(820) Reducing Unplanned Pediatric Extubations by Modifying Sedative Infusions

Introduction: Most mechanically ventilated pediatric patients require sedative infusions to prevent dislodgement and accidental removal of their breathing tubes. Continuous fentanyl infusions are routinely used to sedate these patients. However, at lower infusion doses, other narcotics, like morphine and hydromorphone, may provide more favorable sedative properties compared to fentanyl. We hypothesize that using either morphine or hydromorphone as the initial narcotic infusion rather than fentanyl will reduce unplanned extubations (UEs) in our combined pediatric and pediatric cardiac ICU (PICU/PCICU).

Methods: We performed a unit-based quality improvement project aimed at decreasing the utilization of continuous fentanyl infusions as the first line narcotic used in intubated patients. Baseline data was collected for the year prior to implementation form July 2022-June 2023. The quality improvement initiative began July 2023 and focused on drivers including education, standardization of sedation, and transparency of data. Education was provided to physicians, advance practice practitioners, and nursing staff. A sedative infusion order set was also created to standardize ordering morphine and hydromorphone for intubated patients admitted to the PICU/PCICU. Data was tracked using Statistical Process Control charts, shared at faculty meetings, and displayed on the unit to increase awareness.

Results: During the baseline period, fentanyl was used as the first line narcotic infusion 45.2% of the time. During this period, there were 9 UEs (8 PICU, 1 PCICU). After implementation, first line fentanyl infusions decreased to 17.1%. UEs also decreased to 4 (3 PICU, 1 PCICU) from July 2023 to May 2024. While the UE rate remained stable at 0.93 per 100 ventilator days over the 2-year time period, we did see improvement on a t-chart showing an increase in days between UE events. Since beginning this project in July 2023, we have reached over 200 days consistently between events whereas we only reached a maximum of 73 days between events prior to initiation.

Conclusions: Maintaining pediatric endotracheal tubes is multifactorial with sedative infusions playing a prominent role. Adjusting the medication choice of first line narcotic infusions can decrease UE events.