Iatrogenic Withdrawal Research Articles

The use of methadone to facilitate opioid weaning in pediatric critical care patients: a systematic review of the literature and meta-analysis.

Continuous opioid infusion therapy is commonly utilized in the pediatric intensive care setting to treat pain and facilitate tolerance of invasive therapies. Transitioning to methadone is one common strategy for weaning from continuous opioid infusions, but in practice this transition can be challenging, and many children still experience iatrogenic withdrawal. We reviewed the literature to evaluate the best available evidence to guide methadone therapy in this setting, and to summarize associated adverse events. We included all studies of methadone used to facilitate weaning from continuous opioid infusions in pediatric critical care patients, including medical, cardiac, and surgical patients, excluding case reports and studies treating neonatal abstinence syndrome, or acute or chronic pain. Medline, Embase, and CINAHL databases from inception to May 2015 were queried; references of included works and conference proceedings were also reviewed. Two authors independently extracted data from each study. Meta-analysis with fixed- and random-effects models was used to pool results of studies when applicable. Twelve studies involving 459 patients met criteria for inclusion. A wide variety of methadone dosing and taper strategies were reported. Mean inpatient methadone taper times varied widely, from 4.3 to 26.2 days. Excessive sedation was the most frequently reported adverse event, occurring in up to 16% of patients. Withdrawal occurred in 27% of patients among studies reporting this outcome. In three of three studies in which a new methadone protocol was introduced, a decreased proportion of patients experienced withdrawal (standardized mean difference, SMD = -0.60, 95% CI = -0.998 to -0.195, P = 0.004). We did not identify sufficient evidence to recommend any particular methadone weaning strategy, or to recommend methadone over other medications or prescribed infusion weaning, for successful weaning of continuous opioid infusions in the pediatric intensive care setting.

Patient, Process, and System Predictors of Iatrogenic Withdrawal Syndrome in Critically Ill Children*

To generate a multidimensional predictive model of risk factors for iatrogenic withdrawal syndrome in critically ill children. Secondary analysis of prospective data from the Randomized Evaluation of Sedation Titration for Respiratory Failure clinical trial. PICU. Children who received greater than or equal to 5 days of sedation during mechanical ventilation for acute respiratory failure. The Randomized Evaluation of Sedation Titration for Respiratory Failure study tested the effect of a nurse-led, goal-directed sedation protocol on clinical outcomes. There was no additional intervention in this secondary analysis. Data included 1,157 children from 31 PICUs. Iatrogenic withdrawal syndrome was defined as having at least two Withdrawal Assessment Tool-Version 1 scores greater than or equal to 3 after the start of opioid weaning. Logistic regression with generalized estimating equations to account for clustering by site was used to evaluate patient, process, and healthcare system risk factors for iatrogenic withdrawal syndrome. Subjects with iatrogenic withdrawal syndrome (544/1,157; 47%) were younger and more likely to have preexisting cognitive or functional impairment. They also received higher sedative doses and longer exposure periods. In multivariable analyses, significant predictors of iatrogenic withdrawal syndrome included younger age, preexisting cognitive impairment, higher preweaning mean daily opioid dose, longer duration of sedation, receipt of three or more preweaning sedative classes, higher nursing workload, and more one-to-one nurse staffing. Iatrogenic withdrawal syndrome is common in children recovering from critical illness, and several risk factors are predictive, including patient characteristics, sedative exposure, additional sedative agents, and system-level factors. High-risk patients could be identified before weaning to better prevent iatrogenic withdrawal syndrome among at-risk patients.

