Weaning critically ill children undergoing prolonged sedation: challenges in achieving standardized practice

The aim of this study was to observe how drug dose reduction and interruption is conducted in critically ill children receiving sedation for longer than 5 days, analyzed as drug dose percentage modifications relative to the first day of weaning. We also assessed adherence to a predefined tapering target between 10 and 20% of the initial sedative dose. Retrospective cohort study in a tertiary pediatric intensive care unit (PICU). Overall, 41 patients were enrolled. The cohort median (interquartile range) daily percentage reductions during the weaning phase were 10.6% (3.8–20.4) for fentanyl, 3.3% (0–13.7) for midazolam, 0% (0–10.7) for dexmedetomidine, 5.4% (0–15.4) for ketamine, and 10.5% (0–20.0) for propofol. Median reductions were significantly lower from the 20% target for midazolam, dexmedetomidine, ketamine, and propofol, while fentanyl showed a borderline difference. Adherence to the scheduled tapering range (10–20%) was low across all sedatives during weaning phase. Fentanyl had the highest proportion of weaning days within the target range (19.8%). Overall, only 16 (39%) patients had Withdrawal Assessment Tool 1 (WAT-1) data. Of these, 8 (50%) were positive on the first day of evaluation and three (18%) on the last day. In children sedated for more than 5 days the recommended weaning rate was rarely respected. Withdrawal monitoring was suboptimal and did not guide drug weaning.