109 - An Approach to Minimizing Withdrawal in Pediatric ICU Patients

Publication Number: 109.3821

Katie T. Stahler, University of Arkansas for Medical Sciences College of Medicine, Little Rock, AR, United States; Katherine Irby, University of Arkansas for Medical Sciences College of Medicine, Little Rock, AR, United States; Clint Layes, Arkansas Children's Hospital, LITTLE ROCK, AR, United States; Salim Aljabari, university of arkansas, conway, AR, United States

Background: Children in the pediatric intensive care unit (PICU) who require mechanical ventilation are often given sedation, with continuous opioid infusions being the most commonly used. While essential for managing pain and discomfort, prolonged opioid use can lead to drug habituation, increasing the risk of withdrawal when discontinued.

Objective: The aim of this initiative was to standardize management of drug habituation and prevent withdrawal in our PICU, ensuring consistent and effective care for all at-risk patients.

Design/Methods: To standardize the transition from continuous opioid infusion to enteral methadone, the methadone starting dose was determined through risk stratification based on duration and dose of opioid infusion at the time of discontinuation. Our primary outcome measure was the proportion of positive withdrawal assessment scores out of the total assessments conducted, while our process measure tracked compliance with the clinical pathway. The initiative began by assembling a multidisciplinary team to develop a clinical pathway and an accompanying order set. The intervention involved implementing this pathway and order set after comprehensive education sessions for providers, pharmacists, and nurses.

Results: The average percentage of withdrawal breakthrough episodes was tracked quarterly and displayed on a run chart (Figure 1), covering eight quarters of baseline data and ten quarters after the intervention. Following the introduction of the standardized order set, compliance with the clinical pathway reached 76%. Notably, the overall average withdrawal breakthroughs significantly decreased, from 11.8% during the baseline period to 8.73% post-intervention.

Conclusion(s): We successfully implemented a standardized approach for transitioning patients from opioid infusions to enteral methadone using risk stratification, resulting in a significant reduction in average withdrawal episodes post-implementation. As part of our ongoing improvement efforts, we are currently focusing on standardizing methadone weaning protocols, with dose reduction rates based on the same risk stratification model.

Figure 1
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