Iatrogenic Withdrawal Syndromes in Children: A Review of Sedative and Analgesic Weaning

Iatrogenic withdrawal syndromes develop in children exposed to prolonged sedative and analgesic medications. Signs of withdrawal include central nervous system irritability, gastrointestinal dysfunction, and autonomic dysfunction. The most important steps to the safe management of sedative and analgesic weaning in children are the early identification of the risk of withdrawal, use of a validated withdrawal assessment scale, use of nonpharmacologic interventions, and administration of medication for weaning, if indicated. This article reviews the physiologic mechanisms of opioid tolerance and withdrawal, validated pediatric withdrawal scales, and safe management of iatrogenic withdrawal syndromes. Figures illustrate cellular responses to acute and chronic exposure to opioids. A suggested algorithm for the safe and rapid weaning of sedative and analgesic medications, using the best available evidence, is discussed. Key words: analgesic weaning, opioid tolerance, pediatric withdrawal, sedation weaning, weaning algorithm for children

Iatrogenic Withdrawal Syndromes in Children: A Review of Sedative and Analgesic Weaning

Iatrogenic withdrawal syndromes develop in children exposed to prolonged sedative and analgesic medications. Signs of withdrawal include central nervous system irritability, gastrointestinal dysfunction, and autonomic dysfunction. The most important steps to the safe management of sedative and analgesic weaning in children are the early identification of the risk of withdrawal, use of a validated withdrawal assessment scale, use of nonpharmacologic interventions, and administration of medication for weaning, if indicated. This article reviews the physiologic mechanisms of opioid tolerance and withdrawal, validated pediatric withdrawal scales, and safe management of iatrogenic withdrawal syndromes. Figures illustrate cellular responses to acute and chronic exposure to opioids. A suggested algorithm for the safe and rapid weaning of sedative and analgesic medications, using the best available evidence, is discussed. Key words: analgesic weaning, opioid tolerance, pediatric withdrawal, sedation weaning, weaning algorithm for children

Sedation in Critically Ill Children with Respiratory Failure.

This article discusses the rationale of sedation in respiratory failure, sedation goals, how to assess the need for sedation as well as effectiveness of interventions in critically ill children, with validated observational sedation scales. The drugs and non-pharmacological approaches used for optimal sedation in ventilated children are reviewed, and specifically the rationale for drug selection, including short- and long-term efficacy and safety aspects of the selected drugs. The specific pharmacokinetic and pharmacodynamic aspects of sedative drugs in the critically ill child and consequences for dosing are presented. Furthermore, we discuss different sedation strategies and their adverse events, such as iatrogenic withdrawal syndrome and delirium. These principles can guide clinicians in the choice of sedative drugs in pediatric respiratory failure.

Clinical recommendations for pain, sedation, withdrawal and delirium assessment in critically ill infants and children: an ESPNIC position statement for healthcare professionals.

BackgroundThis position statement provides clinical recommendations for the assessment of pain, level of sedation, iatrogenic withdrawal syndrome and delirium in critically ill infants and children. Admission to a neonatal or paediatric intensive care unit (NICU, PICU) exposes a child to a series of painful and stressful events. Accurate assessment of the presence of pain and non-pain-related distress (adequacy of sedation, iatrogenic withdrawal syndrome and delirium) is essential to good clinical management and to monitoring the effectiveness of interventions to relieve or prevent pain and distress in the individual patient.MethodsA multidisciplinary group of experts was recruited from the members of the European Society of Paediatric and Neonatal Intensive Care (ESPNIC). The group formulated clinical questions regarding assessment of pain and non-pain-related distress in critically ill and nonverbal children, and searched the PubMed/Medline, CINAHL and Embase databases for studies describing the psychometric properties of assessment instruments. Furthermore, level of evidence of selected studies was assigned and recommendations were formulated, and grade or recommendations were added on the basis of the level of evidence.ResultsAn ESPNIC position statement was drafted which provides clinical recommendations on assessment of pain (n = 5), distress and/or level of sedation (n = 4), iatrogenic withdrawal syndrome (n = 3) and delirium (n = 3). These recommendations were based on the available evidence and consensus amongst the experts and other members of ESPNIC.ConclusionsThis multidisciplinary ESPNIC position statement guides professionals in the assessment and reassessment of the effectiveness of treatment interventions for pain, distress, inadequate sedation, withdrawal syndrome and delirium.Electronic supplementary materialThe online version of this article (doi:10.1007/s00134-016-4344-1) contains supplementary material, which is available to authorized users.

Opioid and Benzodiazepine Withdrawal Syndrome in PICU Patients: Which Risk Factors Matter?

