Withdrawal following sufentanil/propofol and sufentanil/midazolam

Epigenetic regulation of beta-endorphin synthesis in hypothalamic arcuate nucleus neurons modulates neuropathic pain in a rodent pain model

Although beta-endorphinergic neurons in the hypothalamic arcuate nucleus (ARC) synthesize beta-endorphin (β-EP) to alleviate nociceptive behaviors, the underlying regulatory mechanisms remain unknown. Here, we elucidated an epigenetic pathway driven by microRNA regulation of β-EP synthesis in ARC neurons to control neuropathic pain. In pain-injured rats miR-203a-3p was the most highly upregulated miRNA in the ARC. A similar increase was identified in the cerebrospinal fluid of trigeminal neuralgia patients. Mechanistically, we found histone deacetylase 9 was downregulated following nerve injury, which decreased deacetylation of histone H3 lysine-18, facilitating the binding of NR4A2 transcription factor to the miR-203a-3p gene promoter, thereby upregulating miR-203a-3p expression. Further, increased miR-203a-3p was found to maintain neuropathic pain by targeting proprotein convertase 1, an endopeptidase necessary for the cleavage of proopiomelanocortin, the precursor of β-EP. The identified mechanism may provide an avenue for the development of new therapeutic targets for neuropathic pain treatment.

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.

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.

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.

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.

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.

Adjusted vs Total Body Weight-Based Dosing of Sedation and Analgesia Used in the Intensive Care Unit

Background: The purpose of this study was to evaluate if dosing fentanyl, dexmedetomidine, and propofol based on ideal or adjusted vs actual weight in patients would decrease overall opioid and sedative use. Methods: This was a retrospective chart review comparing adjusted vs actual weight-based dosing protocol of mechanically ventilated (MV) intensive care unit (ICU) adult patients who required fentanyl and either propofol or dexmedetomidine. Results: A total of 261 patients were included in which 101 patients were in the actual weight group and 160 patients were in the adjusted weight group. Total doses per MV day of fentanyl was 1042 ± 1060 µg in the actual weight group vs 901 ± 1025 µg in the adjusted weight group (P = .13). Total doses per MV day of midazolam was 20 ± 19 mg in the actual group vs 15 ± 19 mg adjusted group (P = .02). Average MV days was 8.2 vs 7.1 days, ICU length of stay was 10.6 vs 9.4 days, and self-extubation rates were 17.8% vs 4.4% in the actual group and adjusted group, respectively. Conclusion: Total midazolam doses per MV day were lower in the adjusted group. No significant change was seen in MV days, ICU length of stay, or self-extubation rates.

Association of Patient-Reported Narcotic Use With Short- and Long-Term Outcomes After Adult Spinal Deformity Surgery: Multicenter Study of 425 Patients With 2-year Follow-up

STUDY DESIGN

Retrospective analysis of a prospective registry OBJECTIVE.: To investigate associations of preoperative narcotic use with outcomes after adult spinal deformity (ASD) surgery.

SUMMARY OF BACKGROUND DATA

We hypothesized that preoperative narcotic use would predict longer hospital stays, greater postoperative narcotic use, and greater disability 2 years after ASD surgery.

METHODS

A multicenter database of surgical ASD patients was analyzed retrospectively for patients with self-reported data on preoperative narcotic use. Patients were categorized as using narcotics daily or non-daily (including those who used no narcotics), according to self-report. Outcomes were prolonged length of hospital stay (LOS) (>7 days); length of intensive care unit (ICU) stay; and daily narcotic use and Oswestry Disability Index (ODI) scores 2 years postoperatively. Groups were compared by demographic characteristics, pain, disability, radiographic deformity, and surgical invasiveness. Multivariate logistic and linear regression were used to determine associations between preoperative narcotic use and outcomes.

RESULTS

Of 575 patients who met the inclusion criteria, 425 (74%) had complete 2-year follow-up data. Forty-four percent reported daily preoperative narcotic use. Compared with non-daily users, daily narcotic users were older, had more comorbidities, more severe back pain, higher ODI scores, longer operative times, and worse preoperative malalignment and were more likely to undergo 3-column osteotomy (all, P < 0.05). Daily narcotic use independently predicted prolonged LOS (odds ratio [OR] = 1.7, 95% confidence interval [CI] = 1.1-2.9), longer ICU stay (difference = 16 hours, 95% CI = 1.9-30 hours), and daily narcotic use 2 years postoperatively (OR = 6.9, 95% CI = 3.7-13), as well as worse 2-year ODI score (difference = 4.5, 95% CI: 0.7-8.3, P = 0.021).

