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

Objective: 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). Design: Retrospective review of hospital records. Setting: Tertiary care center, PICU. Patients: The cohort for the study included patients who had received subcu taneous fentanyl with or without midazolam to prevent withdrawal after prol onged sedation in the PICU. Measurements and Main Results: Subcutaneous fentanyl with or without midazo lam 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 w ithout midazolam during mechanical ventilation for respiratory failure. The starting infusion rate for subcutaneous fentanyl varied from 5 to 9 mu g/k g/hr (mean, 7.1 +/- 1.4 mu g/kg/hr). Four patients also received subcutaneo us midazolam at a rate of 0.15 to 0.3 mg/kg/hr (mean, 0.24 mg/kg/hr). Subcu taneous 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 t reatment. The fentanyl infusion was decreased by 1 mu g/kg/hr every 12-24 h rs and the midazolam infusion was decreased by 0.05 mg/kg/hr every 12-24 hr s. Mo patient demonstrated signs of symptoms of moderate to severe withdraw al. Conclusion: The subcutaneous route provides an effective alternative to int ravenous administration, It allows far gradual weaning from sedative/analge sic agents after prolonged sedation while eliminating the need to maintain intravenous access.