Although iatrogenic withdrawal syndrome (IWS) has been recognized in patients exposed to opioids and benzodiazepines, very few studies have used a validated tool for diagnosis and assessment of IWS in critically ill children. We sought to determine IWS rate, risk factors, and outcomes of IWS patients. Prospective observational study conducted in a pediatric intensive care unit. A total of 137 patients (31 with IWS and 106 with no IWS) received a continuous infusion of fentanyl and midazolam for 3 or more days. The Sophia Observation withdrawal Symptoms scale was repeatedly applied when children were weaned off sedation/analgesia. The overall incidence of IWS was 22.6%. Of the 31 IWS patients, 6 showed IWS with less than 5 days sedation or analgesia. Logistic regression showed that the median peak dose of midazolam was associated with IWS development (odds ratio 1.4). Receiver-operating curve showed a cut-off value of 0.35 mg/kg/h for midazolam peak dose (sensitivity 96.7%, specificity 51%, positive predictive value 36.6%, and negative predictive value 98.2%), with area under the curve of 0.80. IWS patients had a longer time on mechanical ventilation, prolonged pediatric intensive care unit, and hospital stays, and required prolonged period to have drugs discontinued. Although length of sedation/analgesia for at least5 days has been widely proposed for monitoring IWS, our data suggest that initiating monitoring after 3 sedation days is highly recommended. In addition, patients requiring infusion rates of midazolam above 0.35 mg/kg/h should be considered at high risk for IWS.

Patterns of Sedation Weaning in Critically Ill Children Recovering From Acute Respiratory Failure.

To characterize sedation weaning patterns in typical practice settings among children recovering from critical illness. A descriptive secondary analysis of data that were prospectively collected during the prerandomization phase (January to July 2009) of a clinical trial of sedation management. Twenty-two PICUs across the United States. The sample included 145 patients, aged 2 weeks to 17 years, mechanically ventilated for acute respiratory failure who received at least five consecutive days of opioid exposure. None. Group comparisons were made between patients with an intermittent weaning pattern, defined as a 20% or greater increase in daily opioid dose after the start of weaning, and the remaining patients defined as having a steady weaning pattern. Demographic and clinical characteristics, tolerance to sedatives, and iatrogenic withdrawal symptoms were evaluated. Sixty-six patients (46%) were intermittently weaned; 79 patients were steadily weaned. Prior to weaning, intermittently weaned patients received higher peak and cumulative doses and longer exposures to opioids and benzodiazepines, demonstrated more sedative tolerance (58% vs 41%), and received more chloral hydrate and barbiturates compared with steadily weaned patients. During weaning, intermittently weaned patients assessed for withdrawal had a higher incidence of Withdrawal Assessment Tool-version 1 scores of greater than or equal to 3 (85% vs 46%) and received more sedative classes compared with steadily weaned patients. This study characterizes sedative administration practices for pediatric patients prior to and during weaning from sedation after critical illness. It provides a novel methodology for describing weaning in an at-risk pediatric population that may be helpful in future research on weaning strategies to prevent iatrogenic withdrawal syndrome.

Identifying and assessing the substance-exposed infant.

As the rate of opioid prescription grows, so does fetal exposure to opioids during pregnancy. With increasing fetal exposure to both prescription and nonprescription drugs, there has been a concurrent increase in identification of Neonatal Withdrawal Syndrome (NWS) and adaptation difficulties after birth. In addition, extended use of opioids, barbiturates, and benzodiazepines in neonatal intensive care has resulted in iatrogenic withdrawal syndromes. There is a lack of evidence to support the use of any one specific evaluation strategy to identify NWS. Clinicians caring for infants must use a multimethod approach to diagnosis, including interview and toxicology screening. Signs of NWS are widely variable, and reflect dysfunction in autonomic regulation, state control, and sensory and motor functioning. Several assessment tools have been developed for assessing severity of withdrawal in term neonates. These tools assist in determining need and duration of pharmacologic therapy and help in titration of these therapies. Considerable variability exists in the pharmacologic and nonpharmacologic approaches to affected babies across settings. An evidence-based protocol for identification, evaluation, and management of NWS should be in place in every nursery. This article provides an overview of identification and assessment considerations for providers who care for babies at risk for or who are experiencing alterations in state, behavior, and responses after prenatal or iatrogenic exposure to agents associated with the spectrum of withdrawal.