CONCLUSION

Daily narcotic use before ASD surgery was associated with prolonged LOS, longer ICU stays, and increased risk of daily narcotic use and greater disability 2 years postoperatively.

LEVEL OF EVIDENCE

3.

[High blood pressure during the autonomic crises in children in intensive care unit: Etiologic circumstances and modality therapeutic]

The dysautonomic (DC) or neurovegetative crisis remains an imperfectly known entity; it associates in a paroxysmal manner a reaction of sympathetic hyperreactivity that can lead to the prognosis. Our objective is to specify the etiological circumstances (DC) and their modality of treatment in pediatric intensive care unit.

MATERIALS-METHODS

Descriptive study on files of children admitted in the intensive care unit of 2010-2015 who presented a DC acquired during their hospitalization.

RESULTS

In total, 41 patients included with an average age of 56.92 months presented DC. Among the etiological circumstances Guillain-Barré syndrome and head trauma are noted. Observed symptoms occur on average at one week of admission; they are related to the consequences of DC. The manifestations are polymorphic: a systolic hypertension is present in all cases with an average PAS of 141.24±13.48mmHg, an average PAD of 86.80±11.01mmHg, a vasomotor disorder, a hyperthermia are noted. Cerebral anoxia post cardiac arrest in 4 patients preceded the onset of DC. Apart from the etiologic treatment, 39 patients were intubated with mechanical ventilation, sedated with morphinomimetic and benzodiazepine±lioresal (baclofen). Treatment of hypertension resulted in the administration of a central antihypertensive. Evolution is good in addition to 5 deaths related to neurovegetative disorders.

CONCLUSION

DC is a poorly understood situation in pediatric intensive care unit, and the circumstances of the disease are variable. The diagnosis must be made with careful consideration because the prognosis may be fatal.

Tolerance and Withdrawal Issues with Sedatives in the Intensive Care Unit

Prolonged use of sedative medications continues to be a concern for critical care practitioners, with potential adverse effects including tolerance and withdrawal. The amount of sedatives required in critically ill patients can be lessened and tolerance delayed with the use of pain and/or sedation scales to reach the desired effect. The current recommendation for prolonged sedation is to wean patients from the medications over several days to reduce the risk of drug withdrawal. It is important to identify patients at risk for iatrogenic withdrawal and create a treatment strategy.

Responses to noxious stimuli in sedated mechanically ventilated adults

OBJECTIVE

To determine the effect of sedation on physiologic responses and comfort before, during and after a noxious stimulus (endotracheal tube suctioning).

METHODS

The sample was a subset of a larger, longitudinal descriptive study, blood for endorphins and saliva for alpha-amylase were obtained before and after suctioning. Heart rate (HR), respiration rate (RR), oxygen saturation (SPO2), and arm and leg actigraphy were continuously recorded.

RESULTS

67 subjects from medical and surgical ICUs were primarily deeply (37%) or mildly sedated (54%) prior to suctioning. Alpha-amylase increased post suctioning (p = 0.04); endorphins did not change (p = 0.58). Neither were modified by sedation. There were no changes in HR, RR or SPO2 post suctioning. Arm (p = 0.007) and leg actigraphy (p = 0.057) changed from baseline and depended on sedation level (p = 0.0005).

CONCLUSIONS

While a stress marker did increase during suctioning, only the measure of patient arm movement was significantly affected by sedation level.

Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit

OBJECTIVE

To revise the "Clinical Practice Guidelines for the Sustained Use of Sedatives and Analgesics in the Critically Ill Adult" published in Critical Care Medicine in 2002.

