Srinivasan Vijay, Pung Daniel, O'Neill Sean P
Vijay Srinivasan, Department of Anesthesiology and Critical Care Medicine, the Children's Hospital of Philadelphia, Philadelphia, PA 19104, United States.
World J Clin Pediatr. 2017 May 8;6(2):110-117. doi: 10.5409/wjcp.v6.i2.110.
To describe our institutional experience with conversion from intravenous (IV) fentanyl infusion directly to enteral methadone and occurrence of withdrawal in critically ill mechanically ventilated children exposed to prolonged sedation and analgesia.
With Institutional Review Board approval, we retrospectively studied consecutively admitted invasively mechanically ventilated children (0-18 years) sedated with IV fentanyl infusion > 5 d and subsequently converted directly to enteral methadone. Data were obtained on subject demographics, illness severity, daily IV fentanyl and enteral methadone dosing, time to complete conversion, withdrawal scores (WAT-1), pain scores, and need for rescue opioids. Patients were classified as rapid conversion group (RCG) if completely converted ≤ 48 h and slow conversion group (SCG) if completely converted in > 48 h. Primary outcome was difference in WAT-1 scores at 7 d. Secondary outcomes included differences in overall pain scores, and differences in daily rescue opioids.
Compared to SCG ( = 21), RCG ( = 21) had lower median WAT-1 scores at 7 d (2.5 5, = 0.027). Additionally, RCG had lower overall median pain scores (3 6, = 0.007), and required less median daily rescue opioids (3 12, = 0.003) than SCG. The starting daily median methadone dose was 2.3 times the daily median fentanyl dose in the RCG, compared to 1.1 times in the SCG ( = 0.049).
We observed wide variation in conversion from IV fentanyl infusion directly to enteral methadone and variability in withdrawal in critically ill mechanically ventilated children exposed to prolonged sedation. In those children who converted successfully from IV fentanyl infusion to enteral methadone within a period of 48 h, a methadone:fentanyl dose conversion ratio of approximately 2.5:1 was associated with less withdrawal and reduced need for rescue opioids.
描述我院将静脉注射（IV）芬太尼直接转换为肠内美沙酮的经验，以及在接受长时间镇静和镇痛的重症机械通气儿童中戒断反应的发生情况。
经机构审查委员会批准，我们回顾性研究了连续入院的有创机械通气儿童（0至18岁），这些儿童接受静脉注射芬太尼输注超过5天，随后直接转换为肠内美沙酮。获取了受试者的人口统计学数据、疾病严重程度、每日静脉注射芬太尼和肠内美沙酮剂量、完成转换的时间、戒断评分（WAT-1）、疼痛评分以及急救阿片类药物的需求。如果在≤48小时内完全转换，则患者被分类为快速转换组（RCG）；如果在>48小时内完全转换，则为缓慢转换组（SCG）。主要结局是7天时WAT-1评分的差异。次要结局包括总体疼痛评分的差异以及每日急救阿片类药物的差异。
与SCG（n = 21）相比，RCG（n = 21）在7天时的WAT-1评分中位数较低（2.5对5，P = 0.027）。此外，RCG的总体疼痛评分中位数较低（3对6，P = 0.007），并且每日急救阿片类药物的中位数需求比SCG少（3对12，P = 0.003）。在RCG中，美沙酮的起始每日中位数剂量是芬太尼每日中位数剂量的2.3倍，而在SCG中为1.1倍（P = 0.049）。
我们观察到在将静脉注射芬太尼直接转换为肠内美沙酮的过程中存在很大差异，并且在接受长时间镇静的重症机械通气儿童中戒断反应也存在差异。在那些在48小时内成功从静脉注射芬太尼转换为肠内美沙酮的儿童中，美沙酮：芬太尼剂量转换比约为2.5：1与较少的戒断反应和减少的急救阿片类药物需求相关。