Risk Factors Associated With Iatrogenic Opioid and Benzodiazepine Withdrawal in Critically Ill Pediatric Patients

Analgesia and sedation are common therapies in pediatric critical care, and rapid titration of these medications is associated with iatrogenic withdrawal syndrome. We performed a systematic review of the literature to identify all common and salient risk factors associated with iatrogenic withdrawal syndrome and build a conceptual model of iatrogenic withdrawal syndrome risk in critically ill pediatric patients. Multiple databases, including PubMed/Medline, EMBASE, CINAHL, and the Cochrane Central Registry of Clinical Trials, were searched using relevant terms from January 1, 1980, to August 1, 2014. Articles were included if they were published in English and discussed iatrogenic withdrawal syndrome following either opioid or benzodiazepine therapy in children in acute or intensive care settings. Articles were excluded if subjects were neonates born to opioid- or benzodiazepine-dependent mothers, children diagnosed as substance abusers, or subjects with cancer-related pain; if data about opioid or benzodiazepine treatment were not specified; or if primary data were not reported. In total, 1,395 articles were evaluated, 33 of which met the inclusion criteria. To facilitate analysis, all opioid and/or benzodiazepine doses were converted to morphine or midazolam equivalents, respectively. A table of evidence was developed for qualitative analysis of common themes, providing a framework for the construction of a conceptual model. The strongest risk factors associated with iatrogenic withdrawal syndrome include duration of therapy and cumulative dose. Additionally, evidence exists linking patient, process, and system factors in the development of iatrogenic withdrawal syndrome. Most articles were prospective observational or interventional studies. Given the state of existing evidence, well-designed prospective studies are required to better characterize iatrogenic withdrawal syndrome in critically ill pediatric patients. This review provides data to support the construction of a conceptual model of iatrogenic withdrawal syndrome risk that, if supported, could be useful in guiding future research.

Protocolized Sedation vs Usual Care in Pediatric Patients Mechanically Ventilated for Acute Respiratory Failure

Protocolized sedation improves clinical outcomes in critically ill adults, but its effect in children is unknown. To determine whether critically ill children managed with a nurse-implemented, goal-directed sedation protocol experience fewer days of mechanical ventilation than patients receiving usual care. Cluster randomized trial conducted in 31 US pediatric intensive care units (PICUs). A total of 2449 children (mean age, 4.7 years; range, 2 weeks to 17 years) mechanically ventilated for acute respiratory failure were enrolled in 2009-2013 and followed up until 72 hours after opioids were discontinued, 28 days, or hospital discharge. Intervention PICUs (17 sites; n = 1225 patients) used a protocol that included targeted sedation, arousal assessments, extubation readiness testing, sedation adjustment every 8 hours, and sedation weaning. Control PICUs (14 sites; n = 1224 patients) managed sedation per usual care. The primary outcome was duration of mechanical ventilation. Secondary outcomes included time to recovery from acute respiratory failure, duration of weaning from mechanical ventilation, neurological testing, PICU and hospital lengths of stay, in-hospital mortality, sedation-related adverse events, measures of sedative exposure (wakefulness, pain, and agitation), and occurrence of iatrogenic withdrawal. Duration of mechanical ventilation was not different between the 2 groups (intervention: median, 6.5 [IQR, 4.1-11.2] days; control: median, 6.5 [IQR, 3.7-12.1] days). Sedation-related adverse events including inadequate pain and sedation management, clinically significant iatrogenic withdrawal, and unplanned endotracheal tube/invasive line removal were not significantly different between the 2 groups. Intervention patients experienced more postextubation stridor (7% vs 4%; P = .03) and fewer stage 2 or worse immobility-related pressure ulcers (<1% vs 2%; P = .001). In exploratory analyses, intervention patients had fewer days of opioid administration (median, 9 [IQR, 5-15] days vs 10 [IQR, 4-21] days; P = .01), were exposed to fewer sedative classes (median, 2 [IQR, 2-3] classes vs 3 [IQR, 2-4] classes; P < .001), and were more often awake and calm while intubated (median, 86% [IQR, 67%-100%] of days vs 75% [IQR, 50%-100%] of days; P = .004) than control patients, respectively; however, intervention patients had more days with any report of a pain score ≥ 4 (median, 50% [IQR, 27%-67%] of days vs 23% [IQR, 0%-46%] of days; P < .001) and any report of agitation (median, 60% [IQR, 33%-80%] vs 40% [IQR, 13%-67%]; P = .003), respectively. Among children undergoing mechanical ventilation for acute respiratory failure, the use of a sedation protocol compared with usual care did not reduce the duration of mechanical ventilation. Exploratory analyses of secondary outcomes suggest a complex relationship among wakefulness, pain, and agitation. clinicaltrials.gov Identifier: NCT00814099.