METHODS

The American College of Critical Care Medicine assembled a 20-person, multidisciplinary, multi-institutional task force with expertise in guideline development, pain, agitation and sedation, delirium management, and associated outcomes in adult critically ill patients. The task force, divided into four subcommittees, collaborated over 6 yr in person, via teleconferences, and via electronic communication. Subcommittees were responsible for developing relevant clinical questions, using the Grading of Recommendations Assessment, Development and Evaluation method (http://www.gradeworkinggroup.org) to review, evaluate, and summarize the literature, and to develop clinical statements (descriptive) and recommendations (actionable). With the help of a professional librarian and Refworks database software, they developed a Web-based electronic database of over 19,000 references extracted from eight clinical search engines, related to pain and analgesia, agitation and sedation, delirium, and related clinical outcomes in adult ICU patients. The group also used psychometric analyses to evaluate and compare pain, agitation/sedation, and delirium assessment tools. All task force members were allowed to review the literature supporting each statement and recommendation and provided feedback to the subcommittees. Group consensus was achieved for all statements and recommendations using the nominal group technique and the modified Delphi method, with anonymous voting by all task force members using E-Survey (http://www.esurvey.com). All voting was completed in December 2010. Relevant studies published after this date and prior to publication of these guidelines were referenced in the text. The quality of evidence for each statement and recommendation was ranked as high (A), moderate (B), or low/very low (C). The strength of recommendations was ranked as strong (1) or weak (2), and either in favor of (+) or against (-) an intervention. A strong recommendation (either for or against) indicated that the intervention's desirable effects either clearly outweighed its undesirable effects (risks, burdens, and costs) or it did not. For all strong recommendations, the phrase "We recommend …" is used throughout. A weak recommendation, either for or against an intervention, indicated that the trade-off between desirable and undesirable effects was less clear. For all weak recommendations, the phrase "We suggest …" is used throughout. In the absence of sufficient evidence, or when group consensus could not be achieved, no recommendation (0) was made. Consensus based on expert opinion was not used as a substitute for a lack of evidence. A consistent method for addressing potential conflict of interest was followed if task force members were coauthors of related research. The development of this guideline was independent of any industry funding.

CONCLUSION

These guidelines provide a roadmap for developing integrated, evidence-based, and patient-centered protocols for preventing and treating pain, agitation, and delirium in critically ill patients.

Design flaws in randomized, placebo controlled, double blind clinical trials

The hypothesis in drug clinical trials is that the drug is better than a placebo in patients suffering from a disease. The unstated assumption is that the drug cures the disease or is a powerful treatment for the disease. This is an incorrect assumption. Drugs do not cure or treat diseases. The body heals itself; drugs promote this ability of the body to heal itself. Placebos are assumed to be inactive; however, placebos can also promote the ability of the body to heal itself. Placebos are actually treatments that can stimulate endogenous healing mechanisms. The possible place of placebos in health management is controversial. Clinical trial design should be altered. The hypothesis of clinical trials should be that the drug speeds up or improves the healing of the patient, putting patient healing as the first objective. Placebos should not be used as controls but could be tested as drugs in their own right. The control in clinical trials should be no treatment. Alternatively, new drugs could be compared to existing drugs in clinical trials.

Protocolized and target-based sedation and analgesia in the ICU

Protocolized target-based sedation and analgesia is central to effective management of sedation. Important components include identifying goals and specific targets,using valid and reliable tools to measure pain, agitation, and sedation, and titrating a logically selected combination of sedatives and analgesics to defined end-points.A variety of approaches to structured management have been tested in controlled trials with major categories of (1) sedation algorithms and protocols and (2) daily interruption of sedation. Although not all studies that compare new interventions to “usual care” document dramatic improvements, many studies show that by reducing oversedation, using a structured approach, faster recovery from respiratory failure may ensue. The somewhat discrepant results illustrate, however, that various approaches,such as DIS, may not be optimal for all patients. Further research will be necessary to define these patients and examine alternative strategies. Finally, implementation of structured approaches to sedation management is a challenging, time-consuming process for clinicians that must be supported with sufficient resources to be successful.

Flurbiprofen axetil enhances analgesic effect of fentanyl associated with increase in β-endorphin levels

PURPOSE

To examine the analgesic effect of preoperative administration of flurbiprofen axetil and that of postoperative administration of a combination of flurbiprofen axetil and fentanyl, as well as perioperative plasma β-endorphin (β-EP) levels in patients undergoing esophagectomy.

METHODS

Forty-five patients were randomly divided into three groups: group A: 100 mg flurbiprofen axetil preoperative, 10 μg/kg fentanyl + 10 ml placebo postoperative; group B: 100 mg flurbiprofen axetil preoperative, 10 μg/kg fentanyl + 100 mg flurbiprofen axetil postoperative; group C: 10 ml placebo preoperative, 10 μg/kg fentanyl + 10 ml placebo postoperative. Postoperative analgesia was achieved by intravenous infusion containing flurbiprofen axetil and/or fentanyl at 2.0 ml/h (total volume, 100 ml) using infusion pumps. The β-EP was measured at preanesthesia (T(1)), the end of surgery (T(2)), 24 h (T(3)), and 48 h (T(4)) after surgery. Visual analog scale scores (VAS) at T3, T4 (at rest), and rescue analgesic tramadol requirement was recorded.

RESULTS

The VAS of group B was significantly lower than group A and C (P < 0.01) at T(3) and T(4). The β-EP levels at T(2)-T(4) in group A did not differ significantly from those at T(1) (P > 0.05); however, the β-EP levels in group B at T(3)-T(4) increased significantly (P < 0.05), while those in group C increased at T(2) and decreased at T(4) (P < 0.05). The β-EP levels in group B at T(3) and T(4) were the highest as compared to its levels in groups A and C (P < 0.01). Tramadol consumption in group B was significantly lower than in groups A and C (P < 0.01).

CONCLUSION

These results show that flurbiprofen axetil enhances the analgesic effect of fentanyl associated with increase in β-EP levels.

Adverse drug events associated with the use of analgesics, sedatives, and antipsychotics in the intensive care unit

As critically ill patients frequently receive analgesics, sedatives, and antipsychotics to optimize patient comfort and facilitate mechanical ventilation, adverse events associated with the use of these agents can affect all organ systems and result in substantial morbidity and mortality. Although many of these adverse effects are common pharmacologic manifestations of the agent, and therefore frequently reversible, others are idiosyncratic and thus unexpected. The critically ill are more susceptible to adverse drug events than nonintensive care unit patients due to the high doses and long periods for which each of these agents are often administered, the frequent use of intravenous formulations that contain adjuvants that may lead to toxicity in some instances, and the high prevalence of end-organ dysfunction that affects the pharmacokinetic and pharmacodynamic response to therapy. This paper will review the most common and serious adverse drug events reported to occur with the use of sedatives, analgesics, and antipsychotics in the intensive care unit; highlight the pharmacokinetic, pharmacodynamic, and pharmacogenetic factors that can influence analgesic, sedative, and antipsychotic response and safety in the critically ill; and identify strategies that can be used to minimize toxicity with these agents.

[Sedation in neurointensive care unit]

The objectives for using sedation in neurointensive care unit (neuroICU) are somewhat different from those used for patients without severe brain injuries. One goal is to clinically reassess the neurological function following the initial brain insult in order to define subsequent strategies for diagnosis and treatment. Another goal is to prevent severely injured brain from additional aggravation of cerebral blood perfusion and intracranial pressure. Depending on these situations is the choice of sedatives and analgesics: short-term agents, e.g., remifentanil, if a timely neurological reassessment is required, long-term agents, e.g., midazolam and sufentanil, as part of the treatment for elevated intracranial pressure. In that situation, a multimodal monitoring is needed to overcome the lack of clinical monitoring, including repeated measurements of intracranial pressure, blood flow velocities (transcranial Doppler), cerebral oxygenation (brain tissue oxygen tension), and brain imaging. The ultimate stop of neurosedation can distinguish between no consciousness and an alteration of arousing in brain-injured patients. During this period, an elevation of intracranial pressure is usual, and should not always result in reintroducing the neurosedation.

Protocolized and target-based sedation and analgesia in the ICU

Administering sedative and analgesic medications is a cornerstone of optimizing patient comfort and minimizing distress, yet may lead to unintended consequences including delayed recovery from critical illness and slower liberation from mechanical ventilation. The use of structured approaches to sedation management, including guidelines, protocols, and algorithms can promote evidence-based care, reduce variation in clinical practice, and systematically reduce the likelihood of excessive and/or prolonged sedation. Patient-focused sedation algorithms are multidisciplinary, including physician, nurse, and pharmacist development and implementation. Key components of sedation algorithms include identification of goals and specific targets, use of valid and reliable tools to assess analgesia, agitation, and sedation, and incorporation of logical medication selection. Sedation protocols generally focus on a) algorithms that incorporate treating sedation and analgesia based upon escalation, de-escalation, or changing medications according to specific targets, or b) daily interruption of sedative and opioid analgesic infusions. Many published sedation protocols have been tested in controlled clinical trials, often demonstrating benefit such as shorter duration of mechanical ventilation, reduced ICU length of stay, and/or superior sedation management compared to usual care. Implementation of sedation algorithms in ICUs is a challenging process for which sufficient resources must be allocated.

