Pediatric Cardiac Intensive Care Nurse Practitioner University of Virginia Children's Hospital Crozier, Virginia, United States
Abstract:
Introduction: To bring awareness to severe and unusual benzodiazepine withdrawal symptoms in the post-operative pediatric cardiac population. Catatonia, delirium and seizures are described as benzodiazepine withdrawal symptoms in adults but only case reports exist for the pediatric population. Here we report a series of 3 pediatric heart transplant patients with severe benzodiazepine withdrawal symptoms including catatonia and seizures over the past six years at the University of Virginia Children's Hospital.
Methods: Patient chart review and literature review on benzodiazepine withdrawal and weaning guidelines.
Results: Patient 1 was a 4 year old girl with an atrioventricular septal defect (AVSD) transplanted for heart failure. During post-operative recovery she became acutely catatonic: she was mute and immobile though awake. Her symptoms rapidly resolved with the administration of midazolam during preparation for emergent neuroimaging. Patient 2 was a 9 year old boy with and unbalanced AVSD palliated to a Fontan then transplanted. During post-operative recovery his catatonia was characterized by muteness and flat affect. After neurologic and psychiatric evaluations along with neuroimaging, a dose of lorazepam was trialed due to suspicion of benzodiazepine withdrawal. Symptoms resolved within minutes: he began speaking in complete sentences and his baseline personality returned. Patient 3 was a 15 year old boy with a variant of hypoplastic left heart syndrome palliated to a Fontan and then transplanted for protein losing enteropathy. A day prior to anticipated discharge he had a generalized tonic-clonic seizure. He was in a catatonic state during the post-ictal period and then became slightly agitated. Midazolam was given to facilitate neuroimaging. With midazolam his neurologic state normalized. All three patients were weaned rapidly from midazolam or lorazepam, despite an available guideline for minimizing iatrogenic withdrawal. With review of our guideline we noticed it did not include consideration of PRN dosing when stratifying withdrawal risk. Additionally, catatonia and seizures are severe symptoms that are do not result in an increased WAT1 score, our standard tool for monitoring withdrawal symptoms. We have since updated our guideline to ensure PRN dosing is considered when risk stratifying. We have also re-educated on withdrawal scoring, unusual symptoms, and the importance of methodical tapering.
Conclusions: It is important to recognize unique withdrawal symptoms that are often not part of traditional withdrawal scales. We describe three cases of severe benzodiazepine withdrawal catatonia in pediatric cardiac transplant patients. None of the symptoms were immediately recognized as withdrawal. Patients received neurologic consultation and neuroimaging, and patients and families suffered emotional distress. In hindsight, treatment was simple and the withdrawal preventable. As more pediatric cardiac patients survive complex hospitalizations that often involve prolonged benzodiazepine exposure, increased awareness of unusual withdrawal symptoms and careful medication tapering will allow for safer recovery.
