2025 Southeastern Residency Conference

TITLE: Utility of Clonidine Conversion to Prevent Dexmedetomidine Withdrawal Syndrome in Pediatric Patients
 
AUTHORS: Emily Hardy, Andrea Gerwin, Renee Hughes, Paige Klingborg 
 
BACKGROUND: In 2022, the Society of Critical Care Medicine (SCCM) issued a guideline recommending alpha-2 receptor agonists as the preferred class for sedation in critically ill pediatric patients. Amidst emerging concern regarding potential dexmedetomidine withdrawal in this population, recent evidence has supported the use of clonidine, another alpha-2 agonist, as a bridging agent to mitigate or prevent withdrawal. While some institutions may have implemented the use of clonidine in dexmedetomidine weaning, there is no consensus or validated protocol. This study aimed to examine the relationship between cumulative dexmedetomidine exposure and clonidine requirements and will expand upon a previous analysis at the study site that focused on a period prior to the SCCM guideline update.  

METHODS: This IRB-approved, single center, retrospective observational study focused on patients admitted to the PICU from January 2018 to May 2024. Inclusion criteria included receipt of a continuous dexmedetomidine infusion > 24 hours and enteral clonidine for treatment or prevention of dexmedetomidine withdrawal. Patients were excluded if they used clonidine prior to admission or if clonidine was initiated for an alternate indication. Included patients were divided into two groups – a non-escalation and an escalation group – based on whether the patient received an increase in their clonidine dose (at provider discretion). The primary outcome assessed the relationship between cumulative dexmedetomidine exposure and maximum required clonidine dose. Secondary outcomes included dexmedetomidine withdrawal assessment, rate of clonidine failure following initial clonidine dose, hospital and ICU length of stay, ventilator days, central line days, and incidence of tracheostomy placement.
 
RESULTS: Compared to the non-escalation group, the escalation group had a statistically significant increase in duration of dexmedetomidine (346.4 vs 284.3, p-value=0.0114) and increased cumulative dexmedetomidine dose (341.2 vs 230.8, p-value=0.0128). The difference in initial clonidine dose was not significant (5.7 vs 4.9, p-value=0.7928). The escalation group had a statistically significant increase in hospital LOS (36 vs 27.5, p-value=0.0355) and ICU LOS (27 vs 20.5, p-value=0.0426). There was no statistically significant difference in ventilator days, CVL days, or incidence of tracheostomy.  
 
CONCLUSION: Higher cumulative dexmedetomidine exposure is associated with higher clonidine dose requirements. Both hospital and ICU LOS were significantly decreased in patients who did not require an increase in their clonidine dose. Utilizing cumulative dexmedetomidine exposure to determine initial clonidine dose may be beneficial.