LAUSR

To the Editor: We thank Savania et al (1) for their article in this issue of Pediatric Critical Care Medicine, since they renewed our interest to minimize the withdrawal syndrome, moreover, the PICU length of stay. In synopsis, the study describes an alternating phase analgosedation protocol. The phases last approximately 4 days each. The first and third phase are combinations of benzodiazepines with opioids (midazolam—fentanyl/remifentanil), the second propofol with ketamine and the fourth dexmedetomidine with nonsteroidal anti-inflammatory drugs (NSAIDs) metamizole and acetaminophen and morphine as a rescue. In the described protocol, the authors included even non mechanically ventilated patients. The first phase is described as “Fentanyl 2 μg/ kg/hr (maximum 4 μg/kg/hr), Midazolam 2 μg/kg/min (maximum 6 μg/kg/min) and rescue Clonidine 1–4 mg/kg/6 hr oral,” that is, a combination that most would agree is not tolerated without airway protection. Protocol noncompliance created the control group. The unit was mostly cardiac surgery patients. The protocol compliant patients stayed around 16 days, so they received the fourth phase (each phase lasted 4 d) with is dexmedetomidine and NSAIDs. The noncompliant group stayed longer around 25 days. Given that the practitioners were educated to use the protocol, the reasons for abandoning would have been of great interest. Unfortunately, we are presented with the categorization causes only. For example, a physician might have decided to avoid dexmedetomidine and NSAIDS because of the level of analgosedation was judged not to be like the one provided by fentanyl and midazolam (reason). Thus, knowing that the cause was “no rotation,” it is less helpful. The results indicated prolonged use (3–4 additional days) of fentanyl, remifentanil, propofol, and midazolam drip, in the noncompliant group. Such results are what one should expect if deeper analgosedation than provided by dexmedetomidine and NSAIDS at phase four was the practitioners’ goal. By such a view, the withdrawal is expected to be more prevalent in the noncompliant group. If the opioids and benzodiazepines use was similar between the two groups, then one could assume that the rotation was solely responsible, but unequal use toward heavier sedation is indicative of the practitioner’s intention (reason). Perhaps rotating different opioids or adding ketamine or even having a final course of “lighter” analgosedation helps to reduce the frequency of withdrawal. However, such research 5. Milési C, Pierre AF, Deho A, et al; GFRUP Respiratory Study Group: A multicenter randomized controlled trial of a 3-L/kg/min versus 2-L/ kg/min high-flow nasal cannula flow rate in young infants with severe viral bronchiolitis (TRAMONTANE 2). Intensive Care Med 2018; 44:1870–1878 6. Shein SL, Slain KN, Rotta AT, et al: High-flow nasal cannula flow rate in young infants with severe viral bronchiolitis: The question is still open. Intensive Care Med 2019; 45:134–135