Remifentanil discontinuation and subsequent intensive care unit-acquired infection: a cohort study

INTRODUCTION

Recent animal studies demonstrated immunosuppressive effects of opioid withdrawal resulting in a higher risk of infection. The aim of this study was to determine the impact of remifentanil discontinuation on intensive care unit (ICU)-acquired infection.

METHODS

This was a prospective observational cohort study performed in a 30-bed medical and surgical university ICU, during a one-year period. All patients hospitalised in the ICU for more than 48 hours were eligible. Sedation was based on a written protocol including remifentanil with or without midazolam. Ramsay score was used to evaluate consciousness. The bedside nurse adjusted sedative infusion to obtain the target Ramsay score. Univariate and multivariate analyses were performed to determine risk factors for ICU-acquired infection.

RESULTS

Five hundred and eighty-seven consecutive patients were included in the study. A microbiologically confirmed ICU-acquired infection was diagnosed in 233 (39%) patients. Incidence rate of ICU-acquired infection was 38 per 1000 ICU-days. Ventilator-associated pneumonia was the most frequently diagnosed ICU-acquired infection (23% of study patients). Pseudomonas aeruginosa was the most frequently isolated microorganism (30%). Multivariate analysis identified remifentanil discontinuation (odds ratio (OR) = 2.53, 95% confidence interval (CI) = 1.28 to 4.99, P = 0.007), simplified acute physiology score II at ICU admission (1.01 per point, 95% CI = 1 to 1.03, P = 0.011), mechanical ventilation (4.49, 95% CI = 1.52 to 13.2, P = 0.006), tracheostomy (2.25, 95% CI = 1.13 to 4.48, P = 0.021), central venous catheter (2.9, 95% CI = 1.08 to 7.74, P = 0.033) and length of hospital stay (1.05 per day, 95% CI = 1.03 to 1.08, P < 0.001) as independent risk factors for ICU-acquired infection.

CONCLUSIONS

Remifentanil discontinuation is independently associated with ICU-acquired infection.

Withdrawal symptoms in critically ill children after long-term administration of sedatives and/or analgesics: a first evaluation

OBJECTIVE

To establish frequencies of benzodiazepine and opioid withdrawal symptoms, and correlations with total doses and duration of administration.

DESIGN

A prospective, repeated-measures design.

SETTING

Two pediatric intensive care units in a university children's hospital.

PATIENTS

Seventy-nine children, aged 0 days to 16 yrs, who received intravenous midazolam and/or opioids for >5 days.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Pediatric intensive care unit nurses assessed withdrawal symptoms using the Sophia Benzodiazepine and Opioid Withdrawal Checklist, which includes all withdrawal symptoms (n = 24) described in the pediatric literature. Over 6 months, 2188 observations in 79 children were recorded. Forty-two percent of observations were performed within 24 hrs after tapering off or discontinuation of medication. Symptoms representing overstimulation of the central nervous system, such as anxiety, agitation, grimacing, sleep disturbance, increased muscle tension, and movement disorder, were observed in >10% of observations. Of symptoms reflecting gastrointestinal dysfunction, diarrhea and gastric retention were most frequently observed. Tachypnea, fever, sweating, and hypertension as manifestations of autonomic dysfunction were observed in >13% of observations. The Spearman's rank-correlation coefficient between total doses of midazolam and maximum sum score (of the Sophia Benzodiazepine and Opioid Withdrawal Checklist) was .51 (p < 0.001). The correlation between total doses of opioids and the maximum sum score was .39 (p < 0.01). A significant correlation (.52; p < 0.001) was also found between duration of use and maximum sum score.

