Implementation of Sedation Titration and Weaning Guidelines in a Pediatric Cardiac ICU

First Author(s)

• 

  Caitlin King

  n/a
  Durham, North Carolina

  Disclosure information not submitted.

  Slides and Audio

Co-Author(s)

• DW

  Danielle Wood, CPNP-AC

  Pediatric Cardiac Critical Care Nurse Practitioner
  Duke University Hospital
  Durham, North Carolina, United States

  Disclosure information not submitted.
• JK

  Jeannie Koo, CPNP-AC

  Pediatric Cardiac Critical Care Nurse Practitioner
  Duke University Hospital
  Durham, North Carolina, United States

  Disclosure information not submitted.
• AC

  Austin Cutler, PharmD

  Pharmacist
  Duke University Hospital
  Durham, North Carolina, United States

  Disclosure information not submitted.
• TV

  Travis Vesel, MD

  Pediatric Cardiac Intensivist
  Duke University Hospital
  Durham, North Carolina, United States

  Disclosure information not submitted.

Title: Implementation of Sedation Titration and Weaning Guidelines in a Pediatric Cardiac ICU

Introduction: Children undergoing cardiac surgery are exposed to peri-operative and post-operative sedation with the consequent side effects of withdrawal, constipation, delirium, respiratory depression and neurological effects. The goal of treatment is to minimize drug exposure while providing adequate pain control. We developed a quality improvement initiative to improve the sedation titration and weaning in infants undergoing congenital heart surgery.

Methods: The OBJECTIVE was to implement sedation titration and weaning guidelines in infant patients (0-12 months) undergoing cardiac surgery. The SMART AIM was to decrease mean duration of methadone exposure to ≤ 14 days within 3 months. Surgical cardiac patients < 12 months old admitted to the PCICU from 1/2020-12/2020 (pre-intervention) and from 1/2021-12/2021 (post-intervention) were included. PDSA cycles were performed every 3 months. Nurses and providers received periodic surveys and education via email. OUTCOME MEASURES including total drug exposure, mechanical ventilation time, withdrawal scores, length of stay, frequency of discharge weaning medications, and frequency of adverse events were collected from the EHR and analyzed. Data and surveys were used to inform changes to the guidelines for the subsequent 3-month cycle.

Results: Data from 1/1/20-12/31/20 were collected as baseline values. The first post-implementation cycle was 1/1/21-3/31/21. Baseline values vs post-intervention showed methadone was prescribed to 41% vs 48% of children with an average methadone exposure of 25 vs 19 days, and 16% vs 14% of children were discharged home on methadone. Benzodiazepine infusions were used in 22% vs 20% patients, but only 0-1% of patients required infusion for ≥ 5 days. Length of dexmedetomidine exposure was 6.6 vs 5.2 days, and in patients with dexmedetomidine exposure ≥ 5 days, 17% vs 12% were prescribed clonidine for weaning off dexmedetomidine.

Conclusions: Sedation titration and weaning guidelines were successfully implemented in a pediatric cardiac intensive care unit. Preliminary data suggests that we may be able to shorten the duration of methadone weans and that we underutilize clonidine as a weaning medication. Changes in sedation weaning plans may lead to shorter length of stays and decreased costs for the patient and the hospital.