Analgesia and Sedation at Terminal Extubation: A Secondary Analysis From Death One Hour After Terminal Extubation Study Data* : Pediatric Critical Care Medicine

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Clinical Investigations

Analgesia and Sedation at Terminal Extubation: A Secondary Analysis From Death One Hour After Terminal Extubation Study Data*

Tripathi, Sandeep MD, MS1; Laksana, Eugene BS2; McCrory, Michael C. MD, MS3; Hsu, Stephanie MD4; Zhou, Alice X. BA2; Burkiewicz, Kimberly DNP, CPNP-AC1; Ledbetter, David R. BS2; Aczon, Melissa D. PhD2; Shah, Sareen MD5; Siegel, Linda MD5; Fainberg, Nina MD6; Morrow, Katie R. MSN, CPNP-AC7; Avesar, Michael MD8; Chandnani, Harsha K. MD, MBA, MPH8; Shah, Jui MD8; Pringle, Charlene MSN, CPNP/AC-PC9; Winter, Meredith C. MD10,11

Author Information
Pediatric Critical Care Medicine 24(6):p 463-472, June 2023. | DOI: 10.1097/PCC.0000000000003209



To describe the doses of opioids and benzodiazepines administered around the time of terminal extubation (TE) to children who died within 1 hour of TE and to identify their association with the time to death (TTD).


Secondary analysis of data collected for the Death One Hour After Terminal Extubation study.


Nine U.S. hospitals.


Six hundred eighty patients between 0 and 21 years who died within 1 hour after TE (2010–2021).

Measurements and Main Results: 

Medications included total doses of opioids and benzodiazepines 24 hours before and 1 hour after TE. Correlations between drug doses and TTD in minutes were calculated, and multivariable linear regression performed to determine their association with TTD after adjusting for age, sex, last recorded oxygen saturation/Fio2 ratio and Glasgow Coma Scale score, inotrope requirement in the last 24 hours, and use of muscle relaxants within 1 hour of TE. Median age of the study population was 2.1 years (interquartile range [IQR], 0.4–11.0 yr). The median TTD was 15 minutes (IQR, 8–23 min). Forty percent patients (278/680) received either opioids or benzodiazepines within 1 hour after TE, with the largest proportion receiving opioids only (23%, 159/680). Among patients who received medications, the median IV morphine equivalent within 1 hour after TE was 0.75 mg/kg/hr (IQR, 0.3–1.8 mg/kg/hr) (n = 263), and median lorazepam equivalent was 0.22 mg/kg/hr (IQR, 0.11–0.44 mg/kg/hr) (n = 118). The median morphine equivalent and lorazepam equivalent rates after TE were 7.5-fold and 22-fold greater than the median pre-extubation rates, respectively. No significant direct correlation was observed between either opioid or benzodiazepine doses before or after TE and TTD. After adjusting for confounding variables, regression analysis also failed to show any association between drug dose and TTD.


Children after TE are often prescribed opioids and benzodiazepines. For patients dying within 1 hour of TE, TTD is not associated with the dose of medication administered as part of comfort care.

Copyright © 2023 by the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies

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