New Sedation Protocol for Infants with Lung Disease

A neonatal intensive care unit team at Children’s Hospital Colorado developed a transformative sedation protocol for infants born prematurely with lung disease, resulting in less pain medication, fewer side effects and calmer, happier babies. Neonatologist Satya Houin, MD, worked alongside Kathleen Hannan, MD, and five other neonatal colleagues to publish this unprecedented study. “You don’t have a magic bullet very often in medicine, but it almost felt magical just to see how quickly they improved,” Dr. Houin says.

Neonatal patients with severe lung disease typically require long-term use of ventilators, and with that comes high levels of various medications, such as opioids and several sedation drugs, including benzodiazepine and dexmedetomidine (an alpha 2 agonist). Under constant sedation, babies build up a tolerance to the medicine. When they need a procedure such as a tracheostomy, they require even higher doses of additional pain and sedation medication due to their tolerance. This results in unwanted side effects, including delirium and agitation, and it can be very difficult to wean patients off such high doses of medicine.

Drs. Hannan and Houin saw these babies struggling and knew they needed a change. That’s when they reached out to colleagues in the pediatric intensive care unit (PICU) to learn more about a propofol-washout technique. Propofol is an intravenous anesthetic, and during a washout the team starts a continuous infusion. They monitor the baby closely, and if the baby remains calm, the team rapidly weans the sedation medications while monitoring for any signs of agitation or withdrawal. This washout desensitizes receptors that opioids and sedation drugs usually attach to and resets them so the patient’s drug tolerance drops. After 24 hours, providers stop the propofol and restart sedation medications as needed at much lower doses.

The PICU had used this approach on some babies and young toddlers, but until now, providers had not used this technique widely in the neonatal population. The team documented a case study involving three infants with a 24-hour propofol infusion following tracheostomy placement. Researchers determined that the approach was safe and viable for rapid reduction in pain and sedation drugs. From 24 hours prior compared to seven days following the propofol infusion, the team saw an 83% reduction in opioid administration, a 74% reduction in benzodiazepine administration and all infants achieved discontinuation of alpha 2 agonist infusion.

“Just being there bedside and watching this every couple of hours — turning down the meds and turning down the meds — it was almost stunning,” Dr. Houin says. “It was just very gratifying to see how much calmer and happier these babies were and see their medication needs disappear.”

The team hopes these positive results can help other infants and inspire future collaboration around complicated issues for this population.

“I think that these patients are seen as a very challenging population to take care of,” Dr. Hannan says. “They have really unique needs, but we can adapt things from other populations that are kind of innovative and really think differently about how we can treat them to give them the best care possible.”