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Dexmedetomidine Use in Critically Ill Children With Acute Respiratory Failure*

Grant, Mary Jo C. APRN, PhD1; Schneider, James B. MD2; Asaro, Lisa A. MS3; Dodson, Brenda L. PharmD4; Hall, Brent A. PharmD5; Simone, Shari L. APRN, DNP6; Cowl, Allison S. MD7; Munkwitz, Michele M. MD8; Wypij, David PhD3,9,10; Curley, Martha A. Q. RN, PhD11,12; for the Randomized Evaluation of Sedation Titration for Respiratory Failure (RESTORE) Study Investigators

Pediatric Critical Care Medicine: December 2016 - Volume 17 - Issue 12 - p 1131-1141
doi: 10.1097/PCC.0000000000000941
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Objective: Care of critically ill children includes sedation but current therapies are suboptimal. To describe dexmedetomidine use in children supported on mechanical ventilation for acute respiratory failure.

Design: Secondary analysis of data from the Randomized Evaluation of Sedation Titration for Respiratory Failure clinical trial.

Setting: Thirty-one PICUs.

Patients: Data from 2,449 children; 2 weeks to 17 years old.

Interventions: Sedation practices were unrestrained in the usual care arm. Patients were categorized as receiving dexmedetomidine as a primary sedative, secondary sedative, periextubation agent, or never prescribed. Dexmedetomidine exposure and sedation and clinical profiles are described.

Measurements and Main Results: Of 1,224 usual care patients, 596 (49%) received dexmedetomidine. Dexmedetomidine as a primary sedative patients (n = 138; 11%) were less critically ill (Pediatric Risk of Mortality III-12 score median, 6 [interquartile range, 3–11]) and when compared with all other cohorts, experienced more episodic agitation. In the intervention group, time in sedation target improved from 28% to 50% within 1 day of initiating dexmedetomidine as a primary sedative. Dexmedetomidine as a secondary sedative usual care patients (n = 280; 23%) included more children with severe pediatric acute respiratory distress syndrome or organ failure. Dexmedetomidine as a secondary sedative patients experienced more inadequate pain (22% vs 11%) and sedation (31% vs 16%) events. Dexmedetomidine as a periextubation agent patients (n = 178; 15%) were those known to not tolerate an awake, intubated state and experienced a shorter ventilator weaning process (2.1 vs 2.3 d).

Conclusions: Our data support the use of dexmedetomidine as a primary agent in low criticality patients offering the benefit of rapid achievement of targeted sedation levels. Dexmedetomidine as a secondary agent does not appear to add benefit. The use of dexmedetomidine to facilitate extubation in children intolerant of an awake, intubated state may abbreviate ventilator weaning. These data support a broader armamentarium of pediatric critical care sedation.

1Department of Pediatric Critical Care, Primary Children’s Hospital, Salt Lake City, UT.

2Division of Pediatric Critical Care Medicine, Cohen Children’s Medical Center, Hofstra-Northwell School of Medicine, New York, NY.

3Department of Cardiology, Boston Children’s Hospital, Boston, MA.

4Department of Pharmacy, Boston Children’s Hospital, Boston, MA.

5Department of Pharmacy, UC Davis Medical Center, Sacramento, CA.

6Department of Pediatric Critical Care, University of Maryland Medical Center, Baltimore, MD.

7Division of Pediatric Critical Care Medicine, Connecticut Children’s Medical Center, Hartford, CT.

8Division of Pediatric Critical Care Medicine, Department of Pediatric Critical Care, Phoenix Children’s Hospital, University of Arizona College of Medicine, Phoenix, AZ.

9Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA.

10Department of Pediatrics, Harvard Medical School, Boston, MA.

11Department of Family and Community Health, School of Nursing and Department of Anesthesia and Critical Care Medicine, the Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.

12Department of Critical Care and Cardiovascular Nursing, Boston Children’s Hospital, Boston, MA.

*See also p. 1184.

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The Randomized Evaluation of Sedation Titration for Respiratory Failure (RESTORE) Study Investigators are listed in the Acknowledgments section.

Supported, in part, by grants from the National Heart, Lung, and Blood Institute and the National Institute of Nursing Research, National Institutes of Health (U01 HL086622 to Dr. Curley and U01 HL086649 to Dr. Wypij).

Dr. Grant received support for article research from the National Institutes of Health (NIH). Her institution received funding from National Heart, Lung, and Blood Institute (NHLBI), NIH, and from the National Institute of Nursing Research, NIH. She disclosed off-label product use (dexmedetomidine in children). Dr. Schneider disclosed off-label product use (dexmedetomidine in children). Ms. Asaro received support for article research from the NIH and disclosed off-label product use (off-label use of dexmedetomidine [pediatric patients]). Her institution received support from the NIH/NHLBI. Dr. Dodson disclosed off-label product use (dexmedetomidine used for nonprocedural pediatric sedation). Dr. Hall disclosed off-label product use (procedural pediatric sedation dexmedetomidine/pediatric sedation for acute respiratory failure). Ms. Simone disclosed off-label product use (off-label use of dexmedetomidine). Dr. Cowl disclosed off-label product use (dexmedetomidine for prolonged use in pediatric patients). Dr. Munkwitz disclosed off-label product use (use of dexmedetomidine in pediatric patients). Dr. Wypij received support for article research from the NIH and disclosed off-label product use (dexmedetomidine). His institution received funding from NIH/NHLBI and National Institute of Nursing Research. Dr. Curley received support for article research from the NIH, disclosed off-label product use (dexmedetomidine not Food and Drug Administration approved for children), and received funding from Hospira (Subject Matter Expert on the State Behavioral Scale). Her institution received funding from NHLBI.

Address requests for reprints: Mary Jo C. Grant, APRN, PhD, Primary Children’s Hospital, Pediatric Critical Care, 100 North Mario Capecchi Drive, Salt Lake City, UT 84113 USA. E-mail: maryjo.grant@imail.org

Copyright © 2016 by the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies