Acute withdrawal syndrome related to the administration of analgesic and sedative medications in adult intensive care unit patients

Risk Factors Associated With Opioid/Benzodiazepine Iatrogenic Withdrawal Syndrome in COVID-19 Acute Respiratory Distress Syndrome

BackgroundMechanically ventilated COVID-19 acute respiratory distress syndrome (ARDS) patients often receive deeper sedation and analgesia to maintain respiratory compliance and minimize staff exposure, which incurs greater risk of iatrogenic withdrawal syndrome (IWS) and has been associated with worse patient outcomes. Objective: To identify potential risk factors and differences in patient outcomes associated with the development of IWS in COVID-19 ARDS patients. Methods: Retrospective analysis of ventilated COVID-19 ARDS intensive care unit (ICU) patients who received continuous intravenous (IV) analgesia and sedation for ≥5 days from March 2020-May 2021. Patients were classified as IWS and non-IWS based on receipt of scheduled oral sedative/analgesic regimens after cessation of IV therapy. Risk factors were assessed in univariate analyses and multivariable modeling. Results: A total of 115 patients were included. The final multivariable model showed: (1) each additional day of IV opioid therapy was associated with an 8% increase in odds of IWS (95% CI, 1.02-1.14), (2) among sedatives, receipt of lorazepam was associated with 3 times higher odds of IWS (95% CI 1.12-8.15), and (3) each 1-point increase in Simplified Acute Physiology Score (SAPS) II was associated with a 4% reduction in odds of IWS (95% CI 0.93-0.999). Conclusion: Prolonged and high dose exposures to IV opioids and benzodiazepines should be limited when possible. Additional prospective studies are needed to identify modifiable risk factors to prevent IWS.

International Analgesia and Sedation Weaning and Withdrawal Practices in Critically Ill Adults: The Adult Iatrogenic Withdrawal Study in the ICU

OBJECTIVES

Iatrogenic withdrawal syndrome (IWS) associated with opioid and sedative use for medical purposes has a reported high prevalence and associated morbidity. This study aimed to determine the prevalence, utilization, and characteristics of opioid and sedative weaning and IWS policies/protocols in the adult ICU population.

DESIGN

International, multicenter, observational, point prevalence study.

SETTING

Adult ICUs.

PATIENTS

All patients aged 18 years and older in the ICU on the date of data collection who received parenteral opioids or sedatives in the previous 24 hours.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

ICUs selected 1 day for data collection between June 1 and September 30, 2021. Patient demographic data, opioid and sedative medication use, and weaning and IWS assessment data were collected for the previous 24 hours. The primary outcome was the proportion of patients weaned from opioids and sedatives using an institutional policy/protocol on the data collection day. There were 2,402 patients in 229 ICUs from 11 countries screened for opioid and sedative use; 1,506 (63%) patients received parenteral opioids, and/or sedatives in the previous 24 hours. There were 90 (39%) ICUs with a weaning policy/protocol which was used in 176 (12%) patients, and 23 (10%) ICUs with an IWS policy/protocol which was used in 9 (0.6%) patients. The weaning policy/protocol for 47 (52%) ICUs did not define when to initiate weaning, and the policy/protocol for 24 (27%) ICUs did not specify the degree of weaning. A weaning policy/protocol was used in 34% (176/521) and IWS policy/protocol in 9% (9/97) of patients admitted to an ICU with such a policy/protocol. Among 485 patients eligible for weaning policy/protocol utilization based on duration of opioid/sedative use initiation criterion within individual ICU policies/protocols 176 (36%) had it used, and among 54 patients on opioids and/or sedatives ≥ 72 hours, 9 (17%) had an IWS policy/protocol used by the data collection day.

CONCLUSIONS

This international observational study found that a small proportion of ICUs use policies/protocols for opioid and sedative weaning or IWS, and even when these policies/protocols are in place, they are implemented in a small percentage of patients.

Opioid, sedative, preadmission medication and iatrogenic withdrawal risk in UK adult critically ill patients: a point prevalence study

BACKGROUND

Iatrogenic withdrawal syndrome, after exposure medication known to cause withdrawal is recognised, yet under described in adult intensive care.

AIM

To investigate, opioid, sedation, and preadmission medication practice in critically ill adults with focus on aspects associated with iatrogenic withdrawal syndrome.

METHOD

One-day point prevalence study in UK intensive care units (ICUs). We collected ICU admission medication and/or substances with withdrawal potential, sedation policy, opioid and sedative use, dose, and duration.

RESULTS

Thirty-seven from 39 participating ICUs contributed data from 386 patients. The prevalence rate for parenteral opioid and sedative medication was 56.1% (212 patients). Twenty-three ICUs (59%) had no sedation/analgesia policy, and no ICUs screened for iatrogenic withdrawal. Patient admission medications with withdrawal-potential included antidepressants or antipsychotics (43, 20.3%) and nicotine (41, 19.3%). Of 212 patients, 202 (95.3%) received opioids, 163 (76.9%) sedatives and 153 (72.2%) both. Two hundred and two (95.3%) patients received opioids: 167 (82.7%) by continuous infusions and 90 (44.6%) patients for longer than 96-h. One hundred and sixty-three (76.9%) patients received sedatives: 157 (77.7%) by continuous infusions and 74 (45.4%) patients for longer than 96-h.

CONCLUSION

Opioid sedative and admission medication with iatrogenic withdrawal syndrome potential prevalence rates were high, and a high proportion of ICUs had no sedative/analgesic policies. Nearly half of patients received continuous opioids and sedatives for longer than 96-h placing them at high risk of iatrogenic withdrawal. No participating unit reported using a validated tool for iatrogenic withdrawal assessment.

Successful management of suspected propofol dependence with phenobarbital in an adult patient with COVID-19

PURPOSE

In critically ill patients, high sedation requirements for prolonged durations are often needed to achieve ventilator synchrony, a practice that was particularly common during the early stages of the coronavirus disease 2019 (COVID-19) pandemic. We report the successful use of phenobarbital to facilitate propofol weaning after prolonged medication exposure.

SUMMARY

A 64-year-old male with hypertension was admitted for the management of acute respiratory distress syndrome due to COVID-19 pneumonia. The patient received high doses of fentanyl and propofol with periods of concomitant midazolam and dexmedetomidine throughout his prolonged time on mechanical ventilation. Total days of exposure were 19 for fentanyl, 17 for propofol, 12 for midazolam, and 15 for dexmedetomidine. Upon improvement in lung function, attempts to wean the patient from propofol all failed due to symptoms such as tachypnea, tachycardia, and hypertension, with symptom resolution only upon return to the previous dose. Phenobarbital was trialed for possible propofol withdrawal syndrome, allowing for a dose reduction of 10 μg/kg/min within 2 hours of the first dose without any corresponding symptoms. The patient continued to receive intermittent doses of phenobarbital for another 36 hours until propofol was discontinued. He underwent tracheostomy shortly after weaning off all sedation and was discharged to rehab 34 days after his initial admission.

CONCLUSION

Information concerning propofol withdrawal syndrome in the literature is limited. Our experience demonstrates the successful use of phenobarbital to facilitate propofol weaning after prolonged exposure.

Acupuncture for protracted opioid abstinence syndrome: study protocol for a systematic review and meta-analysis

INTRODUCTION

Protracted opioid abstinence syndrome (POAS) refers to a series of physical discomforts and neuropsychiatric symptoms after discontinuation of opioid-type substances for a certain amount of time and is one of the main causes of relapse. Studies have shown that acupuncture is effective in the treatment of POAS. We plan to conduct this systematic review and meta-analysis to assess the efficacy and safety of acupuncture for POAS.

METHODS AND ANALYSIS

A comprehensive search of studies will be carried out in the following databases from inception to 31 January 2023: Web of Science, Embase, PubMed, Chinese Biology Medicine, China National Knowledge Infrastructure, Wan Fang Database and Chinese Scientific Journal Database (VIP). WHO International Clinical Trials Registry Platform, ClinicalTrials.gov and Chinese Clinical Trial Registry will also be searched for ongoing relevant trials, and 'grey literatures' will be identified from GreyNet International, OpenGrey and Google Scholar. Randomised controlled trials regarding acupuncture therapy for treatment of POAS will be included. The primary outcome is the severity of protracted withdrawal symptoms. Two reviewers will screen studies using the inclusion criteria, extract data and assess the risk of bias, respectively. The quality of evidence will be assessed using the Grading of Recommendations, Assessment, Development and Evaluation. Data synthesis will be performed using RevMan V.5.4.1.

ETHICS AND DISSEMINATION

This study will not invade patients' personal privacy, and so ethical review is not required. The results will be disseminated in a peer-reviewed journal.

PROSPERO REGISTRATION NUMBER

CRD42022382978.

Prevalence and Risk Factors for Iatrogenic Opioid Withdrawal in Medical Critical Care Patients

Opioids are the mainstay of pain management and sedation in critically ill patients, which can lead to the development of physiologic tolerance and dependency. The prevalence of iatrogenic opioid withdrawal syndrome (IWS) is reported as 17-32% in the ICU; however, limited evidence exists for the medical ICU patient population.

OBJECTIVES

To identify the and risk factors for IWS in adult patients admitted to critical care medicine services who received greater than or equal to 24 hours of continuous opioid infusion therapy.

DESIGN SETTING AND PARTICIPANTS

A prospective, observational study was conducted in a tertiary care hospital in adult medical ICU patients. Ninety-two patients who received greater than or equal to 24 hours of continuous opioid infusions were included in the study.

MAIN OUTCOMES AND MEASUREMENTS

Patients were assessed daily after opioid infusion discontinuation using the Clinical Opiate Withdrawal Scale (COWS) and the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) opioid withdrawal criteria for a maximum of 5 days. The primary outcome was the prevalence of IWS of moderate severity or greater using COWS. Secondary outcomes included the prevalence of IWS diagnosis of any severity based on COWS, the prevalence of IWS diagnosis based on a positive DSM-V score, and the identification of potential risk factors for developing IWS of any severity.

RESULTS

Four hundred forty-seven patients received greater than or equal to 24 hours of continuous opioid therapy. Of these, 385 were excluded, leaving 92 patients included in the final analysis. Except for a higher prevalence of psychiatric history in the IWS-positive group, baseline characteristics were similar. Overall, 11 patients (12%) developed IWS of moderate severity or greater, based on COWS. The IWS-positive group also had longer durations of opioid infusions, higher cumulative opioid infusion doses, higher mean daily doses, and higher infusion rates at any given time. The concomitant use of dexmedetomidine (38.3 vs 15.6%, p = 0.014) and benzodiazepines (63.8 vs 37.8%, p = 0.021) during or after the opioid infusion were significantly higher in the IWS-positive group compared with the IWS-negative group. No significant differences were found between the two groups for scheduled or as needed opioids after cessation of the opioid infusion. Continuous opioid infusions greater than or equal to 72 hours and total daily dose greater than or equal to 1,200 μg were found to be independent predictors for the development of iatrogenic opioid withdrawal via logistic regression.

CONCLUSIONS AND RELEVANCE

Approximately one in every eight patients receiving continuous infusion opioid for greater than 24 hours while mechanically ventilated in the medical ICU will develop IWS of moderate severity or greater; this increases to one in three patients diagnosed with DSM-V criteria or any level of IWS severity. Patients receiving opioid infusions greater than or equal to 72 hours, or a total daily fentanyl dose of greater than or equal to 1,200 μg (~ 50 μg/hr) are at a higher risk for developing IWS and should be monitored as part of clinical practice when opioid infusions are discontinued.

Mechanical Ventilation in Patients with Traumatic Brain Injury: Is it so Different?

Patients with traumatic brain injury (TBI) frequently require invasive mechanical ventilation and admission to an intensive care unit. Ventilation of patients with TBI poses unique clinical challenges, and careful attention is required to ensure that the ventilatory strategy (including selection of appropriate tidal volume, plateau pressure, and positive end-expiratory pressure) does not cause significant additional injury to the brain and lungs. Selection of ventilatory targets may be guided by principles of lung protection but with careful attention to relevant intracranial effects. In patients with TBI and concomitant acute respiratory distress syndrome (ARDS), adjunctive strategies include sedation optimization, neuromuscular blockade, recruitment maneuvers, prone positioning, and extracorporeal life support. However, these approaches have been largely extrapolated from studies in patients with ARDS and without brain injury, with limited data in patients with TBI. This narrative review will summarize the existing evidence for mechanical ventilation in patients with TBI. Relevant literature in patients with ARDS will be summarized, and where available, direct data in the TBI population will be reviewed. Next, practical strategies to optimize the delivery of mechanical ventilation and determine readiness for extubation will be reviewed. Finally, future directions for research in this evolving clinical domain will be presented, with considerations for the design of studies to address relevant knowledge gaps.

Predicting at-risk opioid use three months after ed visit for trauma: Results from the AURORA study

Objective

Whether short-term, low-potency opioid prescriptions for acute pain lead to future at-risk opioid use remains controversial and inadequately characterized. Our objective was to measure the association between emergency department (ED) opioid analgesic exposure after a physical, trauma-related event and subsequent opioid use. We hypothesized ED opioid analgesic exposure is associated with subsequent at-risk opioid use.

Methods

Participants were enrolled in AURORA, a prospective cohort study of adult patients in 29 U.S., urban EDs receiving care for a traumatic event. Exclusion criteria were hospital admission, persons reporting any non-medical opioid use (e.g., opioids without prescription or taking more than prescribed for euphoria) in the 30 days before enrollment, and missing or incomplete data regarding opioid exposure or pain. We used multivariable logistic regression to assess the relationship between ED opioid exposure and at-risk opioid use, defined as any self-reported non-medical opioid use after initial ED encounter or prescription opioid use at 3-months.

Results

Of 1441 subjects completing 3-month follow-up, 872 participants were included for analysis. At-risk opioid use occurred within 3 months in 33/620 (5.3%, CI: 3.7,7.4) participants without ED opioid analgesic exposure; 4/16 (25.0%, CI: 8.3, 52.6) with ED opioid prescription only; 17/146 (11.6%, CI: 7.1, 18.3) with ED opioid administration only; 12/90 (13.3%, CI: 7.4, 22.5) with both. Controlling for clinical factors, adjusted odds ratios (aORs) for at-risk opioid use after ED opioid exposure were: ED prescription only: 4.9 (95% CI 1.4, 17.4); ED administration for analgesia only: 2.0 (CI 1.0, 3.8); both: 2.8 (CI 1.2, 6.5).

Conclusions

ED opioids were associated with subsequent at-risk opioid use within three months in a geographically diverse cohort of adult trauma patients. This supports need for prospective studies focused on the long-term consequences of ED opioid analgesic exposure to estimate individual risk and guide therapeutic decision-making.

Pain, Anxiety, and the Continuous Use of Opioids and Benzodiazepines in Trauma Intensive Care Unit Survivors: An Exploratory Study

OBJECTIVE

To evaluate at-home opioid and benzodiazepine use, the degrees of pain and anxiety, and the incidence of probable withdrawal in post-discharge Trauma Intensive Care Unit (TICU) survivors.

METHODS

This was an exploratory study of post-TICU survivors who had participated in a previous study of opioid and benzodiazepine withdrawal. We surveyed survivors by telephone asking for retrospective information (during their first 4-months postdischarge- Time 1) and current information (around 2-years post-discharge- Time 2).

RESULTS

A mostly male (82%), young (median 38 years [IQR, 28-52]) sample of 27 TICU survivors reported using opioids (56%) at Time 1 for a median of 30 (IQR,14-90) days. Twelve percent of 26 survivors were still using opioids at Time 2. Sixty percent of the survivors had pain during Time 1, a median pain score of 6 (IQR, 5-8) on a 0-10 numeric rating scale (NRS).; 57% had pain at Time 2, median NRS score=6 (IQR, 4-7). Sixty-five percent of survivors had anxiety during Time 1, NRS median=7 (IQR, 5-9); 50% had anxiety at Time 2, NRS median= 6 (IQR, 3-7). At Time 1, 26% used prescribed benzodiazepines, and 12% used benzodiazepines at Time 2. Five and one of the 27 patients reported symptoms of opioid or benzodiazepine withdrawal, respectively, upon discontinuation or weaning.

CONCLUSION

Many TICU survivors had discontinued opioid/benzodiazepine prescriptions by 4-months post discharge while half reporting pain/anxiety for up to 2-years. Investigating the effects of acute-to-chronic pain in ICU survivors and gaining a better understanding of the mechanisms of prolonged opioid use are warranted.

Iatrogenic opioid withdrawal syndromes in adults in intensive care units: a narrative review

Background and Objective

In hospitalized patients, opiates are essential analgesics and sedatives used in intensive care unit (ICU) patients. However, the iatrogenic opioid withdrawal syndrome (IOWS) in ICU patients has been poorly characterized, and there are no well accepted, standardized diagnostic tools for hospitalized adults. This review analyzed recent clinical studies to determine the frequency, characteristics, and treatment of IOWS in critically ill adults.

Methods

The initial literature search used the PubMed MeSH terms “Analgesics”, “Opioids”, “Iatrogenic Disease”, and “Neurobiology”. The main focus was on clinical studies describing IOWS in adults receiving intravenous opioids in ICUs.

Key Content and Findings

Review of 8 studies indicated that IOWS occurs in 15% to 40% of patients in intensive care units who required opioid infusions. These reports included patients in medical ICUs, trauma ICUs, surgical ICUs, and burn ICUs; many patients also received sedative drugs. Most of the studies used DSM-5 criteria to identify the syndrome. Factors which predicted the development of this syndrome varied from study to study; important considerations included the weaning rate for the opioid, the duration of opioid infusion, and the concomitant infusion of benzodiazepines. Treatment approaches included the reinstitution of the opioid infusion with slower reductions in the rate and the use of an alpha-2 agonist, such dexmedetomidine or clonidine. Many patients appeared to recover without specific treatment.

Postoperative Sedation Duration as an Independent Risk Factor for Postoperative Pneumonia in Head and Neck Cancer Patients Undergoing Free Flap Reconstruction

OBJECTIVE

Patients who had reconstruction for head and neck cancer usually have long duration of postoperative sedation and intensive care. This is due to the complex nature of large-area soft tissue defect surgeries and upper respiratory tract infections associated with them. Postoperative pulmonary complications are common in these patients. In this study, we analyzed the risk factors and the relationship between postoperative complications and the duration of sedation to improve the patients' recovery process after free flap reconstruction for head and neck surgery.

MATERIALS AND METHODS

This was a retrospective study that included 188 patients who had head and neck surgery with free flap reconstruction in 2011 (traditional recovery group) and 2018 (early recovery group). Postoperative recovery events were compared between the 2 groups. Complications such as pneumonia, wound infection, vascular thrombosis, and bleeding were also analyzed.

RESULTS

The results showed that the early recovery group had a shorter duration of sedation (P < 0.001), shorter duration of intensive care unit stay (P = 0.05), more rapid ventilator weaning (P < 0.001), and fewer pneumonia events (8.8% vs 39.1%) than the traditional recovery group. Wound- and vessel-related complications were not affected by the duration of sedation.

CONCLUSIONS

Our study demonstrated that shortening the duration of postoperative sedation can effectively decrease the length of intensive care unit stay and reduce postoperative incidence of pneumonia without increasing wound- and vessel-related complications.

The complications of opioid use during and post-intensive care admission: A narrative review

Opioids are a commonly administered analgesic medication in the intensive care unit, primarily to facilitate invasive mechanical ventilation. Consensus guidelines advocate for an opioid-first strategy for the management of acute pain in ventilated patients. As a result, these patients are potentially exposed to high opioid doses for prolonged periods, increasing the risk of adverse effects. Adverse effects relevant to these critically ill patients include delirium, intensive care unit-acquired infections, acute opioid tolerance, iatrogenic withdrawal syndrome, opioid-induced hyperalgesia, persistent opioid use, and chronic post-intensive care unit pain. Consequently, there is a challenge of optimising analgesia while minimising these adverse effects. This narrative review will discuss the characteristics of opioid use in the intensive care unit, outline the potential short-term and long-term adverse effects of opioid therapy in critically ill patients, and outline a multifaceted strategy for opioid minimisation.

Practices in sedation, analgesia, mobilization, delirium, and sleep deprivation in adult intensive care units (SAMDS-ICU): an international survey before and during the COVID-19 pandemic

Background

Since the publication of the 2018 Clinical Guidelines about sedation, analgesia, delirium, mobilization, and sleep deprivation in critically ill patients, no evaluation and adequacy assessment of these recommendations were studied in an international context. This survey aimed to investigate these current practices and if the COVID-19 pandemic has changed them.

Methods

This study was an open multinational electronic survey directed to physicians working in adult intensive care units (ICUs), which was performed in two steps: before and during the COVID-19 pandemic.

Results

We analyzed 1768 questionnaires and 1539 (87%) were complete. Before the COVID-19 pandemic, we received 1476 questionnaires and 292 were submitted later. The following practices were observed before the pandemic: the Visual Analog Scale (VAS) (61.5%), the Behavioral Pain Scale (BPS) (48.2%), the Richmond Agitation Sedation Scale (RASS) (76.6%), and the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) (66.6%) were the most frequently tools used to assess pain, sedation level, and delirium, respectively; midazolam and fentanyl were the most frequently used drugs for inducing sedation and analgesia (84.8% and 78.3%, respectively), whereas haloperidol (68.8%) and atypical antipsychotics (69.4%) were the most prescribed drugs for delirium treatment; some physicians regularly prescribed drugs to induce sleep (19.1%) or ordered mechanical restraints as part of their routine (6.2%) for patients on mechanical ventilation; non-pharmacological strategies were frequently applied for pain, delirium, and sleep deprivation management. During the COVID-19 pandemic, the intensive care specialty was independently associated with best practices. Moreover, the mechanical ventilation rate was higher, patients received sedation more often (94% versus 86.1%, p < 0.001) and sedation goals were discussed more frequently in daily rounds. Morphine was the main drug used for analgesia (77.2%), and some sedative drugs, such as midazolam, propofol, ketamine and quetiapine, were used more frequently.

Conclusions

Most sedation, analgesia and delirium practices were comparable before and during the COVID-19 pandemic. During the pandemic, the intensive care specialty was a variable that was independently associated with the best practices. Although many findings are in accordance with evidence-based recommendations, some practices still need improvement.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13613-022-00985-y.

Validity of Pulse Oximetry-derived Peripheral Perfusion Index in Pain Assessment in Critically Ill Intubated Patients

OBJECTIVES

Evaluation of pain in critically ill intubated patients is difficult and subjective. This study aimed to evaluate the accuracy of oximetry-derived peripheral perfusion index (PPI) in pain assessment in critically ill intubated patients using the behavioral pain scale (BPS) as a reference.

MATERIALS AND METHODS

This prospective observational study included 35 adult mechanically ventilated surgical patients during their first 2 postoperative days in the intensive care unit. Values of PPI, BPS, Richmond Agitation Sedation Scale (RASS), heart rate, and blood pressure were obtained before and after a standard painful stimulus (changing the patient position) and the ratio between the second and the first reading was calculated to determine the change (Δ) in all variables. The outcomes were the correlation between ΔBPS and ΔPPI as well as other hemodynamic parameters. The ability of the PPI to detect pain (defined as BPS ≥6) was analyzed using the area under receiver operating characteristic curve.

RESULTS

Paired readings were obtained from 35 patients. After the standard painful stimulus, the PPI decreased while the BPS and the Richmond agitation sedation scale increased. The Spearman correlation coefficient (95% confidence interval) between Δ PPI and Δ BPS was 0.41 (0.09-0.65). PPI values showed poor accuracy in detecting pain with area under receiver operating characteristic curve (95% confidence interval): 0.65 (0.53-0.76), with best cutoff value of ≤2.7.

CONCLUSION

The PPI decreased after application of a standard painful stimulus in critically ill intubated patients. ∆PPI showed a low correlation with ∆BPS, and a PPI of ≤2.7 showed a low ability to detect BPS ≥6. Therefore, PPI should not be used for pain evaluation in critically ill intubated surgical patients.

Five-Year Outcomes After Implementing a Pain, Agitation, and Delirium Protocol in a Mixed Intensive Care Unit

Objective: Assess for continued improvements in patient outcomes after updating our institutional sedation and analgesia protocol to include recommendations from the 2013 Society of Critical Care Medicine (SCCM) Pain, Agitation, and Delirium (PAD) guidelines. Methods: Retrospective before-and-after study in a mixed medical/surgical intensive care unit (ICU) at an academic medical center. Mechanically ventilated adults admitted from September 1, 2011 through August 31, 2012 (pre-implementation) and October 1, 2012 through September 30, 2017 (post-implementation) were included. Measurements included number of mechanically ventilated patients, APACHE IV scores, age, type of patient (medical or surgical), admission diagnosis, ICU length of stay (LOS), hospital LOS, ventilator days, number of self-extubations, ICU mortality, ICU standardized mortality ratio, hospital mortality, hospital standardized mortality ratio, medication data including as needed (PRN) analgesic and sedative use, and analgesic and sedative infusions, and institutional savings. Results: Ventilator days (Pre-PAD = 4.0 vs. Year 5 post = 3.2, P < .0001), ICU LOS (Pre-PAD = 4.8 days vs. Year 5 post = 4.1 days, P = .0004) and hospital LOS (Pre-PAD = 14 days vs. Year 5 post = 12 days, P < .0001) decreased after protocol implementation. Hospital standardized mortality ratio (Pre-PAD = 0.69 vs. Year 5 post = 0.66) remained constant; while, APACHE IV scores (Pre-PAD = 77 vs. Year 5 post = 89, P < .0001) and number of intubated patients (Pre-PAD = 1146 vs. Year 5 post = 1468) increased over the study period. Using the decreased ICU and hospital LOS estimates, it is projected the institution saved $4.3 million over the 5 years since implementation. Conclusions: Implementation of an updated PAD protocol in a mixed medical/surgical ICU was associated with a significant decrease in ventilator time, ICU LOS, and hospital LOS without a change in the standardized mortality ratio over a five-year period. These favorable outcomes are associated with a significant cost savings for the institution.

Pain Management Considerations in Patients with Opioid Use Disorder Requiring Critical Care

The opioid epidemic has resulted in increased opioid-related critical care admissions, presenting challenges in acute pain management. Limited guidance exists in the management of critically ill patients with opioid use disorder (OUD). This narrative review provides the intensive care unit (ICU) clinician with guidance and treatment options, including non-opioid analgesia, for patients receiving medications for opioid use disorder (MOUD) and for patients actively misusing opioids. Verification and continuation of the patient's outpatient MOUD regimen, specifically buprenorphine and methadone formulations, assessment of pain and opioid withdrawal, and treatment of acute pain with non-opioid analgesia, nonpharmacologic strategies, and short-acting opioids as needed, are all essential to adequate management of acute pain in patients with OUD. A multidisciplinary approach to treatment and discharge planning in patients with OUD may be beneficial to engage patients with OUD early in their hospital stay to prevent withdrawal, stabilize their OUD, and to reduce the risk of unplanned discharge and other associated morbidity. This article is protected by copyright. All rights reserved.

How to Manage Withdrawal of Sedation and Analgesia in Mechanically Ventilated COVID-19 Patients?

COVID-19 patients suffering from severe acute respiratory distress syndrome (ARDS) require mechanical ventilation (MV) for respiratory failure. To achieve these ventilatory goals, it has been observed that COVID-19 patients in particular require high regimens and prolonged use of sedatives, analgesics and neuromuscular blocking agents (NMBA). Withdrawal from analgo-sedation may induce a "drug withdrawal syndrome" (DWS), i.e., clinical symptoms of anxiety, tremor, agitation, hallucinations and vomiting, as a result of adrenergic activation and hyperalgesia. We describe the epidemiology, mechanisms leading to this syndrome and our strategies to prevent and treat it.

Weaning Analgosedation in Patients Requiring Prolonged Mechanical Ventilation

Although research supports the minimization of sedation in mechanically ventilated patients, many patients with severe acute respiratory distress syndrome (ARDS) receive prolonged opioid and sedative infusions. ICU teams face the challenge of weaning these medications, balancing the risks of sedation with the potential to precipitate withdrawal symptoms. In this article, we use a clinical case to discuss our approach to weaning analgosedation in patients recovering from long-term mechanical ventilation. We believe that a protocolized, multimodal weaning strategy implemented by a multidisciplinary care team is required to reduce potential harm from both under- and over-sedation. At present, there is no strong randomized clinical trial evidence to support a particular weaning strategy in adult ICU patients, but appraisal of the existing literature in adults and children can guide decision-making to enhance the recovery of these patients.

Sleep-Promotion Bundle Development, Implementation, and Evaluation in Critically Ill Adults: Roles for Pharmacists

OBJECTIVE

To review evidence for intensive care unit (ICU) sleep improvement bundle use, identify preferred sleep bundle components and implementation strategies, and highlight the role for pharmacists in developing and evaluating bundle efforts.

DATA SOURCES

Multiple databases were searched from January 1, 1990, to September 1, 2021, using the MeSH terms sleep, intensive care or critical care, protocol or bundle to identify comparative studies evaluating ICU sleep bundle implementation.

STUDY SELECTION AND DATA EXTRACTION

Study screening, data extraction, and risk-of-bias evaluation were conducted in tandem. The ICU quality improvement literature and Institute for Healthcare Improvement bundle improvement guidance were also reviewed to identify recommended strategies for successful sleep bundle use.

DATA SYNTHESIS

Nine studies (3 randomized, 1 quasi-experimental, 5 before-and-after) were identified. Bundle elements varied and were primarily focused on nonpharmacological interventions designed to be performed during either the day or night; only 2 studies included a medication-based strategy. Five studies were associated with reduced delirium; 2 studies were associated with improved total sleep time and 2 with improved patient-perceived sleep. Pharmacists were involved directly in 4 studies.

RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE

Sleep improvement bundles are recommended for use in all critically ill adults; specific bundle elements and ICU team member roles should be individualized at the institution/ICU level. Pharmacists can help lead bundle development efforts and routinely deliver key elements.

CONCLUSIONS

Pharmacists can play an important role in the development and implementation of ICU sleep bundles. Further research regarding the relative benefit of individual bundle elements on relevant patient outcomes is needed.

Sedation strategy and ICU delirium: a multicentre, population-based propensity score-matched cohort study

OBJECTIVES

We examined the relationship between dominant sedation strategy, risk of delirium and patient-centred outcomes in adults admitted to intensive care units (ICUs).

DESIGN

Retrospective propensity-matched cohort study.

SETTING

Mechanically ventilated adults (≥ 18 years) admitted to four Canadian hospital medical/surgical ICUs from 2014 to 2016 in Calgary, Alberta, Canada.

PARTICIPANTS

2837 mechanically ventilated adults (≥ 18 years) requiring admission to a medical/surgical ICU were evaluated for the relationship between sedation strategy and delirium.

INTERVENTIONS

None.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary exposure was dominant sedation strategy, defined as the sedative infusion, including midazolam, propofol or fentanyl, with the longest duration before the first delirium assessment. The primary outcome was 'ever delirium' identified using the Intensive Care Delirium Screening Checklist. Secondary outcomes included mortality, length of stay (LOS), ventilation duration and days with delirium. The cohort was analysed in two propensity score (patient characteristics and therapies received) matched cohorts (propofol vs fentanyl and propofol vs midazolam).

RESULTS

2837 patients (60.7% male; median age 57 years (IQR 43-68)) were considered for propensity matching. In propensity score-matched cohorts(propofol vs midazolam, n=712; propofol vs fentanyl, n=1732), the odds of delirium were significantly higher with midazolam (OR 1.46 (95% CI 1.06 to 2.00)) and fentanyl (OR 1.22 (95% CI 1.00 to 1.48)) compared with propofol dominant sedation strategies. Dominant sedation strategy with midazolam and fentanyl were associated with a longer duration of ventilation compared with propofol. Fentanyl was also associated with increased ICU mortality (OR 1.50, 95% CI 1.07 to 2.12)) ICU and hospital LOS compared with a propofol dominant sedation strategy.

CONCLUSIONS

We identified a novel association between fentanyl dominant sedation strategies and an increased risk of delirium, a composite outcome of delirium or death, duration of mechanical ventilation, ICU LOS and hospital LOS. Midazolam dominant sedation strategies were associated with increased delirium risk and mechanical ventilation duration.

Incidence and clinical manifestation of iatrogenic opioid withdrawal syndrome in mechanically ventilated patients

OBJECTIVE

The incidence of iatrogenic opioid withdrawal syndrome (IOWS) in mechanically ventilated adults has been questioned in settings driven by analgosedation strategies. This study aimed to describe the incidence, risk factors and clinical impact of IOWS in mechanically ventilated adults.

METHODS

This prospective, observational study was performed between 1 January and 31 August 2018. IOWS was identified based on the presence of at least three signs or symptoms according to the Diagnostic and Statistical Manual 5th edition (DSM-5) criteria after opioid discontinuation or rate reduction. Incidence of IOWS, patient characteristics, opioid administration, and the impact of IOWS on the duration of mechanical ventilator and length of stay in the intensive care unit (ICU) were collected.

RESULTS

Thirteen out of 55 patients (23.6%) manifested withdrawal symptoms. Two patients in the non-withdrawal group also developed hypertensive urgency after opioid discontinuation. Patients who received rapid once-daily weaning, especially rate reduction more than 50 µg as fentanyl equivalent per hour, were associated with IOWS. However, there was no statistically significant difference in ventilator-free days and ICU-free days.

CONCLUSIONS

These findings showed that approximately one-fourth of mechanically ventilated patients who received opioid infusion experienced IOWS. Monitoring for IOWS is recommended especially in patients who received rapid weaning rate of opioids. Future studies to develop IOWS assessment tools with the change of hemodynamic parameters should be performed.

TRIAL REGISTRATION

This trial was registered in ClinicalTrials.gov: identifier NCT03374722, date of registration 15 December 2018.

Strategies for the Prevention and Treatment of Iatrogenic Withdrawal from Opioids and Benzodiazepines in Critically Ill Neonates, Children and Adults: A Systematic Review of Clinical Studies

BACKGROUND

Critically ill patients are at high risk of iatrogenic withdrawal syndrome (IWS), due to exposure to high doses or prolonged periods of opioids and benzodiazepines.

PURPOSE

To examine pharmacological management strategies designed to prevent and/or treat IWS from opioids and/or benzodiazepines in critically ill neonates, children and adults.

METHODS

We included non-randomised studies of interventions (NRSI) and randomised controlled trials (RCTs), reporting on interventions to prevent or manage IWS in critically ill neonatal, paediatric and adult patients. Database searching included: PubMed, CINAHL, Embase, Cochrane databases, TRIP, CMA Infobase and NICE evidence. Additional grey literature was examined. Study selection and data extraction were performed in duplicate. Data collected included: population, definition of opioid, benzodiazepine or mixed IWS, its assessment and management (drug or strategy, route of administration, dosage and titration), previous drug exposures and outcomes measures. Methodological quality assessment was performed by two independent reviewers using the Cochrane risk of bias tool for RCTs and the ROBINS-I tool for NRSI. A qualitative synthesis of the results is provided. For the subset of studies evaluating multifaceted protocolised care, we meta-analysed results for 4 outcomes and examined the quality of evidence using GRADE post hoc.

RESULTS

Thirteen studies were eligible, including 10 NRSI and 3 RCTs; 11 of these included neonatal and paediatric patients exclusively. Eight studies evaluated multifaceted protocolised interventions, while 5 evaluated individual components of IWS management (e.g. clonidine or methadone at varying dosages, routes of administration and duration of tapering). IWS was measured using an appropriate tool in 6 studies. Ten studies reported upon occurrence of IWS, showing significant reductions (n = 4) or no differences (n = 6). Interventions failed to impact duration of mechanical ventilation, ICU length of stay, and adverse effects. Impact on opioid and/or benzodiazepine total doses and duration showed no differences in 4 studies, while 3 showed opioid and benzodiazepine cumulative doses were significantly reduced by 20-35% and 32-66%, and treatment durations by 1.5-11 and 19 days, respectively. Variable effects on intervention drug exposures were found. Weaning durations were reduced by 6-12 days (n = 4) for opioids and/or methadone and by 13 days (n = 1) for benzodiazepines. In contrast, two studies using interventions centred on transition to enteral routes or longer tapering durations found significant increases in intervention drug exposures. Interventions had overall non-significant effects on additional drug requirements (except for one study). Included studies were at high risk of bias, relating to selection, detection and reporting bias.

CONCLUSION

Interventions for IWS management fail to impact duration of mechanical ventilation or ICU length of stay, while effect on occurrence of IWS and drug exposures is inconsistent. Heterogeneity in the interventions used and methodological issues, including inappropriate and/or subjective identification of IWS and bias due to study design, limited the conclusions.

Evaluation of the Development of Tolerance Following Frequent Administration of Propofol in Children Requiring Successive Sedation for Separate Procedures

OBJECTIVE

Propofol is frequently used for outpatient sedation for pediatric patients, some of whom require multiple rounds of sedation for separate procedures within a short period. Anecdotal experience suggests that frequent use of propofol results in escalating doses; however, clinical evidence is unconvincing. This study was designed to evaluate if tolerance develops with frequent administration of propofol for children requiring multiple successive sedations.

METHODS

A retrospective chart review of patients requiring multiple doses of propofol for separate procedures from 2011 through 2019 was conducted. Cumulative propofol dose and induction dose were analyzed using a mixed model for patients requiring sedation for serial procedures.

RESULTS

Data from 24 different patients who required 3 or more sedations during the study period were analyzed. The number of sedations ranged from 3 to 28. The mean total propofol dose rate was 0.19 ± 0.14 mg/kg/min, and the mean induction dose was 3.2 ± 0.97 mg/kg. The total doses and induction doses were not statistically significantly different at different sedations (p = 0.089 and 0.180, respectively). There was a statistically significant decrease in the total dose as the time interval between 2 sedations increased (p < 0.001).

CONCLUSIONS

Repeated administrations of propofol at time intervals used in outpatient sedation do not lead to the development of tolerance. A small decrease per day interval may be significant when propofol is used more frequently (multiple times per day or as a continuous drip) in an ICU setting.

Challenges in Sedation Management in Critically Ill Patients with COVID-19: a Brief Review

Purpose of Review

To highlight the challenges associated with providing sedation and analgesia to critically ill patients with coronavirus disease 2019 (COVID-19) and also understand the pathophysiological alterations induced by the disease process as well as the logistical difficulties encountered by providers caring for these patients. We also discuss the rationale and risks associated with the use of common sedative agents specifically within the context of COVID-19 and provide evidence-based management strategies to help manage sedation and analgesia in such patients.

Recent Findings

A significant proportion of patients with COVID-19 require intensive care and mechanical ventilation, thus requiring sedation and analgesia. These patients tend to require higher doses of sedative medications and often for long periods of time. Most of the commonly used sedative and analgesic agents carry unique risks that should be considered within the context of the unique pathophysiology of COVID-19, the logistical issues the disease poses, and the ongoing drug shortages.

Summary

With little attention being paid to sedation practices specific to patients with COVID-19 in critical care literature and minimal mention in national guidelines, there is a significant gap in knowledge. We review the existing literature to discuss the unique challenges that providers face while providing sedation and analgesia to critically ill patients with COVID-19 and propose evidence-based management strategies.

Therapeutic options for agitation in the intensive care unit

Agitation is common in the intensive care unit (ICU). There are numerous contributing factors, including pain, underlying disease, withdrawal syndrome, delirium and some medication. Agitation can compromise patient safety through accidental removal of tubes and catheters, prolong the duration of stay in the ICU, and may be related to various complications. This review aims to analyse evidence-based medical literature to improve management of agitation and to consider pharmacological strategies. The non-pharmacological approach is considered to reduce the risk of agitation. Pharmacological treatment of agitated patients is detailed and is based on a judicious choice of neuroleptics, benzodiazepines and α2 agonists, and on whether a withdrawal syndrome is identified. Specific management of agitation in elderly patients, brain-injured patients and patients with sleep deprivation are also discussed. This review proposes a practical approach for managing agitation in the ICU.

Safety, Tolerability, and Efficacy of Pain Reduction by Gabapentin for Acute Headache and Meningismus After Aneurysmal Subarachnoid Hemorrhage: A Pilot Study

Introduction: Severe, often sudden-onset headache is the principal presenting symptoms of aneurysmal subarachnoid hemorrhage (aSAH). We hypothesized that gabapentin would be safe and tolerable for aSAH-induced headaches and would reduce concurrent opioid use.

Methods: We performed a single-center, double-blind, randomized, placebo-controlled trial (registered at ClinicalTrials.gov; NCT02330094) from November 24, 2014, to June 24, 2017, where aSAH patients received either dose-escalating gabapentin or oral placebo, both alongside a standard of care pain regimen. After 7 days, patients had the option to continue in an open-label period until 14 days after enrollment or until discharge from the intensive care unit. Our primary endpoint was the efficacy of gabapentin in reducing headache numeric pain scores and opioid usage in patients with aSAH compared to the placebo group. We identified 63 potential patients with aSAH for the study. After applying stringent exclusion criteria, 16 eligible patients were enrolled into one of two arms.

Results: The study ended prematurely after reaching a pre-specified funding period and an unexpected drop in aSAH cases. There was a trend toward lower headache numeric pain scores and opioid use in the gabapentin treated arm; however this was not significantly different. Gabapentin was well tolerated by participants and no adverse effects were reported.

Conclusions: While there was a trend toward lower pain scores and opioid requirement in the gabapentin group, the study was underpowered to detect a difference. Larger multicenter trials are required to evaluate the efficacy of gabapentin to reduce opioid requirements after aSAH.

Opioid and Benzodiazepine Withdrawal Syndromes in Trauma ICU Patients: A Prospective Exploratory Study

Supplemental Digital Content is available in the text.

Trauma ICU patients may require high and/or prolonged doses of opioids and/or benzodiazepines as part of their treatment. These medications may contribute to drug physical dependence, a response manifested by withdrawal syndrome. We aimed to identify risk factors, symptoms, and clinical variables associated with probable withdrawal syndrome.

Iatrogenic Opioid Withdrawal Syndrome in Critically Ill Patients: a Retrospective Cohort Study

BACKGROUND

Opioid withdrawal syndrome (OWS) may occur following the reduction or discontinuation of opioid analgesics. In critically ill pediatric patients, OWS is a common and clinically significant condition. However, OWS in adult patients has not been assessed in detail. Therefore, we aimed to investigate the incidence, risk factors, and clinical features of OWS in mechanically ventilated patients treated in an adult intensive care unit (ICU).

METHODS

This study was a retrospective evaluation of data from patients treated in the medical ICU for > 3 days and who received only one type of opioid analgesic. OWS was assessed over a 24 hours period from discontinuation or reduction (by > 50%) of continuous opioid infusion. OWS was defined as the presence of ≥ 3 central nervous system or autonomic nervous system symptoms.

RESULTS

In 126 patients treated with remifentanil (n = 58), fentanyl (n = 47), or morphine (n = 21), OWS was seen in 31.0%, 36.2%, and 9.5% of patients, respectively (P = 0.078). The most common symptom was a change in respiratory rate (remifentanil, 94.4%; fentanyl, 76.5%; morphine, 100%). Multivariate Cox-proportional hazards model showed that OWS was negatively associated with morphine treatment (hazard ratio [HR], 0.17; 95% confidence interval [CI], 0.037-0.743) and duration of opioid infusion (HR, 0.566; 95% CI, 0.451-0.712).

CONCLUSION

OWS is not uncommon in mechanically ventilated adult patients who received continuous infusion of opioids for > 3 days. The use of morphine may be associated with a decreased risk of OWS.

Pain management in trauma patients affected by the opioid epidemic: A narrative review

Acute and chronic pain in trauma patients remains a challenging entity, particularly in the setting of the escalating opioid epidemic. It has been reported that chronic opioid use increases the likelihood of hospital admissions as a result of traumatic injuries. Furthermore, patients admitted with traumatic injuries have a greater than average risk of developing opioid use disorder after discharge. Practitioners providing care to these patients will encounter the issue of balancing analgesic goals and acute opioid withdrawal with the challenge of reducing postdischarge persistent opioid use. Additionally, the practitioner is faced with the worrisome prospect that inadequate treatment of acute pain may lead to the development of chronic pain and overtreatment may result in opioid dependence. It is therefore imperative to understand and execute alternative nonopioid strategies to maximize the benefits and reduce the risks of analgesic regimens in this patient population. This narrative review will analyze the current literature on pain management in trauma patients and highlight the application of the multimodal approach in potentially reducing the risks of both short- and long-term opioid use. LEVEL OF EVIDENCE: Narrative review, moderate to High.

Neurological dysfunction after cardiac surgery and cardiac intensive care admission: A narrative review part 2: Cognitive dysfunction after critical illness; potential contributors in surgery and intensive care; pathogenesis; and therapies to prevent/treat perioperative neurological dysfunction

Severe cognitive decline and cognitive dysfunction has been attributed to patient's stay in the cardiovascular intensive care unit. Prolonged mechanical ventilation, long duration of stay, sedation protocols, and sleep deprivation contribute to patients developing neurocognitive disorder after intensive care admission and it is associated with poor clinical outcomes. Trauma of surgery, stress of critical care, and administration of anaesthesia evoke a systemic inflammatory response and trigger neuroinflammation and oxidative stress. Anaesthetic agents modulate the function of the GABA receptors. The persistence of these effects in the postoperative period promotes development of cognitive dysfunction. A number of drugs are under investigation to restrict or prevent this cognitive decline.

Opioid and Benzodiazepine Iatrogenic Withdrawal Syndrome in Patients in the Intensive Care Unit

Iatrogenic withdrawal syndrome is an increasingly recognized issue among adult patients in the intensive care unit. The prolonged use of opioids and benzodiazepines during the intensive care unit stay and preexisting disorders associated with their use put patients at risk of developing iatrogenic withdrawal syndrome. Although research to date is scant regarding iatrogenic withdrawal syndrome in adult patients in the intensive care unit, it is important to recognize and adequately manage iatrogenic withdrawal syndrome in order to prevent possible negative outcomes during and after a patient's intensive care unit stay. This article discusses in depth 8 studies of iatrogenic withdrawal syndrome among adult patients in the intensive care unit. It also addresses important aspects of opioid and benzodiazepine iatrogenic withdrawal syndrome, including prevalence, risk factors, and assessment and considers its prevention and management.

Critical Care Pain Management in Patients Affected by the Opioid Epidemic: A Review

The rapid rise in the opioid epidemic has had a deleterious impact across the United States. This increase has drawn the attention of the critical care community not only because of the surge in acute opioid overdose-related admissions, but also due to the increase in the number of opioid-dependent and opioid-tolerant patients being treated in the intensive care unit (ICU). Opioid-related issues relevant to the critical care physician include direct care of patients with opioid overdoses, the provision of sufficient analgesia to patients with opioid dependence and tolerance, and the task of preventing long-term opioid dependence in patients who survive ICU care. This review identifies the challenges facing the ICU physician working with patients presenting with opioid-related complications, discusses current solutions, and suggests future areas of research and heightened ICU clinician attention.

Effects of deep sedation on sleep in critically ill medical patients on mechanical ventilation

Atypical EEG patterns not consistent with standard sleep staging criteria have been observed in medical intensive care unit (ICU) patients. Our aim was to examine the relationship between sleep architecture and sedation in critically ill mechanically ventilated patients pre- and post-extubation. We performed a prospective observational repeated measures study where 50 mechanically ventilated patients with 31 paired analyses were examined at an academic medical centre. The sleep efficiency was 58.3 ± 25.4% for intubated patients and 45.6 ± 25.4% for extubated patients (p = .02). Intubated patients spent 76.33 ± 3.34% of time in non-rapid eye movement (NREM) sleep compared to 64.66 ± 4.06% of time for extubated patients (p = .02). REM sleep constituted 1.36 ± 0.67% of total sleep time in intubated patients and 2.06 ± 1.09% in extubated patients (p = .58). Relative sleep atypia was higher in intubated patients compared to extubated patients (3.38 ± 0.87 versus 2.79 ± 0.42; p < .001). Eleven patients were sedated with propofol only, 18 patients with fentanyl only, 11 patients with fentanyl and propofol, and 10 patients had no sedation. The mean sleep times on "propofol", "fentanyl", "propofol and fentanyl," and "no sedation" were 6.54 ± 0.64, 4.88 ± 0.75, 6.20 ± 0.75 and 4.02 ± 0.62 hr, respectively. The sigma/alpha values for patients on "propofol", "fentanyl", "propofol and fentanyl" and "no sedation" were 0.69 ± 0.04, 0.54 ± 0.01, 0.62 ± 0.02 and 0.57 ± 0.02, respectively. Sedated patients on mechanical ventilation had higher sleep efficiency and more atypia compared to the same patients following extubation. Propofol was associated with higher sleep duration and less disrupted sleep architecture compared to fentanyl, propofol and fentanyl, or no sedation.

Perioperative Pain Management in the Critically Ill Patient

PURPOSE OF REVIEW

The assessment and management of perioperative pain in an intensive care setting is complex and challenging, requiring several patient-specific considerations. Administering analgesia is difficult due to interacting effects of pre-existing conditions, interventions, and deviation from standard levels of expressiveness of pain. A significant part of this complexity also arises from the reduced capacity of critically ill patients to fully communicate the severity and nature of their pain. We provide an overview of pharmacological approaches and regional techniques, which can be employed alongside the management of anxiety and sleep, to alleviate pain in the critically ill patients in the perioperative period. These interventions require additional assessments unique to critical care, yet achieving pain relief for improving clinical outcomes and patient satisfaction remains a constant.

RECENT FINDINGS

The latest research has found that the development of standardized mechanisms and protocols to optimize the diagnosis, assessment, and management of pain in the critically ill can provide the best outcomes. The numerical rating scale, critical care pain observation criteria, and behavior pain scale has shown higher reliability to accurately assess pain in the critically ill. Most importantly, preemptive analgesia and the emphasis on early pain control-in the perioperative setting, ICU, and post-discharge-are crucial in minimizing chronic post-discharge pain. Finally, the multimodal approach is still found to be the most effective. This includes pharmacological treatments, regional nerve block, and epidural techniques, as well as alternative methods that are cheap, safe, and easily available. All these together have shown to help control pain, provide psychological support, and prevent long-term co-morbidities in the critically ill. Largely, pain in the critically ill patient is still a very complex issue that requires appropriate diagnosis, assessment, and management of the pain itself and treating all the underlying co-morbidities as well. Many different factors makes it challenging, especially the difficulty in communicating with an ICU patient. However, by looking at the patient as a whole, treating pain early with the multimodal approach, there seems to be some promising results in improving outcomes. It has shown that the improved outcomes in critically ill patients in the perioperative period seen with optimized pain management and ICU can shorten hospital stays, decreased inpatient costs, and limit the use of limited resources.

Sedation Practice in Extracorporeal Membrane Oxygenation-Treated Patients with Acute Respiratory Distress Syndrome: A Retrospective Study

Our objective was to characterize sedation management in adult patients with severe respiratory distress syndrome (ARDS) treated with venovenous extracorporeal membrane oxygenation (VV-ECMO). We conducted a retrospective chart review of these patients treated at Toronto General Hospital between January 2012 and October 2015. Medications administered (sedative, analgesic, paralytic, and antipsychotic), sedation depth (Sedation Agitation Scale [SAS] score) delirium assessments, and mobilization were recorded daily. Forty-five adults (33 males, median age 47 years; interquartile range [IQR], 35-56]) with ARDS (median PaO2/FiO2 71; IQR 59-83) because of respiratory infection (91%) were treated with VV-ECMO for a median of 11 days (IQR, 7-17). After ECMO initiation, 96% patients were deeply sedated (SAS score < 3) with continuous infusions of midazolam (49%), propofol (18%), or both (29%) and 98% were receiving opioid infusions (93% fentanyl). Patients were deeply sedated for a median of 6 days (IQR, 3-10) after cannulation before transitioning to intermediate or light sedation (SAS score ≥ 3). Before ECMO discontinuation, 77% of surviving patients were intermediately or lightly sedated, 20% were receiving no sedatives, and 9% were receiving no opioids. During ECMO, 58% had positive delirium assessment and 24% experienced agitation (SAS ≥ 6). During ECMO support, 71% received physical therapy that occurred after a median of 7 days (IQR, 4-12) after cannulation. In conclusion, we found that although patients were deeply sedated for a prolonged duration after VV-ECMO initiation, many were able to safely achieve light sedation and active mobilization.

A Novel Research Method for Determining Sedative Exposure in Critically Ill Patients

BACKGROUND

Although potent sedative and opioid drugs are some of the most commonly used medications to manage pain, anxiety, and discomfort in critically ill patients, conducting clinical trials where sedative and opioid medications are outcome variables within a longitudinal research design can be a methodological challenge.

OBJECTIVES

The purpose of this article is to provide in detail a conceptual discussion of the concept and analysis of sedative exposure: A novel research analysis method for aggregating sedative and opioid medication doses from disparate drug classes commonly administered to critically ill patients and used by our team in several clinical research studies.

METHODS

Comparing the dose of each sedative and opioid administered to an individual patient (within a defined time interval) to all other patients in a research study receiving the same medications allows for ranking of dosages for each medication by quartiles. Rank values for all sedatives and opioids received can be summed to a single value resulting in a Sedation Intensity Score. In addition, a simple count of how many hours at least one dose of a sedative or opioid medication has been administered can determine sedation frequency.

RESULTS

This method can allow for comparison of sedative exposure with medications from disparate drug classes and for analysis of estimates of change in medication use over time.

DISCUSSION

This novel research analysis method can overcome the challenges and limitations of determining changes in sedative and opioid medication regimens in cohort and clinical trial study designs.

Chronic Pain and Chronic Opioid Use After Intensive Care Discharge - Is It Time to Change Practice?

Almost half of patients treated on intensive care unit (ICU) experience moderate to severe pain. Managing pain in the critically ill patient is challenging, as their pain is complex with multiple causes. Pharmacological treatment often focuses on opioids, and over a prolonged admission this can represent high cumulative doses which risk opioid dependence at discharge. Despite analgesia the incidence of chronic pain after treatment on ICU is high ranging from 33-73%. Measures need to be taken to prevent the transition from acute to chronic pain, whilst avoiding opioid overuse. This narrative review discusses preventive measures for the development of chronic pain in ICU patients. It considers a number of strategies that can be employed including non-opioid analgesics, regional analgesia, and non-pharmacological methods. We reason that individualized pain management plans should become the cornerstone for critically ill patients to facilitate physical and psychological well being after discharge from critical care and hospital.

Delirium after cardiac surgery. Incidence, phenotypes, predisposing and precipitating risk factors, and effects

BACKGROUND

In cardiac surgical patients little is known about different phenotypes of delirium and how the symptoms fluctuate over time.

OBJECTIVES

Evaluate risk factors, incidence, fluctuations, phenotypic characteristics and impact on patients' outcomes of delirium.

METHODS

Prospective longitudinal study. In postoperative intensive care unit 199 patient were assessed three-times a day through an adapted versions of the Intensive Care Delirium Screening Checklist.

RESULTS

Delirium and subsyndromal delirium incidence were 30.7% and 31.2%, respectively. Delirium manifested mostly in the hypoactive form and showed a fluctuating trend for several days. Atrial fibrillation, benzodiazepine/opioids dosages, hearing impairment, extracorporeal circulation length, SAPS-II and mean arterial pressure were independent predictors for delirium. Delirium was a statistically significant predictor of chemical/physical restraint use and hospital length of stay.

CONCLUSIONS

Given the fluctuating and phenotypic characteristics, delirium screening should be a systematic/intentional activity. Multidisciplinary prevention strategies should be implemented to identify and treat the modifiable risk factors.

Evaluation of a Multidisciplinary Pain, Agitation, and Delirium Guideline in Mechanically Ventilated Critically Ill Adults

Background: A multidisciplinary team updated an institution-specific pain, agitation, and delirium (PAD) guideline based on the recommendations from the Society of Critical Care Medicine (SCCM) PAD guidelines. This institution-specific guideline emphasized protocolized sedation with increased as needed boluses, and nonbenzodiazepine infusions, daily sedation interruption, and pairing of spontaneous awakening (SAT) and breathing trials (SBT). Objective: The purpose of this study was to evaluate the impact of implementation of a PAD guideline on clinical outcomes and medication utilization in an academic medical center intensive care unit (ICU). It was hypothesized that implementation of an updated guideline would improve clinical outcomes and decrease usage of benzodiazepine infusions. Methods: Pre-post retrospective chart review of 2417 (1147 pre, 1270 post) critically ill, mechanically ventilated adults in a medical/surgical ICU over a 2-year period (1 year pre and post guideline implementation). Results: After guideline implementation, average ventilation days was reduced (3.98 vs 3.43 days, P = .0021), as well as ICU and hospital length of stay (LOS) (4.79 vs 4.34 days, P = .048 and 13.96 vs 12.97 days, P = .045, respectively). Hospital mortality (19 vs 19%, P = .96) and acute physiology and chronic health evaluation (APACHE) IV scores (77.28 vs 78.75, P = .27) were similar. After guideline implementation, the percentage of patients receiving midazolam infusions decreased (422/1147 [37%] vs 363/1270 patients [29%], P = .0001). The percentage of patients receiving continuous infusion propofol (679/1147 [59%] vs 896/1270 [70%], P = .0001) and dexmedetomidine (78/1147 [7%] vs 147/1270 [12%], P = .0001) increased. Conclusions: Implementing a multidisciplinary PAD guideline utilizing protocolized sedation and daily sedation interruption decreased ventilation days and ICU and hospital LOS while decreasing midazolam drip usage.

Psychometric analysis of subjective sedation scales used for critically ill paediatric patients

AIMS

This study evaluated the psychometric properties of subjective sedation scales using one psychometric scoring system to identify the appropriate scale that is most suitable for clinical care practice.

BACKGROUND

A number of published sedation assessment scales for paediatric patients are currently used to attempt to achieve a moderate depth of sedation to avoid the undesirable effects caused by over- or undersedation. However, there has been no systematic review of these scales.

SEARCH STRATEGY

We searched the Cochrane Library, PubMed, EMBASE, the Cumulative Index to Nursing and Allied Health Literature, etc., to obtain relevant articles. The quality of the selected studies was evaluated according to the Consensus-based Standards for the Selection of Health Measurement Instruments checklist.

INCLUSION CRITERIA

Articles that had been published or were in press and discussed the psychometric properties of sedation scales were included. The population comprised critically ill infants and non-verbal children ranging in age from 0 to 18 years who underwent sedation in an intensive care unit.

FINDINGS

Data were independently extracted by two investigators using a standard data extraction checklist: 43 articles were included in this review, and 13 sedation scales were examined. The quality of the psychometric evidence for the Comfort Scale and Comfort Behaviour Scale was 'very good', with the Comfort Scale having a higher quality (total weighted scores, Comfort Scale = 17·3 and Comfort Behaviour Scale = 15·5).

CONCLUSIONS

We suggest that the scales be systematically and comprehensively tested in terms of development method, reliability, validation, feasibility and correlation with clinical outcome. The Comfort Scale and Comfort Behaviour Scale are useful tools for measuring sedation in paediatric patients.

RELEVANCE TO CLINICAL PRACTICE

Nursing staff should choose one subjective sedation scale that is suitable for assessing paediatric patients' depth of sedation. We recommend the Comfort Scale and Comfort Behaviour Scale as optimal choices if the clinical environment permits.

Risk Factors of Delirium in Sequential Sedation Patients in Intensive Care Units

Background

Delirium is a primary adverse event in ventilated patients who receive long-term monosedative treatment. Sequential sedation may reduce these adverse effects. This study evaluated risk factors for delirium in sequential sedation patients.

Methods

A total of 141 patients who underwent sequential sedation were enrolled. Delirium was diagnosed using Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) scale. Univariate and multivariate Cox proportional hazards regressions were used to predict risk factors.

Results

Older age (≥51) (RR = 2.432, 95% CL 1.316–4.494, p = 0.005), higher SOFA score (≥14) (RR = 2.022, 95% CL 1.076–3.798, p = 0.029), regular smoking (RR = 2.366, 95% CL 1.277–4.382, p = 0.006), and higher maintenance dose of midazolam (RR = 1.052, 95% CL 1.000–1.107, p = 0.049) and fentanyl (RR = 1.045, 95% CL 1.019–1.072, p = 0.001) when patients met sequential criteria, were independent risk factors of delirium. Sequential sedation with dexmedetomidine (RR = 0.448, 95% CL 0.209–0.963, p = 0.040) was associated with a lower risk of delirium.

Conclusions

Older age, higher SOFA score, regular smoking, and higher maintenance dose of midazolam and fentanyl when patients met sequential criteria were independent risk factors of delirium in sequential sedation patients. Sequential sedation with dexmedetomidine reduced risk of delirium.

Opioid-associated iatrogenic withdrawal in critically ill adult patients: a multicenter prospective observational study

Background

Opioids and benzodiazepines are frequently used in the intensive care unit (ICU). Regular use and prolonged exposure to opioids in ICU patients followed by abrupt tapering or cessation may lead to iatrogenic withdrawal syndrome (IWS). IWS is well described in pediatrics, but no prospective study has evaluated this syndrome in adult ICU patients. The objective of this study was to determine the incidence of IWS caused by opioids in a critically ill adult population. This multicenter prospective cohort study was conducted at two level-1 trauma ICUs between February 2015 and September 2015 and included 54 critically ill patients. Participants were eligible if they were 18 years and older, mechanically ventilated and had received more than 72 h of regular intermittent or continuous intravenous infusion of opioids. For each enrolled patient and per each opioid weaning episode, presence of IWS was assessed by a qualified ICU physician or senior resident according to the 5th edition of Diagnostic and Statistical Manual of Mental Disorders criteria for opioid withdrawal.

Results

The population consisted mostly of males (74.1%) with a median age of 50 years (25th–75th percentile 38.2–64.5). The median ICU admission APACHE II score was 22 (25th–75th percentile 12.0–28.2). The overall incidence of IWS was 16.7% (95% CI 6–27). The median cumulative opioid dose prior to weaning was higher in patients with IWS (245.7 vs. 169.4 mcg/kg, fentanyl equivalent). Patients with IWS were also exposed to opioids for a longer period of time as compared to patients without IWS (median 151 vs. 125 h). However, these results were not statistically significant.

Conclusions

IWS was occasionally observed in this very specific population of mechanically ventilated, critically ill ICU patients. Further studies are needed to confirm these preliminary results and identify risk factors.

Iatrogenic Opioid Withdrawal in Critically Ill Patients: A Review of Assessment Tools and Management

OBJECTIVE

To (1) provide an overview of the epidemiology, clinical presentation, and risk factors of iatrogenic opioid withdrawal in critically ill patients and (2) conduct a literature review of assessment and management of iatrogenic opioid withdrawal in critically ill patients.

DATA SOURCES

We searched MEDLINE (1946-June 2017), EMBASE (1974-June 2017), and CINAHL (1982-June 2017) with the terms opioid withdrawal, opioid, opiate, critical care, critically ill, assessment tool, scale, taper, weaning, and management. Reference list of identified literature was searched for additional references as well as www.clinicaltrials.gov .

STUDY SELECTION AND DATA EXTRACTION

We restricted articles to those in English and dealing with humans.

DATA SYNTHESIS

We identified 2 validated pediatric critically ill opioid withdrawal assessment tools: (1) Withdrawal Assessment Tool-Version 1 (WAT-1) and (2) Sophia Observation Withdrawal Symptoms Scale (SOS). Neither tool differentiated between opioid and benzodiazepine withdrawal. WAT-1 was evaluated in critically ill adults but not found to be valid. No other adult tool was identified. For management, we identified 5 randomized controlled trials, 2 prospective studies, and 2 systematic reviews. Most studies were small and only 2 studies utilized a validated assessment tool. Enteral methadone, α-2 agonists, and protocolized weaning were studied.

CONCLUSION

We identified 2 validated assessment tools for pediatric intensive care unit patients; no valid tool for adults. Management strategies tested in small trials included methadone, α-2 agonists, and protocolized sedation/weaning. We challenge researchers to create validated tools assessing specifically for opioid withdrawal in critically ill children and adults to direct management.