ABSTRACT 296

Background and aims: Iatrogenic withdrawal syndrome (IWS) – physiologic symptoms that manifest following rapid weaning or abrupt cessation of opioids or benzodiazepines in drug tolerant patients – is prevalent in critically ill children receiving >5 days of sedation. Aims: The purpose of this study was to develop a conceptual model of risk factors contributing to the development of IWS, to provide a theoretical basis for future research. Methods: A systematic review of the literature (1 January 1980 to 10 December 2013) was conducted, using PubMed, EMBASE, CINAHL, and the Cochrane Registry of Clinical Trials. Search terms included “respiration, artificial,” “weaning,” and “analgesics, opioid” and “benzodiazepines.” Data were extracted into pre-determined tables and qualitatively synthesized. Results: Current literature suggests three categories of risk factors associated with IWS in critically ill children: patient-, process- and system-level factors. Risk factors specific to the patient include age, disease severity, and cumulative dose of sedative medication. Use of validated assessment tools, standardized weaning protocols, and prescription of multiple adjunctive agents are process-level factors. Finally, sedation therapy occurs within a system context, which determines factors such as protocol compliance. However, further work is needed to elucidate the contributions of system-level factors to overall risk of IWS.FigureConclusions: The proposed conceptual model illustrates the convergence of patient-, process-, and system-level factors with physiologic tolerance in determining a patient’s risk for IWS.

Risk factor of withdrawal syndrome in the paediatric ICU

Critically ill paediatric patients supported on mechanical ventilation frequently receive analgesia and sedation. Iatrogenic withdrawal syndrome occurs with the abrupt discontinuation or too rapid weaning of opioids and benzodiazepines. We induce the Withdrawal Assessment Tool-1 (WAT-1) [1] to evaluate children during weaning from analgesics and sedatives. The patient is diagnosed with withdrawal syndrome when the score is 3 or >3. We compared the subjects who ever had a score over 3 and those with lower scores and assessed the risk factors and outcome of withdrawal syndrome between two groups.

Babies breaking bad

This review will summarize the symptoms, evaluation, and treatment of neonatal and iatrogenic withdrawal syndromes. Buprenorphine is emerging as the drug of choice for maintaining opioid-dependent women during pregnancy, because of its association with less severe withdrawal symptoms. Recent findings suggest it may be the drug of choice for treating the opioid-exposed neonate as well. Healthcare workers should be cognizant of the risk factors for neonatal abstinence syndrome (NAS), as well as its symptoms, so that nonpharmalogic and pharmacologic therapies can be initiated. With increased emphasis on pain control in children, it is likely that iatrogenic withdrawal will continue to be a concern, and healthcare workers should understand the similarities and differences between this and NAS.

