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Reducing Exposure to Opioid and Benzodiazepine Medications for Pediatric Cardiac Intensive Care Patients

A Quality Improvement Project*

Donnellan, Amy, DNP, CPNP-AC1; Sawyer, Jaclyn, PharmD, BCPPS2; Peach, Anne, MSN, CPNP-AC1; Staveski, Sandra, RN, PhD, CPNP-AC1,3; Nelson, David P., MD, PhD1,4; Pratap, J. Nick, MB BChir, MRCPCH, FRCA1,4,5

Pediatric Critical Care Medicine: April 2019 - Volume 20 - Issue 4 - p 340–349
doi: 10.1097/PCC.0000000000001870
Cardiac Intensive Care
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Objectives: To evaluate the effect of implementation of a comfort algorithm on infusion rates of opioids and benzodiazepines in postneonatal postoperative pediatric cardiac surgery patients.

Design: A quality improvement project, using statistical process control methodology.

Setting: Twenty-five-bed tertiary care pediatric cardiac ICU in an urban academic Children’s hospital.

Patients: Postoperative pediatric cardiac surgery patients.

Interventions: Implementation of a guided comfort medication algorithm which consisted of key components; a low dose opioid continuous infusion, judicious use of frequent as needed opioids, initiation of dexmedetomidine infusion postoperatively, and minimal use of benzodiazepines.

Measurements and Main Results: Among the baseline group admitted over the 18 month period prior to comfort algorithm implementation, 58 of 116 intubated patients (50%) received a continuous opioid infusion, compared with 30 of 41 (73%) for the implementation group over the 9-month period following implementation. Following algorithm implementation, opioid infusion rates were decreased and benzodiazepine infusions were nearly eliminated. Dexmedetomidine use and infusion rates did not change. Although mean duration of sedative drug infusions did not change with implementation, the frequency of high outliers was diminished. Duration of mechanical ventilation, length of ICU stay (outcome measures), and the frequency of unplanned extubation (balancing measure) were not affected by implementation.

Conclusions: Implementation of a pediatric comfort algorithm reduced opioid and benzodiazepine dosing, without compromising safety for postoperative pediatric cardiac surgical patients.

1Cardiac Intensive Care Unit, The Heart Institute, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH.

2Division of Pharmacy, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH.

3Nursing Division, Research in Patient Services, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH.

4University of Cincinnati College of Medicine, Cincinnati, OH.

5Department of Anesthesia, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH.

*See also p. 382.

Dr. Staveski’s institution received funding from Children's Heart Association of Cincinnati, the Center for Clinical and Translational Science and Training, and internal funding. Dr. Pratap received funding from the Agency for Healthcare Research and Quality and internal funding for unrelated projects. The remaining authors have disclosed that they do not have any potential conflicts of interest.

For information regarding this article, E-mail: jayant.pratap@cchmc.org

©2019The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies