Surgical intensive care unit pain management in the era of intravenous opioid shortages
Bouwma A, Mlynarek M, Peters M, Procopio V, and Martz C. Surgical intensive care unit pain management in the era of intravenous opioid shortages. Crit Care Med 2020; 48:23.
Crit Care Med
Introduction/Hypothesis: Fentanyl is widely used for the treatment of pain in mechanically ventilated (MV) intensive care unit (ICU) patients, but a shortage of fentanyl forced hospitals to utilize other medications. This study compared pain control in MV patients before and during continuous intravenous infusion (CIVI) fentanyl shortages. Methods: This was a multi-center, IRB approved, quasi-experimental study conducted in surgical ICU (SICU) patients. Patients were included if they were admitted due to trauma or post-procedure, excluding neurologic and cardiac surgeries, and on MV for >24 hours. The before and during shortage groups included patients prior to fentanyl shortages (4/2017-9/2017) who received CIVI fentanyl and during fentanyl shortages (4/2018-9/2018) without CIVI fentanyl administration, respectively. Patients were excluded if they were comfort care, pharmacologically paralyzed, in alcohol withdrawal, or able to verbalize a pain score. Randomization for patient inclusion occurred via a random number generator. The primary outcome was the percentage of Critical-Care Pain Observation Tool (CPOT) scores within goal. Secondary endpoints included the percentage of Richmond Agitation-Sedation Scale scores within goal, time to first CPOT goal, morphine milligram equivalents (MME), ventilator days, ICU length of stay, medications used for pain, agitation, delirium (PAD), rates of CIVI PAD medications, and confusion assessment method for the ICU (CAM-ICU). Data was collected until extubation or up to 7 days on MV. Descriptive statistics, chi-squared, and Mann Whitney U test were used, as appropriate. Results: A total of 164 patients were included (82 patients in the before and during shortage groups respectively). There was no statistically significant difference in the percentage of CPOT scores at goal (79.5% vs. 80.6%; p=0.365) however, the during shortage group did have significantly less oral MME compared to the before group (37.9 MME vs. 240 MME, respectively; p < 0.001). There were no statistically significant differences found in other secondary endpoints, with the exception of higher CIVI propofol rates and increased positive CAM-ICU scores in the during shortage group. Conclusions: Patients on MV in the SICU appear to have adequate pain control with less overall MME without CIVI fentanyl utilization.