Defining sedation-related adverse events in the pediatric intensive care unit

BackgroundClinical trials exploring optimal sedation management in critically ill pediatric patients are urgently needed to improve both short- and long-term outcomes. Concise operational definitions that define and provide best-available estimates of sedation-related adverse events (AE) in the pediatric population are fundamental to this line of inquiry. ObjectivesTo perform a multiphase systematic review of the literature to identify, define, and provide estimates of sedation-related AEs in the pediatric ICU setting for use in a multicenter clinical trial. MethodsIn Phase One, we identified and operationally defined the AE. OVID-MEDLINE and CINAHL databases were searched from January 1998 to January 2012. Key terms included sedation, intensive and critical care. We limited our search to data-based clinical trials from neonatal to adult age. In Phase Two, we replicated the search strategy for all AEs and identified pediatric-specific AE rates. ResultsWe reviewed 20 articles identifying sedation-related adverse events and 64 articles on the pediatric-specific sedation-related AE. A total of eleven sedation-related AEs were identified, operationally defined and estimated pediatric event rates were derived. AEs included: inadequate sedation management, inadequate pain management, clinically significant iatrogenic withdrawal, unplanned endotracheal tube extubation, post-extubation stridor with chest-wall retractions at rest, extubation failure, unplanned removal of invasive tubes, ventilator-associated pneumonia, catheter-associated bloodstream infection, Stage II+ pressure ulcers and new tracheostomy. ConclusionsConcise operational definitions that defined and provided best-available event rates of sedation-related AEs in the pediatric population are presented. Uniform reporting of adverse events will improve subject and patient safety.

Prospective evaluation of sedation-related adverse events in pediatric patients ventilated for acute respiratory failure*

Sedation-related adverse events in critically ill pediatric patients lack reproducible operational definitions and reference standards. Understanding these adverse events is essential to improving the quality of patient care and for developing prevention strategies in critically ill children. The purpose of this study was to test operational definitions and estimate the rate and site-to-site heterogeneity of sedation-related adverse events. Prospective cohort study. Twenty-two pediatric intensive care units in the United States enrolling baseline patients into a prerandomization phase of a multicenter trial on sedation management. Pediatric patients intubated and mechanically ventilated for acute respiratory failure. Analysis of adverse event data using consistent operational definitions from a Web-based data management system. There were 594 sedation-related adverse events reported in 308 subjects, for a rate of 1.9 adverse events per subject and 16.6 adverse events per 100 pediatric intensive care unit days. Fifty-four percent of subjects had at least one adverse event. Seven (1%) adverse events were classified as severe, 347 (58%) as moderate, and 240 (40%) as mild. Agitation (30% of subjects, 41% of events) and pain (27% of subjects, 29% of events) were the most frequently reported events. Eight percent of subjects (n = 24) experienced 54 episodes of clinically significant iatrogenic withdrawal. Unplanned endotracheal tube extubation occurred at a rate of 0.82 per 100 ventilator days, and 32 subjects experienced postextubation stridor. Adverse events with moderate intraclass correlation coefficients included: Inadequate sedation management (intraclass correlation coefficient = 0.130), clinically significant iatrogenic withdrawal (intraclass correlation coefficient = 0.088), inadequate pain management (intraclass correlation coefficient = 0.080), and postextubation stridor (intraclass correlation coefficient = 0.078). Operational definitions for sedation-related adverse events were consistently applied across multiple pediatric intensive care units. Adverse event rates were different from what has been previously reported in single-center studies. Many adverse events have moderate intraclass correlation coefficients, signaling site-to-site heterogeneity.

Validity and generalizability of the Withdrawal Assessment Tool-1 (WAT-1) for monitoring iatrogenic withdrawal syndrome in pediatric patients

