Pediatric Ventilation Liberation: Bundled Extubation Readiness and Analgosedation Pathways Decrease Mechanical Ventilation Duration and Benzodiazepine Exposure

Abstract

Background: Recent studies reported that children on mechanical ventilation who were managed with an analgosedation approach and standardized extubation readiness testing experienced better outcomes, including decreased delirium and invasive mechanical ventilation duration.

Methods: This was a quality improvement project in a 24-bed pediatric ICU within a single center, including subjects ≤ 18 years old who required invasive mechanical ventilation via an oral or nasal endotracheal tube. The aim was to decrease the invasive mechanical ventilation duration for all the subjects by 25% within 9 months through the development and implementation of bundled benzodiazepine-sparing analgosedation and extubation readiness testing clinical pathways.

Results: In the pre-implementation cohort, there were 274 encounters, with 253 (92.3%) that met inclusion for ending in an extubation attempt. In the implementation cohort, there were 367 encounters with 332 (90.5%) that ended in an extubation attempt. The mean invasive mechanical ventilation duration decreased by 23% (Pre 3.95 d vs Post 3.1 d; P = .039) after the implementation without a change in the mean pediatric ICU length of stay (Pre 7.5 d vs Post 6.5 d; P = .42). No difference in unplanned extubation (P > .99) or extubation failure rates (P = .67) were demonstrated. Sedation levels as evaluated by the mean State Behavioral Scale were similar (Pre -1.0 vs Post -1.1; P = .09). The median total benzodiazepine dose administered decreased by 75% (Pre 0.4 vs Post 0.1 mg/kg/ventilated day; P < .001). No difference in narcotic withdrawal (Pre 17.8% vs Post 16.4%; P = .65) or with delirium treatment (Pre 5.5% vs Post 8.7%; P = .14) was demonstrated.

Conclusions: A multidisciplinary, bundled benzodiazepine-sparing analgosedation and extubation readiness testing approach resulted in a reduction in mechanical ventilation duration and benzodiazepine exposure without impacting key balancing measures. External validity needs to be evaluated in similar centers and consensus on best practices developed.

Keywords: analgesia; benzodiazepine; clinical pathways; mechanical ventilation; opioid; pediatrics.

Fig. 1.

PICU sedation algorithm. AKI = acute kidney injury; CKD = chronic kidney disease; IV = intravenous; MD = medical doctor; NSAID = non-steroidal anti-inflammatory drug; NP = nurse practitioner; PCA = patient controlled analgesia; PICU = pediatric ICU; PRN = as needed; SBS = State Behavioral Scale; TBI = traumatic brain injury.

Fig. 2.

A: Statistical process control chart (individuals) and B: corresponding moving range chart, depicting mechanical ventilation duration (in days) for each ventilation encounter across the continuous baseline, planning, and intervention phases. The dashed horizontal lines denote the upper control limit. Note that the lower control limit was omitted due to a negative value, which is not clinically possible. 1) Pulmonary disease cohort ERT pilot #1 (January 2019), 2) PICU liberation project planning begins (February 2019), C) PICU liberation project launch (July 2019) and pulmonary disease cohort ERT pilot #2 (July 2019–October 2019).