CONCLUSIONS

This is the first study to report frequencies of all 24 withdrawal symptoms observed in children after decrease or discontinuation of benzodiazepines and/or opioids. Agitation, anxiety, muscle tension, sleeping <1 hr, diarrhea, fever, sweating, and tachypnea were observed most frequently. Longer duration of use and high dosing are risk factors for development of withdrawal symptoms in children.

[Sedation and analgesia for the brain-injured patient]

Sedation-analgesia occupies an essential place in the specific therapeutic arsenal of the brain-injured patients. The maintenance of the perfusion of the brain, its relaxation and its protection are the fundamental objectives whose finality is to avoid the extension of the lesions and to preserve the neuronal capital. Sedation is instituted when patients are severely agitated or present a deterioration of their state of consciousness (GCS< or =8). Under cover of mechanical ventilation, sedation is the first line treatment of intracranial hypertension, a common pathway of various acute brain diseases of traumatic, vascular or other origin. The use of the combination of hypnotic and opioids is the rule. The combined action of these two classes reinforces and improves their sedative effects. Midazolam is the 2 benzodiazepine of reference. Propofol is more and more frequently added to the combination of hypnotic and opioids. The "propofol infusion syndrome" is a severe limitation to its long term administration in particular among patients presenting a severe septic or inflammatory state. Propofol will be imperatively stopped in the event of metabolic acidosis, rhabdomyolysis, acute renal insufficiency, hyperkaliemia or increase in the blood triglyceride levels. The use of thiopental is restricted to the most severe cases. Its use as a monotherapy at high doses is abandoned to the profit of a co-administration with midazolam or even with the combination of midazolam and propofol. Thiopental overdose is very frequent in the event of associated hypothermia. Etomidate does not have its place apart from induction in fast sequence. The neuro-protective effects of ketamine require to be demonstrated in man before being recommended routinely. Withdrawal of sedation can be responsible for a state of agitation which can be controlled by neuroleptics.

Analgesia and sedation in the intensive care unit: an overview of the issues

Analgesic and sedative medications are widely used in intensive care units to achieve patient comfort and tolerance of the intensive care unit environment, and to eliminate pain, anxiety, delirium and other forms of distress. Surveys and prospective cohort studies have revealed wide variability in medication selection, monitoring using sedation scales, and implementation of structured treatment algorithms among practitioners in different countries and regions of the world. Successful management of analgesia and sedation incorporates a patient-based approach that includes detection and management of predisposing and causative factors, including delirium; monitoring using analgesia and sedation scales and other instruments; proper medication selection, with an emphasis on analgesia-based drugs; and incorporation of structured strategies that have been demonstrated to reduce likelihood of excessive or prolonged sedation.

EEG changes and serum anticholinergic activity measured in patients with delirium in the intensive care unit

The aim of this study was to examine whether serum anticholinergic activity (SAA) is a reliable indicator of delirium in the ICU, and whether there is a significant correlation between SAA and quantitative electroencephalographic (EEG) data in delirious patients. In a prospective cohort study, we assessed ICU patients diagnosed with delirium (n = 37). EEG measurements and blood analysis including SAA were performed 48 h following ICU admission. The presence of delirium was evaluated using the Confusion Assessment Method for critically ill patients in ICU (CAM-ICU). The SAA level was measured using a competitive radioreceptor binding assay for muscarinergic receptors and quantitative EEG was measured using the CATEEM system. We found that, under comparable conditions, patients in the delirium group showed a higher relative EEG theta power and a reduced alpha power (n = 17) than did the non-delirious patients (n = 20). No difference in measured SAA levels were seen; therefore, there was no correlation between SAA and EEG measurements in delirious patients. We conclude that, in contrast to the EEG, the SAA level cannot be proposed as a tool for diagnosing delirium in ICU patients.

Withdrawal symptoms in children after long-term administration of sedatives and/or analgesics: a literature review. "Assessment remains troublesome"

BACKGROUND

Prolonged administration of benzodiazepines and/or opioids to children in a pediatric intensive care unit (PICU) may induce physiological dependence and withdrawal symptoms.

OBJECTIVE

We reviewed the literature for relevant contributions on the nature of these withdrawal symptoms and on availability of valid scoring systems to assess the extent of symptoms.

METHODS

The databases PubMed, CINAHL, and Psychinfo (1980-June 2006) were searched using relevant key terms.

