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Lindström AC, von Oelreich E, Eriksson J, Eriksson M, Mårtensson J, Larsson E, Oldner A. Onset of Prolonged High-Potency Benzodiazepine Use Among ICU Survivors: A Nationwide Cohort Study. Crit Care Explor 2024; 6:e1124. [PMID: 38984149 PMCID: PMC11233102 DOI: 10.1097/cce.0000000000001124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/11/2024] Open
Abstract
OBJECTIVES Exposure to critical illness and intensive care may lead to long-term psychologic and physical impairments. To what extent ICU survivors become prolonged users of benzodiazepines after exposure to critical care is not fully explored. This study aimed to describe the extent of onset of prolonged high-potency benzodiazepine use among ICU survivors not using these drugs before admission, identify factors associated with this use, and analyze whether such usage is associated with increased mortality. DESIGN Retrospective cohort study. SETTING Sweden, including all registered ICU admissions between 2010 and 2017. PATIENTS ICU patients surviving for at least 3 months, not using high-potency benzodiazepine before admission, were eligible for inclusion. INTERVENTIONS Admission to intensive care. MEASUREMENTS AND MAIN RESULTS A total of 237,904 patients were screened and 137,647 were included. Of these 5338 (3.9%) became prolonged users of high-potency benzodiazepines after ICU discharge. A peak in high-potency benzodiazepine prescriptions was observed during the first 3 months, followed by sustained usage throughout the follow-up period of 18 months. Prolonged usage was associated with older age, female sex, and a history of both somatic and psychiatric comorbidities, including substance abuse. Additionally, a longer ICU stay, a high estimated mortality rate, and prior consumption of low-potency benzodiazepines were associated with prolonged use. The risk of death between 6 and 18 months post-ICU admission was significantly higher among high-potency benzodiazepine users, with an adjusted hazard ratio of 1.8 (95% CI, 1.7-2.0; p < 0.001). No differences were noted in causes of death between users and nonusers. Conclusions Despite the lack of evidence supporting long-term treatment, prolonged usage of high-potency benzodiazepines 18 months following ICU care was notable and associated with an increased risk of death. Considering the substantial number of ICU admissions, prevention of benzodiazepine misuse may improve long-term outcomes following critical care.
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Affiliation(s)
- Ann-Charlotte Lindström
- Department of Perioperative Medicine and Intensive Care, Karolinska University Hospital, Solna, Stockholm, Sweden
- Section of Anaesthesiology and Intensive Care Medicine, Department of Physiology and Pharmacology, Karolinska Institute, Stockholm, Sweden
| | - Erik von Oelreich
- Department of Perioperative Medicine and Intensive Care, Karolinska University Hospital, Solna, Stockholm, Sweden
- Section of Anaesthesiology and Intensive Care Medicine, Department of Physiology and Pharmacology, Karolinska Institute, Stockholm, Sweden
| | - Jesper Eriksson
- Department of Perioperative Medicine and Intensive Care, Karolinska University Hospital, Solna, Stockholm, Sweden
- Section of Anaesthesiology and Intensive Care Medicine, Department of Physiology and Pharmacology, Karolinska Institute, Stockholm, Sweden
| | - Mikael Eriksson
- Department of Anaesthesia and Intensive Care, Uppsala University Hospital, Uppsala, Sweden
- Department of Surgical Sciences, Anaesthesia and Intensive Care, Uppsala University, Uppsala, Sweden
| | - Johan Mårtensson
- Department of Perioperative Medicine and Intensive Care, Karolinska University Hospital, Solna, Stockholm, Sweden
- Section of Anaesthesiology and Intensive Care Medicine, Department of Physiology and Pharmacology, Karolinska Institute, Stockholm, Sweden
| | - Emma Larsson
- Department of Perioperative Medicine and Intensive Care, Karolinska University Hospital, Solna, Stockholm, Sweden
- Section of Anaesthesiology and Intensive Care Medicine, Department of Physiology and Pharmacology, Karolinska Institute, Stockholm, Sweden
| | - Anders Oldner
- Department of Perioperative Medicine and Intensive Care, Karolinska University Hospital, Solna, Stockholm, Sweden
- Section of Anaesthesiology and Intensive Care Medicine, Department of Physiology and Pharmacology, Karolinska Institute, Stockholm, Sweden
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Andonovic M, Shaw M, Quasim T, MacTavish P, McPeake J. Factors Associated With New Analgesic Requirements Following Critical Illness. J Intensive Care Med 2024; 39:550-557. [PMID: 38087427 PMCID: PMC11092297 DOI: 10.1177/08850666231219916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2023]
Abstract
BACKGROUND Chronic opioid use represents a significant burden to global healthcare with adverse long-term outcomes. Elevated patient reported pain levels and analgesic prescriptions have been reported following discharge from critical care. We describe analgesic requirements following discharge from hospital and identify if a critical care admission is a significant factor for stronger analgesic prescriptions. METHODS This retrospective observational cohort study identified patients in the UK Biobank with a registered admission to any UK hospital between January 1, 2010 and December 31, 2015 and information on prescriptions drawn both prior to and following hospital discharge. Two matched cohorts were created from the dataset: critical care patients and hospital patients admitted without a critical care encounter. Outcomes were analgesic requirements following hospital discharge and factors associated with increased analgesic prescriptions. Multivariable logistic regression was used to identify factors associated with prescriptions from higher steps on the World Health Organization (WHO) analgesic ladder. RESULTS In total, 660 formed the total study population. Strong opioid prescriptions following discharge were significantly higher in the critical care cohort (P value <.001). Critical care admission (OR = 1.45) and increasing Townsend deprivation (OR = 1.04) index were significantly associated with increasing strength of analgesic prescriptions following discharge. CONCLUSIONS Critical care patients require stronger analgesic prescriptions in the 12 months following hospital discharge. Patients from areas of high socioeconomic deprivation may also be associated with increased analgesic requirements. Multidisciplinary support is required for patients who may be at risk of chronic opioid use and could be delivered within critical care recovery programs.
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Affiliation(s)
- Mark Andonovic
- Academic Unit of Anaesthesia, Critical Care and Perioperative Medicine, University of Glasgow, Glasgow, UK
| | - Martin Shaw
- Academic Unit of Anaesthesia, Critical Care and Perioperative Medicine, University of Glasgow, Glasgow, UK
| | - Tara Quasim
- Academic Unit of Anaesthesia, Critical Care and Perioperative Medicine, University of Glasgow, Glasgow, UK
| | | | - Joanne McPeake
- The Healthcare Improvement Studies Institute, University of Cambridge, Cambridge, UK
- Healthcare Improvement Scotland, Edinburgh, UK
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Wee C, Boas S, Coquillard C, Cai Y, Kurlander D, Maasarani S, Leavitt T, Long T, Lineberry K, Khouri J. Combined Targeted Muscle Reinnervation With Regenerative Peripheral Nerve Interfaces Decreases Long-Term Narcotic Use in Amputees: A Case Control Study. Ann Plast Surg 2024; 92:432-436. [PMID: 38527350 DOI: 10.1097/sap.0000000000003836] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/27/2024]
Abstract
PURPOSE Combined targeted muscle reinnervation with regenerative peripheral nerve interfaces ("TMRpni") is a recently described nerve management strategy that leverages beneficial elements of targeted muscle reinnervation (TMR) and regenerative peripheral nerve interface (RPNI) techniques. This study aimed to evaluate the effect of TMRpni on long-term opioid consumption after amputation. We hypothesize that TMRpni decreases chronic opioid consumption in amputees. METHODS This is a retrospective cohort study of all patients who underwent TMRpni between 2019 and 2021. These patients were age-matched at a 1:1 ratio with a control group of patients who underwent amputation without TMRpni. Statistical analysis was performed using SPSS Version 28.0. RESULTS Thirty-one age-matched pairs of patients in the TMRpni and control groups were included. At 30 days after surgery, there was no significant difference in number of patients who required an additional refill of their opioid prescriptions (45% vs 55%, P = 0.45) or patients who continued to actively use opioids (36% vs 42%, P = 0.60). However, at 90 days after surgery, there was a significantly lower number of patients from the TMRpni group who reported continued opioid use compared with the control group (10% vs 32%, P = 0.03). CONCLUSIONS This study demonstrates that TMRpni may translate to decreased rates of chronic opiate use. Continued study is indicated to optimize TMRpni techniques and patient selection and to determine its long-term efficacy.
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Affiliation(s)
- Corinne Wee
- From the Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Boston, MA
| | - Samuel Boas
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY
| | | | - Yida Cai
- Division of Plastic Surgery, Rutgers New Jersey Medical School, Newark, NJ
| | - David Kurlander
- Department of Plastic Surgery, Rush University Medical Center, Chicago, IL
| | - Samantha Maasarani
- Department of Plastic Surgery, Cleveland Clinic Foundation, Cleveland, OH
| | - Tripp Leavitt
- Department of Orthopaedic Surgery, Baylor College of Medicine, Houston, TX
| | - Tobias Long
- Penn State Department of Plastic Surgery, Reading, PA
| | | | - Joseph Khouri
- Division of Plastic Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH
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Hauser CD, Bell CM, Zamora RA, Mazur J, Neyens RR. Characterization of Opioid Use in the Intensive Care Unit and Its Impact Across Care Transitions: A Prospective Study. J Pharm Pract 2024; 37:343-350. [PMID: 36259532 DOI: 10.1177/08971900221134553] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Purpose: The objective of this study is to characterize opioid intensity in the intensive care unit (ICU) and its association with opioid utilization across care transitions. Methods: This is a prospective cohort study. Medically ill ICU patients with complete medication histories who survived to discharge were included. Opioid intensity was characterized based on IV morphine milligram equivalents (IV MME). Primary outcomes were opioid prescribing upon ICU and hospital discharge. Results: Opioids were prescribed to 34.1% and 31.1% of patients upon ICU and hospital discharge. Within the ≥50 mean IV MME/ICU day cohort, 64.7% of patients received opioids after ICU discharge compared to 45.8% and 13.6% in the 1-49 mean IV MME/ICU day and no opioid groups (P < .05). Within the ≥50 mean IV MME/ICU day cohort, 70.6% of patients were prescribed opioids after hospitalization compared to 37.3% and 13.6% of patients who received less or no opioids. (P < .05). Within the ≥50 mean IV MME/ICU day cohort, 29.4% of patients were opioid naïve and discharged with an opioid, which is over double compared to patients with lower opioid requirements (P < .05). Conclusion: Patients with higher mean daily ICU opioid requirements had increased opioid prescribing across care transitions despite preadmission opioid use.
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Affiliation(s)
- Christian D Hauser
- Critical Care and Emergency Medicine Clinical Pharmacy Specialist, Department of Pharmacy, Indiana University Health Methodist Hospital, Indianapolis, IN, USA
| | - Carolyn M Bell
- Department of Pharmacy, Medical University of South Carolina
| | | | - Joseph Mazur
- Department of Pharmacy, Medical University of South Carolina
| | - Ron R Neyens
- Department of Pharmacy, Medical University of South Carolina
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Erstad BL, Glenn MJ. Considerations and limitations of buprenorphine prescribing for opioid use disorder in the intensive care unit setting: A narrative review. Am J Health Syst Pharm 2024; 81:171-182. [PMID: 37979138 DOI: 10.1093/ajhp/zxad289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Indexed: 11/19/2023] Open
Abstract
PURPOSE The purpose of this review is to discuss important considerations when prescribing buprenorphine for opioid use disorder (OUD) in the intensive care unit (ICU) setting, recognizing the challenges of providing detailed recommendations in the setting of limited available evidence. SUMMARY Buprenorphine is a partial mu-opioid receptor agonist that is likely to be increasingly prescribed for OUD in the ICU setting due to the relaxation of prescribing regulations. The pharmacology and pharmacokinetics of buprenorphine are complicated by the availability of several formulations that can be given by different administration routes. There is no single optimal dosing strategy for buprenorphine induction, with regimens ranging from very low-dose to high dose regimens. Faster induction with higher doses of buprenorphine has been studied and is frequently utilized in the emergency department. In patients admitted to the ICU who were receiving opioids either medically or illicitly, analgesia will not occur until their baseline opioid requirements are covered when their preadmission opioid is either reversed or interrupted. For patients in the ICU who are not on buprenorphine at the time of admission but have possible OUD, there are no validated tools to diagnose OUD or the severity of opioid withdrawal in critically ill patients unable to provide the subjective components of instruments validated in outpatient settings. When prescribing buprenorphine in the ICU, important issues to consider include dosing, monitoring, pain management, use of adjunctive medications, and considerations to transition to outpatient therapy. Ideally, addiction and pain management specialists would be available when buprenorphine is prescribed for critically ill patients. CONCLUSION There are unique challenges when prescribing buprenorphine for OUD in critically ill patients, regardless of whether they were receiving buprenorphine when admitted to the ICU setting for OUD or are under consideration for buprenorphine initiation. There is a critical need for more research in this area.
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Affiliation(s)
- Brian L Erstad
- Department of Pharmacy Practice and Science, University of Arizona College of Pharmacy, Tucson, AZ, USA
| | - Melody J Glenn
- Department of Emergency Medicine and Department of Psychiatry, University of Arizona College of Medicine/Banner University Medical Center, Tucson, AZ, USA
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Casamento A, Ghosh A, Hui V, Neto AS. Hospital and long-term opioid use according to analgosedation with fentanyl vs. morphine: Findings from the ANALGESIC trial. CRIT CARE RESUSC 2024; 26:24-31. [PMID: 38690190 PMCID: PMC11056422 DOI: 10.1016/j.ccrj.2023.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Accepted: 11/10/2023] [Indexed: 05/02/2024]
Abstract
Objectives Opioid use disorder is extremely common. Many long-term opioid users will have their first exposure to opioids in hospitals. We aimed to compare long-term opioid use in patients who received fentanyl vs. morphine analgosedation and assess ICU related risk factors for long-term opioid use. Design We performed a post-hoc analysis of the Assessment of Opioid Administration to Lead to Analgesic Effects and Sedation in Intensive Care (ANALGESIC) cluster randomised crossover trial of fentanyl and morphine infusions for analgosedation in mechanically ventilated patients. Setting Two mixed, adult, university affiliated intensive care units in Melbourne, Australia. Participants Adult patients who were mechanically ventilated and received fentanyl or morphine for analgosedation in the ANALGESIC trial. Main outcome measures We assessed discharge and long-term (90-365 days) opioid use in opioid-naïve patients at hospital admission according to the agent used for analgosedation. Results We studied 477 patients (242 fentanyl and 235 morphine). There were no differences between discharge (16.5% vs. 14.0%, p = 0.45), 90-180 day post-discharge use (3.7% vs 2.1%, p = 0.30) or 180-365 day post-discharge use (3.4% vs 1.3%, p = 0.22) of opioids when comparing those patients who received fentanyl vs. those who received morphine. Surgical diagnosis and one chronic condition were associated with increased hospital discharge prescription of opioids, whereas increasing APACHE II score was associated with decreased discharge prescription. No ICU-related factors were associated with long-term opioid use. Conclusions Approximately one in seven opioid-naïve patients who receive analgosedation for mechanical ventilation in ICU will be prescribed opioid medications at hospital discharge. There was no difference in discharge prescription or long-term use of opioids depending on whether fentanyl or morphine was used for analgosedation.
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Affiliation(s)
- Andrew Casamento
- Department of Intensive Care, Austin Hospital, Melbourne, Australia
- Department of Intensive Care, Northern Hospital, Melbourne, Australia
- Department of Critical Care, University of Melbourne, Melbourne, Australia
| | - Angajendra Ghosh
- Department of Intensive Care, Northern Hospital, Melbourne, Australia
- Department of Critical Care, University of Melbourne, Melbourne, Australia
- Department of Medical Education, University of Melbourne, Melbourne, Australia
| | - Victor Hui
- Department of Anaesthesia, Austin Hospital, Melbourne, Australia
- Data Analytics Research & Evaluation (DARE) Center, University of Melbourne and Austin Hospital, Melbourne, Australia
| | - Ary Serpa Neto
- Department of Intensive Care, Austin Hospital, Melbourne, Australia
- Department of Critical Care, University of Melbourne, Melbourne, Australia
- Data Analytics Research & Evaluation (DARE) Center, University of Melbourne and Austin Hospital, Melbourne, Australia
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Department of Critical Care Medicine, Hospital Israelita Albert Einstein, Sao Paulo, Brazil
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McKenzie C, Skrobik Y, Devlin JW. Scheduled intravenous opioids. Intensive Care Med 2023; 49:1541-1543. [PMID: 37922011 PMCID: PMC10709215 DOI: 10.1007/s00134-023-07254-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 10/10/2023] [Indexed: 11/05/2023]
Affiliation(s)
- Cathrine McKenzie
- National Institute of Health and Social Care Research (NIHR) Biomedical Research Centre, School of Medicine, Perioperative and Critical Care Theme and NIHR Applied Research Collaborative (ARC), University of Southampton, Wessex, Southampton, UK
- Pharmacy and Critical Care, University Hospital, Southampton NHS Foundation Trust, Southampton, UK
- Institute of Pharmaceutical Sciences, School of Cancer and Pharmacy, King's College London, London, UK
| | - Yoanna Skrobik
- Department of Medicine, McGill University, Montreal, QC, Canada
- Department of Medicine, Cambridge University, Cambridge, UK
| | - John W Devlin
- School of Pharmacy and Pharmaceutical Sciences, Bouve College of Health Sciences, Northeastern University, Boston, MA, USA.
