Implementing a Novel Pediatric Dexmedetomidine Weaning Guideline in the Cardiac ICU: A QI Initiative

Introduction: Dexmedetomidine (DEX), a selective α2-adrenergic agonist, is a recommended sedative in the pediatric cardiovascular intensive care unit (CVICU). Reported risks associated with its use, however, include delirium, withdrawal, and potential hemodynamic changes. Despite DEX popularity in sedation guidelines, structured DEX weaning protocols remain scarce. This quality improvement (QI) initiative aimed to enhance the safety of DEX use by developing and implementing a weaning guideline utilizing a novel DEX withdrawal assessment tool. The project sought to reduce DEX exposure, delirium rate, and practice variability without increasing iatrogenic withdrawal.


Methods: A multidisciplinary team employed Plan-Do-Study-Act (PDSA) cycles to guide implementation. We included patients ≥36 weeks gestation to 18 years of age who received ≥48 consecutive hours of DEX in the CVICU. We introduced a weaning guideline and calculated novel withdrawal categories (mild, moderate, severe), incorporating heart rate and blood pressure changes as well as WAT-1 score. Data were collected across historical (N=35), implementation (N=15), and two follow-up cohorts (N=30; N=27). Outcomes included CAP-D (delirium) and WAT-1 (withdrawal) scores, DEX dose, documentation rates, and staff perceptions assessed by questionnaire.


Results: At follow-up, the average daily DEX dose decreased from 20.8 to 17.0 mcg/kg/day without a corresponding rise in WAT-1 scoring or withdrawal as measured by our novel categorization. Over time, the average maximum CAP-D score decreased from 10.8 to 6.6, and the proportion of patients with CAP-D ≥9 dropped from 72% to 26%, indicating a substantial reduction in delirium. Documentation of CAP-D and WAT-1 scores improved, and staff-reported consistency in weaning increased from 10% to 50%.


Conclusions: This project indicates that a structured DEX weaning protocol, combined with a novel withdrawal assessment tool, can safely reduce delirium and DEX exposure in pediatric CVICU patients without increasing withdrawal. Sustained improvements in practice consistency and documentation support the value of protocolized care. Future efforts should focus on validation of the withdrawal tool, EMR integration, and expansion to broader pediatric ICU settings.