Poster presented at: Annual Update on Pediatric Cardiovascular Disease; February 2008; Scottsdale Arizona

Helvie, Amy E.

Kalsekar, Iftekhar D.

Kibby, Brandon T.

Knoderer, Chad A.

Mazurek, Michael S.

Digital Commons @ Butler University

Butler UniversityDigital Commons @ Butler UniversityScholarship and Professional Work – COPHS College of Pharmacy & Health Sciences2008Impact of Decmedetomidine on Opioid andBenzodiazepine Dosing Requirements in Children.Amy E. HelvieChad A. KnodererButler University, cknodere@butler.eduIftekhar D. KalsekarBrandon T. KibbyMichael S. MazurekFollow this and additional works at: http://digitalcommons.butler.edu/cophs_papersPart of the Pediatrics Commons, and the Pharmacy and Pharmaceutical Sciences CommonsThis Presentation is brought to you for free and open access by the College of Pharmacy & Health Sciences at Digital Commons @ Butler University. Ithas been accepted for inclusion in Scholarship and Professional Work – COPHS by an authorized administrator of Digital Commons @ ButlerUniversity. For more information, please contact fgaede@butler.edu.Recommended CitationHelvie, Amy E.; Knoderer, Chad A.; Kalsekar, Iftekhar D.; Kibby, Brandon T.; and Mazurek, Michael S., "Impact of Decmedetomidineon Opioid and Benzodiazepine Dosing Requirements in Children." (2008). Scholarship and Professional Work – COPHS. Paper 43.http://digitalcommons.butler.edu/cophs_papers/43IMPACT OF DEXMEDETOMIDINE ON OPIOID AND BENZODIAZEPINE DOSING REQUIREMENTS IN CHILDRENAmy E. Helvie*, PharmD, Chad A. Knoderer, PharmD, Iftekhar D. Kalsekar, PhD, Brandon T. Kibby, DO, Michael S. Mazurek, MD*Department of Pharmacy, Riley Hospital for Children, Indianapolis IN.BACKGROUND Dexmedetomidine is a potent and selective alpha2-adrenergic agonist whichhas sedative, analgesic, and anxiolytic effects.   In adults, dexmedetomidine has been shown to decrease opioid dosing requirements when utilized for pain and sedation management.   We hypothesized that similar to adult data, the addition of dexmedetomidine to standard pain and sedation management protocols may reduce the overall opioid and benzodiazepine dosing requirements in children after cardiac surgery.OBJECTIVESTo determine the difference in opioid and benzodiazepine dosingrequirements in children treated with and without dexmedetomidine aftercardiac surgery.METHODSStudy DesignIRB approved retrospective cohort studyData Source Computer generated lists were used to randomly select both case (DEX) and comparison (COMP) subjects. Dosing information was collected via medication administration records for the duration of anesthesiologist management.Patient Population Patients included were pediatric cardiovascular surgery patients who were admitted to the intensive care unit post-operatively. Exclusion criteria:Patients greater than 18 yearsCardiovascular surgery patients whose operative procedure was not performed for repair or palliation of a congenital heart defect Dexmedetomidine patients who did not have dexmedetomidine initiated within 24 hours of surgery.Pain and Sedation Management Standard pain management and sedation protocol managed by pediatric anesthesiologist in all patients. Therapeutic options and dosing were dependent on patient’s airway status.Mechanically ventilatedContinuous fentanyl infusionAs needed (PRN) IV morphinePRN IV midazolam+/- dexmedetomidine Spontaneously breathingPRN IV morphinePRN IV midazolam+/- dexmedetomidine Data Analysis Total cumulative doses of fentanyl, morphine, and midazolam were determined. For equal comparison, opioid dosing was standardized by using equipotent morphine doses.. RESULTSThirty six patients in each group were included.Baseline Demographics •No difference between groupsContinuous InfusionsFentanylAdministered to 18 (50%) in the DEX group and 14 (38%) in the COMP groupDEX group required fewer days of therapy 4.8 vs. 8.9 (p = 0.064)MidazolamNot utilized in any patientDexmedetomidineMean initial infusion:  0.34 ± 0.1 mcg/kg/hrMaximum infusion: 0.44 ± 0.17 mcg/kg/hrBolus doses administered to 8 patients (22%)Average length of infusion:  2.4 ± 1.9 daysDISCUSSIONWhen compared to a historical control population, dexmedetomidine administration to children within 24 hours after surgery for congenital heart disease, was associated with a 37% reduction in total daily opioid dosing requirement, although not statistically significant.Decreased opioid use may also result in decreased PICU days and decreased incidences of opioid withdrawal, both of which impact overall length of stay and associated healthcare costs. Trending towards statistical significance, a reduction in continuous fentanyl infusion requirements was also observed.In our study, cumulative midazolam dosing requirements were higher in patients who received dexmedetomidine, although not statistically significant.  This could be explained by limited upward dexmedetomidine dose titration and may signify that the dexmedetomidine doses were not optimized to achieve desired sedation outcomes.Baseline DemographicsDexmedetomidine(n = 36)No Dexmedetomidine(n = 36)pAge* (months)50.9 (0.85 – 207.4) 44.9 (0.13 – 233) 0.707Weight* (kg)18.5 (3.2 – 104) 16.4 (2 – 99)                   0.695Male 21 (58%) 20 (56%) 0.812Bypass 35 (97%) 34 (94%) 0.555Intubated 26 (72%) 20 (56%) 0.141RACHS-1, n (%)1234564 (11%)9 (25%)22 (61%)1 (3%)003 (8%)10 (28%)21 (58%)2 (6%)001.0000.7890.8101.000007.3 6.93.62.202468Number of dosesOpiod MidazolamMean daily PRN dosesDexmedetomidine No Dexmedetomidine2.94.60.14 0.070246mg/kg/dayOpioid MidazolamMean daily dosing requirementsDexmedetomidine No DexmedetomidineRESULTSOpioid and Midazolam Dosing Requirements Total daily opioid dosing requirements were reduced 37% in the dexmedetomidine verus the comparison group. Patients in the dexmedetomidine group had higher midazolam dosing requirements.p = 0.44 p = 0.071p = 0.78 p = 0.21

Impact of Decmedetomidine on Opioid and Benzodiazepine Dosing Requirements in Children.

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Impact of Decmedetomidine on Opioid and Benzodiazepine Dosing Requirements in Children.

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