(205) The Comfort Zone: Implementation of an Analgesia and Sedation Protocol in a Pediatric CVICU

Introduction: Optimization of sedative and analgesic agents among critically ill pediatric patients can be difficult due to complex medical conditions, evolving pathophysiology, as well as unique pharmacodynamics and pharmacokinetics. While sedation and analgesia may be needed for patient comfort and safety, oversedation can increase patient risk of opioid tolerance, withdrawal syndrome, and contribute longer length of ICU stay. This study aims to describe opioid and non-opioid analgesic use among pediatric patients in the cardiovascular intensive care unit (CVICU) following the implementation of an analgesia and sedation protocol.

Methods: An analgesia and sedation protocol was developed by the CVICU sedation workgroup at Lucile Packard Children’s Hospital Stanford, which comprised of an attending physician, two fellow physicians, a pharmacist, an advanced practice provider, and two nurses. Following protocol implementation and staff education in August and September 2023, a retrospective analysis was conducted for opioid and non-opioid analgesics ordered in the CVICU from January 2023 to June 2024. The primary outcome compared morphine and hydromorphone use, in morphine milligram equivalents (MME) per ICU patient days, before and after protocol implementation. Secondary outcomes included gabapentin and ketorolac use among CVICU patients.

Results: Following protocol implementation and staff education in the CVICU, the average morphine MME per ICU patient days decreased from 9.97 (± 4.65) to 6.37 (± 2.72). The average hydromorphone MME per ICU patient days also decreased from 2.78 (± 1.4) to 0.59 (± 0.46). The average number of gabapentin administrations increased from 226 (± 66.6) pre-protocol to 409 (± 120) post-protocol implementation. The average duration of ketorolac courses slightly increased, from 0.79 (± 0.21) days to 0.9 (± 0.29) days.

Conclusions: Study results demonstrate successful decrease of morphine and hydromorphone use in the CVICU, and increased utilization of non-opioid agents, such as gabapentin and ketorolac for pain control. While ketorolac use is typically limited to a five-day time maximum due to the risk of bleeding, the average ketorolac course is currently less than one day, suggesting that ketorolac may be a potential agent for further optimization in the CVICU.