TOP 73 - Standardizing Sedation: A retrospective cohort study measuring the impact of a protocolized sedation pathway on length of intubation in pediatric ICU patients

Publication Number: 1832.TOP 73

Kelsey M. Larkin, NewYork-Presbyterian Morgan Stanley Children's Hospital, New York, NY, United States; Andrew S. Geneslaw, Columbia University Irving Medical Center, New York, NY, United States; Danielle Ahn, Columbia University Medical Center, New York, NY, United States

Background: Respiratory failure requiring invasive mechanical ventilation (IMV) occurs in about 30% of children admitted to the pediatric intensive care unit (PICU). Prolonged intubation is associated with a wide range of complications and poor outcomes. IMV in children requires continuous infusions and intermittent boluses of sedative/analgesic medications to achieve comfort and safety. Sedation medications have notable side effects such as delirium, and long courses typically require wean plans to minimize withdrawal, potentially prolonging hospitalizations. Nursing directed sedation pathways have been shown to decrease duration of mechanical ventilation in some adult and pediatric trials, but the overall data for pediatrics is variable. At our center, a protocolized sedation pathway was created to target a specific Richmond Agitation-Sedation Scale (RASS) score through carefully titrated combinations of continuous and intermittent doses of medications in sedated, intubated patients.

Objective: The aim of our study is to determine if a protocolized sedation pathway reduces the duration of critically ill children receiving IMV for acute respiratory failure. Secondary outcomes include the pathway’s impact on cumulative sedation medication doses in the peri-extubation period (48 hours before and after extubation), achievement of desired sedation levels, withdrawal, and delirium.

Design/Methods: Our study is a retrospective cohort study of data collected from the electronic health record at our urban tertiary care children’s hospital. We included patients < 18 years old who required IMV for >5 days. The pathway is being implemented in a stepped fashion across 3 PICUs and has been initiated in one PICU as of January 2023. The pre-intervention period will be the control for the analysis, as will the other two PICUs that are pending pathway implementation. Changes will be compared across time intervals within each unit to assess the pre/post effects of pathway implementation and address confounding variables related to each PICU's unique patient population. We assessed level of sedation via RASS, withdrawal via the Withdrawal Assessment Tool (WAT), and delirium via the Cornell Assessment of Pediatric Delirium (CAPD). For patient-level assessment, the duration of IMV will be compared using time-to-event analyses, continuous outcomes using Wilcoxon rank-sum tests, and categorical outcomes using Chi-square tests. For unit-level outcomes, interrupted time series and difference-in-differences analyses will be used.
Timeline: Nov/Dec: analysis of primary outcome, Jan: analysis of secondary outcomes