RESULTS

Symptoms of benzodiazepine and opioid withdrawal can be classified in two groups: central nervous system effects and autonomic dysfunction. However, symptoms of the two types show a large overlap for benzodiazepine and opioid withdrawal. Symptoms of gastrointestinal dysfunction in the PICU population have been described for opioid withdrawal only. Six assessment tools for withdrawal symptoms are used in children. Four of these have been validated for neonates only. Two instruments are available to specifically determine withdrawal symptoms in the PICU: the Sedation Withdrawal Score (SWS) and the Opioid Benzodiazepine Withdrawal Scale (OBWS). The OBWS is the only available assessment tool with prospective validation; however, the sensitivity is low.

CONCLUSIONS

Withdrawal symptoms for benzodiazepines and opioids largely overlap. A sufficiently sensitive instrument for assessing withdrawal symptoms in PICU patients needs to be developed.

UK drug analysis prints and anaesthetic adverse drug reactions

PURPOSE

Anaesthetic drugs were selected from the Medicines and Healthcare products Regulatory Agency Drug Analysis Prints in order to determine the number and types of reported reactions and associated mortality.

METHODS

The chosen drug groups were the intravenous induction agents, the neuromuscular blocking drugs and neostigmine, the inhalational anaesthetic agents and nitrous oxide, local anaesthetic agents and a selection of analgesics agents, naloxone and midazolam and its antagonist flumazenil. From each drug file, the number and type of reactions were analysed. Mortality was calculated as a percentage of the number of deaths against patient reports.

RESULTS

A total of 11,199 reactions were analysed from 6603 patients of whom 620 (9%) died. Few drug records reported reactions from multiple constituent formulations. The majority of reactions were not allergic. The highest mortality was in the inhalational anaesthetic group. Although the greatest number of fatal events was associated with halothane, this drug is no longer used. Nevertheless the percentage remains high because cardiovascular mortality is still being reported. Local anaesthetic use was associated with the smallest percentage mortality (3%). The highest reported number of reactions was associated with the intravenous induction agents and idiosyncratic neurological and peripheral vascular reactions were linked with the use of etomidate.

CONCLUSIONS

The reporting of allergic reactions was low. The data demonstrate that induction of anaesthesia presents the highest risk of adverse drug reaction; there is also mortality from newer drugs for example, desflurane, remifentanil as well as from drugs for which there is no alternative, for example, suxamethonium.

Endogenous opiates and behavior: 2005

This paper is the 28th consecutive installment of the annual review of research concerning the endogenous opioid system, now spanning over a quarter-century of research. It summarizes papers published during 2005 that studied the behavioral effects of molecular, pharmacological and genetic manipulation of opioid peptides, opioid receptors, opioid agonists and opioid antagonists. The particular topics that continue to be covered include the molecular-biochemical effects and neurochemical localization studies of endogenous opioids and their receptors related to behavior (Section 2), and the roles of these opioid peptides and receptors in pain and analgesia (Section 3); stress and social status (Section 4); tolerance and dependence (Section 5); learning and memory (Section 6); eating and drinking (Section 7); alcohol and drugs of abuse (Section 8); sexual activity and hormones, pregnancy, development and endocrinology (Section 9); mental illness and mood (Section 10); seizures and neurologic disorders (Section 11); electrical-related activity, neurophysiology and transmitter release (Section 12); general activity and locomotion (Section 13); gastrointestinal, renal and hepatic functions (Section 14); cardiovascular responses (Section 15); respiration and thermoregulation (Section 16); immunological responses (Section 17).

Economic evaluation of sustained sedation/analgesia in the intensive care unit

Lorazepam, midazolam, propofol and opioids are the primary agents that are used for sustained sedation and analgesia of critically ill patients. The choice of agent depends on safety profiles, expected outcomes, cost, patient characteristics and clinical experience. Few studies have comparatively evaluated the sedatives in terms of cost. Many factors, aside from drug costs, influence the total cost of sedation in the intensive care unit. This article reviews the cost parameters of intensive care unit sedation that are specific to the characteristics of commonly used sedatives and analgesics, evaluates economic studies and cost models, summarises alternative methods of sedation and analgesia, and provides practical recommendations for methods of cost containment, including daily sedation interruption, sedation monitoring and protocol implementation.