Retrospective Study
Copyright ©The Author(s) 2017. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Clin Pediatr. May 8, 2017; 6(2): 110-117
Published online May 8, 2017. doi: 10.5409/wjcp.v6.i2.110
Conversion from prolonged intravenous fentanyl infusion to enteral methadone in critically ill children
Vijay Srinivasan, Daniel Pung, Sean P O’Neill
Vijay Srinivasan, Department of Anesthesiology and Critical Care Medicine, the Children’s Hospital of Philadelphia, Philadelphia, PA 19104, United States
Vijay Srinivasan, Department of Anesthesiology, Critical Care and Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA 19104, United States
Daniel Pung, Department of Pharmacy Services, Children’s Hospital of New Jersey at Newark Beth Israel Medical Center, Newark, NJ 07112, United States
Sean P O’Neill, Office of Patient Safety and Quality, the Children’s Hospital of Philadelphia, Philadelphia, PA 19104, United States
Author contributions: Srinivasan V, Pung D and O’Neill SP contributed equally to this work and approve the final version of this submitted manuscript; Srinivasan V is the guarantor and designed the study; Srinivasan V, Pung D and O’Neill SP participated in the acquisition, analysis and interpretation of data; Srinivasan V drafted the initial manuscript; Srinivasan V, Pung D and O’Neill SP revised the manuscript critically for important intellectual content.
Supported by Russell Raphaely Endowed Chair Funds in Critical Care Medicine, the Children’s Hospital of Philadelphia, Philadelphia, PA, No. 08-005894.
Institutional review board statement: The study was reviewed and approved by the Institutional Review Board at the Children’s Hospital of Philadelphia (CHOP IRB Research Protocol 08-3-5894).
Informed consent statement: Informed consent and assent was waived by the Institutional Review Board at the Children’s Hospital of Philadelphia due to the retrospective nature of the observational study and analysis of only de-identified subject data.
Conflict-of-interest statement: There are no conflicts of interest to report.
Data sharing statement: No additional data are available.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Vijay Srinivasan, MD, FCCM, Department of Anesthesiology and Critical Care Medicine, the Children’s Hospital of Philadelphia, 34th Street and Civic Center Boulevard, Philadelphia, PA 19104, United States. srinivasan@email.chop.edu
Telephone: +1-215-5905505 Fax: +1-215-5904327
Received: January 7, 2017
Peer-review started: January 10, 2017
First decision: February 17, 2017
Revised: March 4, 2017
Accepted: March 23, 2017
Article in press: March 24, 2017
Published online: May 8, 2017
Processing time: 121 Days and 14.4 Hours
Abstract
AIM

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.

METHODS

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.

RESULTS

Compared to SCG (n = 21), RCG (n = 21) had lower median WAT-1 scores at 7 d (2.5 vs 5, P = 0.027). Additionally, RCG had lower overall median pain scores (3 vs 6, P = 0.007), and required less median daily rescue opioids (3 vs 12, P = 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 (P = 0.049).

CONCLUSION

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.

Keywords: Methadone; Withdrawal; Children; Intensive care; Prolonged opioid infusion

Core tip: Critically ill children exposed to prolonged opioid infusions for sedation and analgesia frequently experience withdrawal symptoms when these infusions are discontinued. Conversion to intermittent opioids such as methadone may reduce such withdrawal symptoms, but published studies and guidelines vary widely in terms of dosing and timeframes for such conversions. In this pragmatic analysis of current practice in our institution, we observed wide variation in dosing conversion and timeframes. We observed that it is feasible to convert from intravenous fentanyl infusion directly to enteral methadone within a timeframe of 48 h using a methadone:fentanyl dose conversion ratio of approximately 2.5:1 to minimize withdrawal and reduce need for rescue opioids.