Patrick SW, Barfield WD, Poindexter BB, Committee On F Newborn, COSU Prevention. Neonatal Opioid Withdrawal Syndrome. Pediatrics [Internet]. 2020;146(5). https://doi.org/10.1542/peds.2020-029074
(26) Bagley SM, Wachman EM, Holland E, Brogly SB. Review of the assessment and management of neonatal abstinence syndrome. Addict Sci Clin Pract [Internet]. 2014;9(1):19. https://doi.org/10.1186/1940-0640-9-19
(27) Grossman MR, Lipshaw MJ, Osborn RR, Berkwitt AK. A Novel Approach to Assessing Infants With Neonatal Abstinence Syndrome. Hosp Pediatr [Internet]. 2018;8(1):1-6. https://doi.org/10.1542/hpeds.2017-0128
(28) Schiff DM, Grossman MR. Beyond the Finnegan scoring system: Novel assessment and diagnostic techniques for the opioid-exposed infant. Semin Fetal Neonatal Med [Internet]. 2019;24(2):115-20. https://doi.org/10.1016/j.siny.2019.01.003
(29) Gomez-Pomar E, Finnegan LP, Devlin L, Bada H, Concina VA, Ibonia KT, et al. Simplification of the Finnegan Neonatal Abstinence Scoring System: retrospective study of two institutions in the USA. BMJ Open [Internet]. 2017;7(9):e016176. https://doi.org/10.1136/bmjopen-2017-016176
(30) US Department of Veterans Affairs. Opioid taper decision tool [Internet]. US Department of Veterans Affairs; 2016. Available from: https://www.pbm.va.gov/AcademicDetailingService/Documents/Pain_Opioid_Taper_Tool_IB_10_939_P96820.pdf
(31) Bichaff P, Setani KT, Motta EHG, Delgado AF, Carvalho WB, Luglio M. Opioid tapering and weaning protocols in pediatric critical care units: a systematic review. Rev Assoc Med Bras (1992) [Internet]. 2018;64(10):909-15. https://doi.org/10.1590/1806-9282.64.10.909
(32) Kral LA, Jackson K, Uritsky TJ. A practical guide to tapering opioids. Ment Health Clin [Internet]. 2015;5(3):102-8. https://doi.org/10.9740/mhc.2015.05.102
(33) Muirhead R, Kynoch K. Implementation of an opioid weaning protocol to improve pain management, and to prevent or decrease iatrogenic withdrawal syndrome in the neonatal intensive care. Int J Evid Based Healthc [Internet]. 2019;17(3):147-56. https://doi.org/10.1097/XEB.0000000000000169
(34) da Silva PS, Reis ME, Fonseca TS, Fonseca MC. Opioid and Benzodiazepine Withdrawal Syndrome in PICU Patients: Which Risk Factors Matter? J Addict Med [Internet]. 2016;10(2):110-6. https://doi.org/10.1097/ADM.0000000000000197
(35) Rubio MC. Destete de opiáceos: Cómo evitar el síndrome de abstinencia Cómo evitar el síndrome de abstinencia [Internet]. Neonatología - Hospital Garrahan; 2016. Disponible en: http://www.sap.org.ar/docs/Congresos2016/2016Mes6%20Neonatologia/Dia%201%20Mie/Rubio_Destete%20de%20opiaceos.pdf
(36) CHOP. Withdrawal Present - Weaning Rescue Dose Guidance [Internet]. Children's Hospital of Philadelphia; 2021. Available from: https://www.chop.edu/clinical-pathway/sedation-analgesia-cicu-mechanically-ventilated-patient-withdrawl-present-clinical
(37) Barr J, Fraser GL, Puntillo K, Ely EW, Gelinas C, Dasta JF, et al. Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit. Crit Care Med [Internet]. 2013;41(1):263-306. https://doi.org/10.1097/CCM.0b013e3182783b72
(38) Korff MV, Saunders K, Thomas-Ray G, Boudreau D, Campbell C, Merrill J, et al. De facto long-term opioid therapy for noncancer pain. Clin J Pain [Internet]. 2008;24(6):521-7. https://doi.org/10.1097/AJP.0b013e318169d03b
(39) Krebs EE, Becker WC, Zerzan J, Bair MJ, McCoy K, Hui S. Comparative mortality among Department of Veterans Affairs patients prescribed methadone or long-acting morphine for chronic pain. Pain [Internet]. 2011;152(8):1789-95. https://doi.org/10.1016/j.pain.2011.03.023
(40) Ferreras-Vega R, Ruiz-Escobar A, Romero-Layos M, Méndez-Marín MD. Uso de metadona para el destete de sedación en paciente pediátrico. Rev Elect AnestesiaR. [Internet] 2020;11(4):1. https://doi.org/10.30445/rear.v11i4.743
(41) Van-Donge T, Samiee-Zafarghandy S, Pfister M, Koch G, Kalani M, Bordbar A, et al. Methadone dosing strategies in preterm neonates can be simplified. Br J Clin Pharmacol [Internet]. 2019;85(6):1348-56. https://doi.org/10.1111/bcp.13906
(42) Capilnean A, Martone A, Rosu VA, Sandu PR, Murgoi P, Frenette AJ, et al. Validation of the Withdrawal Assessment Tool-1 in Adult Intensive Care Patients. Am J Crit Care [Internet]. 2019;28(5):361-9. https://doi.org/10.4037/ajcc2019559
(43) Priscilla J, Dudell G. Treatment of Iatrogenic Opiate Withdrawal in the NICU - Guideline. East Bay Newborn Specialists; 2015.