Critically ill pediatric patients frequently receive prolonged analgesia and sedation to provide pain relief and facilitate intensive care therapies. Iatrogenic withdrawal syndrome occurs when these drugs are stopped abruptly or weaned too rapidly. We investigated the validity and generalizability of the Withdrawal Assessment Tool-1 (WAT-1) in children during weaning of analgesics and sedatives. Of 308 children initially supported on mechanical ventilation for acute respiratory failure, 126 (41%) from 21 centers (median age 1.6 years; interquartile range 0.6–7.7 years) were exposed to 5 or more days of opioids. Subjects were assessed for withdrawal symptoms with the WAT-1, an 11-item (12-point) scale, from the first day of weaning from analgesia/sedation until 72 h after the last opioid dose. A total of 836 daily WAT-1 assessments were completed, with a median (interquartile range) WAT-1 score of 2 (0–4) over 6 (3–9) days per subject. There were no significant differences in WAT-1 scores as a function of age. Factor analyses confirmed that motor-related symptoms and behavioral state accounted for the most variance in WAT-1 scores. Supporting construct validity, cumulative opioid exposures were greater [40.2 (19.7–83.4) vs 17.6 (14.6–39.7) mg/kg, P = .004], length of opioid treatment before weaning was longer [7 (6–11) vs 5 (5–8) days, P = .004], and length of weaning from opioids was longer [10 (6–14) vs 6 (3–9) days, P = .008] in subjects with WAT-1 scores of ⩾3 compared to subjects with WAT-1 scores of <3. The WAT-1 shows good psychometric performance and generalizability when used to assess clinically important withdrawal symptoms in pediatric intensive care and general ward settings.

Opioid and benzodiazepine withdrawal syndromes in the paediatric intensive care unit: a review of recent literature

This paper aims to critically review and analyse available literature to inform and advance patient care. Withdrawal syndromes related to the routine administration of sedation and analgesia in paediatric intensive care unit (PICU) have been recognized since the 1990 s. Common symptoms include tremors, agitation, inconsolable crying and sleeplessness. A critical review was undertaken to assess developments in this area. Four databases were searched using Ovid Online. These were Ovid Medline, CINAHL, BNI and Embase. Key terms included were 'Paediatric', 'Sedation', 'Withdrawal' and 'Intensive care'. Articles from 1980 onwards were reviewed for their relevance to paediatric iatrogenic withdrawal. Additionally, seminal work from the 1970s was included. Because of the scarcity of literature, relevant editorials and opinion pieces were included. A total of 2,232,586 papers resulted from keyword searches. Use of Boolean operators to combine terms reduced the number of results to 62. Exclusion criteria reduced the number of suitable papers to 20. Tracking reference lists yielded a further 18 papers. In total, 38 papers were retrieved examining 1375 patients. Four papers surveyed drug usage on PICU, 14 listed withdrawal symptoms, 4 described the frequency of withdrawal in the PICU population, 9 described risk factors, 4 presented or validated clinical tools and 14 describe treatment strategies. Withdrawal syndromes may affect 20% of exposed children and are related to infusion duration and total dose. Fifty-one symptoms are described in the literature. Future studies need accurate, validated clinical tools to be effective. Risk factors, signs and symptoms have been identified, and validation studies must now take place. Withdrawal syndromes continue to be widespread and difficult to diagnose. Awareness of their causes and treatments should influence clinical decisions at the bedside.

Guidelines for sedation of the critically ill child.

Michelle Bennett RGN, RSCN, ENB 998, ENB N51, BSc(Hons), Lecturer Practitioner, Paediatric Intensive Care, Queen’s Medical Centre, Nottingham Critically ill children often receive sedative agents and analgesics to induce sedation in order to reduce their body’s stress responses, relieve pain and anxiety, prevent dislodgement of essential invasive lines and facilitate supportive measures (Fonsmark et al 1999, Scottish Intercollegiate Guidelines Network (SIGN) 2002). These medications are essential for the safe management of a critically ill child but unfortunately they can have several undesirable side effects, including physical dependence, tolerance and withdrawal symptoms. As Carnevale and Ducharme (1997) write, the time course and pharmacology of sedatives in children differ greatly from that of adults, and recognition of iatrogenic withdrawal reactions in the paediatric critical care setting is only now beginning to emerge. As a result of concerns raised in the paediatric intensive care unit (PICU), Queen’s Medical Centre, Nottingham, the author has devised sedation guidelines based on current research findings and incorporating a combined sedation and comfort assessment score, a weaning programme and a withdrawal symptoms assessment score (see Box 1). This article reviews the research findings regarding sedation assessment and management in the PICU setting and highlights the changes to practice made by the implementation of the guidelines.