Key Point

Withdrawal symptoms, such as agitation, sleep disturbance, and movement disorder, may occur in children with prolonged exposure to sedatives.

Longer duration of use and high dosing of benzodiazepine and opioids are risk factors for withdrawal symptoms in ventilated, critically ill children, researchers reported in the August Critical Care Medicine.

To determine the prevalence of withdrawal symptoms, Erwin Ista, RN, PhD, from Sophia Children’s Hospital in Rotterdam, the Netherlands, and coauthors developed a symptom checklist based on a literature review specific to critically ill children. Scoring for the screening tool, called the Sophia Benzodiazepine and Opioid Withdrawal Checklist (SBOWC), ranges from 0 to 24 (ie, no symptoms vs all symptoms of withdrawal). Attending nurses completed the SBOWC at a set time during every shift.

Seventy-nine children 16 years or younger (median age, 3.4 months) who received intravenous midazolam and/or opioids (morphine or fentanyl) by continuous infusion for at least five days in pediatric and pediatric surgical ICUs were evaluated. All patients were sedated with midazolam at a median dose of 176 μg/kg/h, and 92% of subjects received opioids. Midazolam was weaned by decreasing in steps of 50 μg/kg/h per eight hours and morphine by steps of 10 μg/kg/h per 24 hours.

Observations were divided into four groups: the total group (2,161 observations in all 79 children); the “weaning group” (932 observations in 76 children obtained within 24 hours after decrease and/or discontinuation of medication); the “high doses” group (496 observations in 19 children with the highest total doses of midazolam during admission [more than 70 mg/kg] who are at particular risk for withdrawal symptoms); and the “unsuccessful weaning” group (93 observations in 27 children obtained before increasing sedation during the weaning process to counteract possible withdrawal-related symptoms).

Symptoms of central nervous system irritability such as anxiety, agitation, grimacing, sleep disturbance, increased muscle tension, and movement disorder were noted in more than 10% of all observations. These frequencies differed little between the total, weaning, and high-dose groups. Symptoms such as seizures, tremors, high-pitched crying, pupil dilation, and hallucinations were rarely seen in any of the groups.

“The unsuccessful weaning group showed much higher frequencies of the symptoms agitation, anxiety, increased muscle tone, motor disturbance, grimacing, and sleep less than one hour than observed in the two other weaning groups,” reported the researchers.

Diarrhea and increased gastric residuals after feeding were the most frequently observed gastrointestinal dysfunction in all four groups. Vomiting was twice as frequent in the unsuccessful weaning group as in the three other groups; increased gastric residuals after feeding were more frequent as well.

Autonomic dysfunction such as tachypnea, fever, sweating, and hypertension was observed in more than 13% of assessments overall. The unsuccessful weaning group showed higher frequencies of sweating and mottling.

The median SBOWC sum score was 6, with a range of 1 to 12. Duration of use and total dose of midazolam administration correlated with maximum SBOWC sum score. Total doses of opioids and maximum sum score had a moderate correlation.

Risk for withdrawal symptoms was observed in the weaning group and the high-dose group, the researchers found. Surprisingly, frequencies of withdrawal symptoms hardly differed between groups. “Based on these findings and in line with other authors, we recommend awareness of possible overdiagnosis of withdrawal symptoms,” they concluded, as some symptoms actually may be signs of discomfort, pain, or ventilator distress. The investigators recommended that future studies use videotaped material to increase validity and reliability through independent observers.

—Marguerite Spellman

Suggested Reading
Easley RB, Nichols DG. Withdrawal assessment in the pediatric intensive care unit: quantifying a morbidity of pain and sedation management in the critically ill child. Crit Care Med. 2008;36(8):2479-2480.
Ista E, van Dijk M, Gamel C, et al. Withdrawal symptoms in critically ill children after long-term administration of sedatives and/or analgesics: a first evaluation. Crit Care Med. 2008;36(8):2427-2432.

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