dose trial of opioid sparing effect

Conditions: Dexmedetomidine; Mechanical Ventilation Complication; Critically Ill

Summary: multicenter, double blind randomized controlled trial of fentanyl vs. fentanyl + dexmedetomidine as the initial regimen for maintenance of sedation in mechanically-ventilated, critically ill children. this trial will evaluate the opioid-sparing effect of dexmedetomidine when administered with fentanyl to mechanically ventilated, critically ill children. study drug or placebo will be administered with fentanyl, which will be titrated to achieve sedation scores consistent with response to light touch. plasma samples and bedside assessments for pain, sedation, and delirium will be collected.

phase 1b randomized, double-blind, placebo-controlled dose escalation trial of sedation regimens in critically ill children. testing the hypothesis of mean daily fentanyl dose through day 7 of mechanical ventilation will be reduced by ≥25% by the addition of dexmedetomidine to fentanyl therapy. this trial will involve multiple clinical sites. randomization will occur by individual and investigators will be blinded to study/treatment arm. the statistical analysis will account for center effects, participant characteristics (including post-surgical state), and changes over time to minimize bias. in addition, pis and study coordinators will undergo training to standardize assessment procedures. the study will randomize participants to receive placebo (fentanyl standard of care) titrated to sedation+saline placebo (bolus+infusion) or one of the following 3 dexmedetomidine treatment arms in a sequential cohort fashion: cohort 1: fentanyl soc titrated to sedation + dexmedetomidine (0.5mcg/kg bolus load + 0.2 mcg/kg/hr infusion); cohort 2: fentanyl soc titrated to sedation + dexmedetomidine (0.5mcg/kg bolus load + 0.5mcg/kg/hr infusion); and, cohort 3: fentanyl soc titrated to sedation + dexmedetomidine (0.5mcg/kg bolus load + 0.7mcg/kg/hr infusion). an interim analysis is planned for this trial.

Eligibility criteria:
inclusion criteria: 1. ages 0 to \<18 years at the time of enrollment. 2. if \< 6 months postnatal age, gestational age ≥ 35 weeks. 3. admitted to an intensive care unit. 4. planned or anticipated mechanically ventilation for ≥2 days. 5. require sedation to maintain mechanical ventilation per clinical judgment. 6. no contraindication to receipt of fentanyl or dexmedetomidine per clinician judgment. 7. availability and willingness of the parent/legal guardian to provide written informed consent. exclusion criteria: 1. previous participation in this study. 2. severe traumatic brain injury as the underlying etiology for critical illness requiring mechanical ventilation or baseline pediatric cerebral performance category (pcpc) \>3. 3. planned receipt of sedatives other than fentanyl or dexmedetomidine. 4. anticipated receipt of neuromuscular blockade for \>48 consecutive hours during the study period. 5. receipt of fentanyl or dexmedetomidine via continuous infusion for \>12 hours in the 24 hours prior to enrollment. 6. extracorporeal life support (including renal replacement therapy, extracorporeal membrane oxygenation, ventricular assist device, etc.) at the time of enrollment. 7. chronic use of or recent overdose of serotonergic agents (selective serotonin reuptake inhibitors (ssris), serotonin-norepinephrine reuptake inhibitors (snris), monoamine oxidase (mao) inhibitors, cyclic antidepressants) 8. known pregnancy 9. known liver dysfunction, defined as: aspartate aminotransferase (ast) or alanine aminotransferase (alt) \>2x the upper limit of normal for age 10. known or impending renal failure defined as: anuria \> or equal to 12 hours prior to enrollment or requiring renal replacement therapy 11. high risk children, define as: a. known heart block b. known bradyarrythmia including clinically significant bradycardia (defined as requiring chronotropic agents or cardiac pacing to treat) 12. receipt of mechanical ventilation during an admission for cardiac surgery note: receipt of drugs other than fentanyl or dexmedetomidine for intubation, and receipt of neuromuscular blockage for intubation, will not be considered exclusionary criteria.