(44) Bowens CD, Thompson JA, Thompson MT, Breitzka RL, Thompson DG, Sheeran PW. A trial of methadone tapering schedules in pediatric intensive care unit patients exposed to prolonged sedative infusions. Pediatr Crit Care Med [Internet]. 2011;12(5):504-11. https://doi.org/10.1097/PCC.0b013e3181fe38f5
(45) Lugo RA, MacLaren R, Cash J, Pribble CG, Vernon DD. Enteral methadone to expedite fentanyl discontinuation and prevent opioid abstinence syndrome in the PICU. Pharmacotherapy [Internet]. 2001;21(12):1566-73. https://doi.org/10.1592/phco.21.20.1566.34471
(46) Berens RJ, Meyer MT, Mikhailov TA, Colpaert KD, Czarnecki ML, Ghanayem NS, et al. A prospective evaluation of opioid weaning in opioid-dependent pediatric critical care patients. Anesth Analg [Internet]. 2006;102(4):1045-50. https://doi.org/10.1213/01.ane.0000202395.94542.3e
(47) Meyer MM, Berens RJ. Efficacy of an enteral 10-day methadone wean to prevent opioid withdrawal in fentanyl-tolerant pediatric intensive care unit patients. Pediatr Crit Care Med [Internet]. 2001;2(4):329-33. https://doi.org/10.1097/00130478-200110000-00009
(48) Robertson RC, Darsey E, Fortenberry JD, Pettignano R, Hartley G. Evaluation of an opiate-weaning protocol using methadone in pediatric intensive care unit patients. Pediatr Crit Care Med [Internet]. 2000;1(2):119-23. https://doi.org/10.1097/00130478-200010000-00005
(49) Siddappa R, Fletcher JE, Heard AM, Kielma D, Cimino M, Heard CM. Methadone dosage for prevention of opioid withdrawal in children. Paediatr Anaesth [Internet]. 2003;13(9):805-10. https://doi.org/10.1046/j.1460-9592.2003.01153.x
(50) Steineck KJ, Skoglund AK, Carlson MK, Gupta S. Evaluation of a pharmacist-managed methadone taper*. Pediatr Crit Care Med [Internet]. 2014;15(3):206-10. https://doi.org/10.1097/PCC.0000000000000048
(51) Hudak ML, Tan RC, The Committee On Drugs, The Committee on Fetus and Newborn, Frattarelli DA, Galinkin J, et al. Neonatal drug withdrawal. Pediatrics [Internet]. 2012;129(2):e540-60. https://doi.org/10.1542/peds.2011-3212
(52) Dervan LA, Yaghmai B, Watson RS, Wolf FM. The use of methadone to facilitate opioid weaning in pediatric critical care patients: a systematic review of the literature and meta-analysis. Pediatr Anaesth [Internet]. 2017;27(3):228-39. https://doi.org/10.1111/pan.13056
(53) Ford J, Harthan A, McGarvey J, Mischler M. Implementation of an Opioid Weaning Protocol at a Tertiary Care Children’s Hospital. Hospital Pediatrics [Internet]. 2022;12(11):945-53. https://doi.org/10.1542/hpeds.2021-006306
(54) Herzig SJ, Mosher HJ, Calcaterra SL, Jena AB, Nuckols TK. Improving the Safety of Opioid Use for Acute Noncancer Pain in Hospitalized Adults: A Consensus Statement From the Society of Hospital Medicine. J Hosp Med [Internet]. 2018;13(4):263-71. https://doi.org/10.12788/jhm.2980
(55) Smith HAB, Besunder JB, Betters KA, Johnson PN, Srinivasan V, Stormorken A, et al. 2022 Society of Critical Care Medicine Clinical Practice Guidelines on Prevention and Management of Pain, Agitation, Neuromuscular Blockade, and Delirium in Critically Ill Pediatric Patients With Consideration of the ICU Environment and Early Mobility. Pediatr Crit Care Med [Internet]. 2022;23(2):e74-e110. https://doi.org/10.1097/PCC.0000000000002873
(56) Sanchez-Pinto LN, Nelson LP, Lieu P, Koh JY, Rodgers JW, Larson KA, et al. Implementation of a risk-stratified opioid weaning protocol in a pediatric intensive care unit. J Crit Care [Internet]. 2018;43:214-9. https://doi.org/10.1016/j.jcrc.2017.08.049
(57) Amirnovin R, Sanchez-Pinto LN, Okuhara C, Lieu P, Koh JY, Rodgers JW, et al. Implementation of a Risk-Stratified Opioid and Benzodiazepine Weaning Protocol in a Pediatric Cardiac ICU. Pediatr Crit Care Med [Internet]. 2018;19(11):1024-32. https://doi.org/10.1097/PCC.0000000000001719
(58) Salazar-Sanchez MB, Hernández-Valdivieso AM, Mañanas-Villanueva MA, Zuluaga-Salazar AF. Potential clinical application of surface electromyography as indicator of neuromuscular recovery during weaning tests after organophosphate poisoning. Rev Bras Ter Intensiva [Internet]. 2017;29(2):253-8. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5496761/
(59) Sneyers B, Duceppe MA, Frenette AJ, Burry LD, Rico P, Lavoie A, et al. Strategies for the Prevention and Treatment of Iatrogenic Withdrawal from Opioids and Benzodiazepines in Critically Ill Neonates, Children and Adults: A Systematic Review of Clinical Studies. Drugs [Internet]. 2020;80(12):1211-33 https://doi.org/10.1007/s40265-020-01338-4
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