(993) Protocolized Initiation of Clonidine to Prevent Dexmedetomidine Withdrawal: A Cohort Study

Introduction: Dexmedetomidine (Dex) is the recommended agent for sedation in pediatrics. With more widespread use, a Dex withdrawal syndrome of tachycardia, hypertension, agitation, and insomnia has been noted. Previous retrospective studies using clonidine to treat or prevent Dex withdrawal are mixed in terms of effectiveness. We present a prospective pre and post interventional cohort study assessing the use of a clonidine initiation protocol to prevent Dex withdrawal.

Methods: Patients were enrolled in our study after Dex infusion time of ≥72 hours. The pre-intervention phase lasted 6 months, and data was collected in an observational manner. Then, the study protocol was implemented, and patient enrollment continued. Clonidine was started in a tiered dosing approach based on the number of hours on Dex infusion. Dex was weaned by 25% every 6 hours to off over 24 hours. The primary outcome was Dex withdrawal, defined as at least one of: increase in HR, SBP or DBP by at least 10% from the 24 hours prior to Dex weaning to the 24 hours after Dex was discontinued AND at least one of: two documented Withdrawal Assessment Tool scores of ≥ 3 or two study questionnaire scores of ≥ 3.

Results: The preintervention cohort included 91 patients and the intervention cohort included 30. Withdrawal in the overall pre vs intervention cohorts was not different (36% vs 33%, p=0.829), but there was a trend towards less withdrawal in the intervention clonidine cohort vs the pre-intervention clonidine cohort (45% vs 36%, p=0.615). The total hours on Dex did not differ in the two cohorts, but the cumulative Dex dose was higher in the intervention cohort (94.01 mcg/kg vs 134.76 mcg/kg, p=0.030). With the implementation of the protocol, there were more patients weaned off Dex within 24 hours (43% vs 67%, p=0.100) and when broken down by patients who received clonidine statistical significance was reached (31% vs 68%, p=0.022).

Conclusions: To our knowledge this is the first prospective study assessing Dex withdrawal in pediatrics and we documented a trend towards reduction in withdrawal with use of the protocol. In spite of an increase in cumulative Dex dose and a faster weaning period, the incidence of withdrawal did not increase. This supports that use of the protocol did lessen the burden of withdrawal.