Sedation Weaning Initiative Targeting Methadone Exposure: Single Center Improvements in Withdrawal Symptoms and Hospital Length of Stay for Pediatric Cardiac Critical Care

Abstract

Objectives: Sedation and pain medications are necessary in the management of postoperative pediatric cardiac patients. Prolonged exposure to these medications can lead to negative side effects including withdrawal. We hypothesized that standardized weaning guidelines would decrease exposure to sedation medications and decrease withdrawal symptoms. The primary aim was to decrease average days of methadone exposure to within goal for moderate- and high-risk patients within 6 months. Design: Quality improvement methods were used to standardize sedation medication weaning in a pediatric cardiac ICU. Setting: This study took place at Duke Children’s Hospital Pediatric Cardiac ICU in Durham, North Carolina from January 1, 2020, to December 31, 2021. Patients: Children less than 12 months old admitted to the pediatric cardiac ICU who underwent cardiac surgery. Interventions: Sedation weaning guidelines were implemented over the course of 12 months. Data were tracked every 6 months and compared with the 12 months pre-intervention. Patients were stratified into low, moderate, and high risk withdrawal categories based on duration of opioid infusion exposure. Measurements and Main Results: Total sample size was 94 patients in the moderate and high risk categories. Process measures included documentation of Withdrawal Assessment Tool scores and appropriate methadone prescription in patients which increased to 100% post-intervention. For outcome measures, we observed decreased dexmedetomidine infusion duration, decreased methadone wean duration, decreased frequency of elevated Withdrawal Assessment Tool scores, and decreased hospital length of stay post-intervention. For the primary aim, methadone wean duration consistently decreased after each study period. Our intervention did not adversely impact balancing measures. Conclusions: A quality improvement initiative to standardize sedation weaning in a Pediatric Cardiac ICU was successfully implemented and was correlated with decreased duration of sedation medications, decreased withdrawal scores, and decreased length of stay.