Subcutaneous administration of fentanyl and midazolam to prevent withdrawal after prolonged sedation in children.

Abstract

To determine the efficacy of switching to subcutaneous fentanyl with or without midazolam to prevent withdrawal after prolonged sedation in children in the pediatric intensive care unit (PICU). Retrospective review of hospital records. Tertiary care center, PICU. The cohort for the study included patients who had received subcutaneous fentanyl with or without midazolam to prevent withdrawal after prolonged sedation in the PICU. Subcutaneous fentanyl with or without midazolam was administered to nine patients ranging in age from 3 to 7 yrs (mean, 4.4 +/- 1.8 yrs) and ranging in weight from 11 to 31 kg (mean, 20.1 +/- 6.8 kg). All patients required prolonged administration of fentanyl with or without midazolam during mechanical ventilation for respiratory failure. The starting infusion rate for subcutaneous fentanyl varied from 5 to 9 microg/kg/hr (mean, 7.1 +/- 1.4 microg/kg/hr). Four patients also received subcutaneous midazolam at a rate of 0.15 to 0.3 mg/kg/hr (mean, 0.24 mg/kg/hr). Subcutaneous access was maintained for 3-7 days (mean, 5.7 +/- 1.4 days) in the nine patients. No problems with the subcutaneous access were noted during treatment. The fentanyl infusion was decreased by 1 microg/kg/hr every 12-24 hrs and the midazolam infusion was decreased by 0.05 mg/kg/hr every 12-24 hrs. No patient demonstrated signs of symptoms of moderate to severe withdrawal. The subcutaneous route provides an effective alternative to intravenous administration. It allows for gradual weaning from sedative/analgesic agents after prolonged sedation while eliminating the need to maintain intravenous access.