Evaluation of IV to Enteral Benzodiazepine Conversion Calculations in a Pediatric Intensive Care Setting

Objectives: To evaluate if institutionally established calculations for transitioning continuous IV midazolam to enteral benzodiazepines maintain Withdrawal Assessment Tool—Version 1 scores equal to or less than preconversion values. Design: Retrospective cohort study evaluating the effectiveness and safety of benzodiazepine conversion calculations embedded within an institution-specific clinical pathway for sedation and weaning of mechanically ventilated pediatric patients. Setting: A 55-bed, mixed-medical, noncardiac surgical PICU in a tertiary care children’s hospital. Patients: All patients age 6 months to 18 years who received continuous midazolam for 5 days or longer while mechanically ventilated for 5–21 days and were then converted to either enteral diazepam or lorazepam following extubation (or return to baseline ventilator settings in tracheostomy-dependent patients) between January 1, 2015, and June 30, 2016. Interventions: Benzodiazepine conversion calculations were applied according to institutional clinical pathway guidance. Measurements and Main Results: Withdrawal Assessment Tool—Version 1 scores were compared pre and post benzodiazepine conversion. Patient demographics, benzodiazepine dose escalations, as needed benzodiazepine requirements, and severe adverse events within 48 hours of conversion were assessed. Seventy-one patient encounters were analyzed (median age, 2.5 yr; interquartile range, 1.2–5.3). The median Withdrawal Assessment Tool—Version 1 scores pre conversion and post conversion were not significantly different (1 [interquartile range, 0.75–2] and 1 [interquartile range, 0.25–2], respectively, p = 0.1). As needed benzodiazepine doses were administered in 38% of encounters post conversion, but escalation of a scheduled enteral benzodiazepine regimen was only required in 2.8% of encounters. Post conversion, one patient (1.4%) had increased seizure activity, and four patients (5.6%) required fluid boluses secondary to tachycardia or dehydration, but not hypotension. Conclusions: These findings suggest that standardized benzodiazepine conversions successfully achieved consistent Withdrawal Assessment Tool—Version 1 scores compared with preconversion values. Severe adverse events associated with oversedation and/or withdrawal were minimal and confounded by underlying disease states. This work was performed at the Children’s Hospital of Philadelphia. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (https://ift.tt/2gIrZ5Y). The authors have disclosed that they do not have any potential conflicts of interest. For information regarding this article, E-mail: susan.warrington@lvhn.org ©2018The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies

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