(919) Utility of Clonidine Conversion to Prevent Dexmedetomidine Withdrawal Syndrome in Pediatric Patients

Introduction: Adequate sedation and analgesia are important factors in the PICU setting. Dexmedetomidine, an alpha-2 adrenergic agonist, is an increasingly popular option as adjunct sedation. Several studies have supported a bridge with clonidine to prevent dexmedetomidine withdrawal syndrome (DWS), yet there are no defined protocols.

Methods: We analyzed our institution’s current dexmedetomidine to enteral clonidine conversion practice to treat DWS. A retrospective medical record review of patients admitted to the PICU of a tertiary care children’s hospital over a 5-year period was performed. All patients who received dexmedetomidine infusions for greater than 24 hours and initiation of enteral clonidine were included.

Results: Forty-three patients met inclusion criteria. The most common diagnosis was respiratory failure. Twenty-five patients required an escalation in initial clonidine dosing. The initial clonidine dose did not differ between the escalation and non-escalation group; 6.29 mcg/kg/day versus 5.95 (p = 0.239). The maximum clonidine dose in the escalation group was 10.93 mcg/kg/day (SD +/- 6.32). The mean cumulative dexmedetomidine dose in the escalation group was 433.03 mcg/kg (SD +/- 347.97) compared to 202.15 (SD +/- 139.95) in the non-escalation group (p = 0.018). Duration of dexmedetomidine exposure in the escalation group averaged 19.4 days (SD +/- 11.2) compared to 11.7 (SD +/- 5.52) in the non-escalation group (p = 0.028). Concomitant use of dexmedetomidine and clonidine differed between the groups; mean 3.69 days (SD +/- 3.28) in the escalation group compared to 1.59 (SD +/- 1.85); p = 0.036. Cumulative dexmedetomidine doses of 200 mcg/kg correlated to 7.43 mcg/kg/day of clonidine (p =0.006). There was no difference between the groups for hospital LOS, ICU LOS, CVL days, ventilator days, or age.

Conclusions: Prolonged infusions and higher cumulative doses of dexmedetomidine were likely to be associated with an escalation of clonidine dosage to prevent DWS. Patients who required clonidine dose escalation had more days of therapy overlap. Across both escalation and non-escalation groups, increased cumulative dexmedetomidine was associated with higher daily clonidine requirements to prevent withdrawal.