Iatrogenic withdrawal syndrome in the pediatric cardiac intensive care unit: Incidence, risk factors and outcome

Objectives: Critically ill children and neonates routinely receive opioids and benzodiazepines for analgesia and sedation in the pediatric intensive care unit (PICU). Prolonged opioid therapy often leads to tolerance and is associated with iatrogenic withdrawal syndrome (IWS) when opioids and benzodiazepines are weaned or discontinued. Our aim is to study the incidence, risk factors and outcome of IWS following use of a withdrawal protocol on pediatric patients after cardiac surgery. Methods: We prospectively included all postoperative pediatric patients who developed IWS after being assessed by the Withdrawal Assessment Tool (WAT-1) score (WAT-1 >= 3) over 9 months. Unit-based withdrawal management protocol was used. Patients' outcome was assessed by duration to be completely off opioids & benzodiazepines, duration of ICU and hospital stay. Results: 432 patients were admitted during study period. Twenty-five patients (5.8%) developed IWS. The mean age and weight was 15.2 +/- 31.4 months and 6.9 +/- 7.7 kg respectively. 60% of the patients who developed withdrawal had previous ICU admissions with exposure to sedatives. In the IWS group the mean duration for use of fentanyl and midazolam infusions was 8.6 +/- 5.1 & 9.6 +/- 6 days respectively. The mean duration for completely stopping opioids and benzodiazepines was 17.2 +/- 6.8 days with a mean duration of ventilation of 8.2 +/- 6.8 days. The mean ICU and hospital stay for IWS patients was 26.5 +/- 21.9 and 31.5 +/- 21.1 days respectively. There was statistically significant difference in the mean age, and duration of use of sedatives between the patients who developed IWS and those who did not with P value of 0.003 and < 0.0001, respectively. Conclusion: Withdrawal syndrome after pediatric cardiac surgery prolongs ICU and hospital stay. Our data shows that younger age and longer duration for use of sedatives seem to be risk factors for developing withdrawal syndrome.