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, MA, USA.
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Devlin JW. Buprenorphine: Its Emerging Role as a Strategy to Reduce Full Opioid Agonist Use in the ICU. Crit Care Med 2023; 51:1817-1819. [PMID: 37971335 DOI: 10.1097/ccm.0000000000006052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2023]
Affiliation(s)
- John W Devlin
- Department of Pharmacy and Health Systems Sciences, Bouve College of Health Sciences, Northeastern University, Boston, MA
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, MA
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Pérez Lucendo A, Piñeiro Otero P, Matía Almudévar P, Alcántara Carmona S, López López E, Ramasco Rueda F. Individualised analgesia, sedation, delirium and comfort management strategies in the ICU: a narrative review. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2023; 70:509-535. [PMID: 37742996 DOI: 10.1016/j.redare.2023.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/16/2022] [Accepted: 03/20/2023] [Indexed: 09/26/2023]
Abstract
This group is a product of the collaboration agreement signed by SOMIAMA (Sociedad de Medicina Intensiva de Madrid) and SAR MADRID (Sociedad de Anestesiología, Reanimación y Terapéutica del Dolor de Madrid) under which the organisations agreed to create joint working groups to improve critical patient care. Pain, discomfort, agitation, and delirium cause suffering, delay discharge, and can lead to serious complications in patients admitted to medical and surgical critical care units and post-anaesthesia care units. The main objectives in this type of unit include: Ensuring the comfort of patients suffering or recovering from a critical illness.Avoiding complications associated with the measures, particularly pharmacological, taken to ensure that comfort.
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Affiliation(s)
- A Pérez Lucendo
- Servicio de Medicina Intensiva, Hospital Universitario de La Princesa, Madrid, Spain.
| | - P Piñeiro Otero
- Servicio de Anestesiología y Reanimación, Hospital Universitario Gregorio Marañón, Madrid, Spain
| | - P Matía Almudévar
- Servicio de Medicina Intensiva, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, Spain
| | - S Alcántara Carmona
- Servicio de Medicina Intensiva, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, Spain
| | - E López López
- Servicio de Anestesiología y Reanimación, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - F Ramasco Rueda
- Servicio de Anestesiología y Reanimación, Hospital Universitario de La Princesa, Madrid, Spain
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Lindberg HB, Steindal SA, Kvande ME. Critical care nurses' experiences of caring for patients with iatrogenic opioid withdrawal in the intensive care unit: A qualitative study. Intensive Crit Care Nurs 2023; 78:103452. [PMID: 37178587 DOI: 10.1016/j.iccn.2023.103452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Revised: 04/20/2023] [Accepted: 05/02/2023] [Indexed: 05/15/2023]
Abstract
OBJECTIVES To explore critical care nurses' experiences of caring for adult patients experiencing iatrogenic opioid withdrawal in the intensive care unit. RESEARCH METHODOLOGY/DESIGN A qualitative study with an explorative and descriptive design was conducted. Data were collected through semi-structured interviews and systematic text condensation was used to analyse the data. The study was reported according to the consolidated criteria for reporting qualitative research checklist. SETTING AND PARTICIPANTS Ten critical care nurses, working at three different intensive care units in two university hospitals in Norway. FINDINGS Three categories were identified in the data analysis. "Subtle signs and symptoms of opioid withdrawal", lack of a systematic approach to opioid withdrawal, and the prerequisites for appropriate management of opioid withdrawal. Critical care nurses experienced challenges in identifying opioid withdrawal due to subtle and vague signs and symptoms, especially when not knowing their patient or when difficulties were encountered with patient communication. A systematic approach to opioid withdrawal and increased knowledge, definitive plans for weaning, as well as interdisciplinary unity and collaboration, could improve the management of opioid withdrawal. CONCLUSION Validated assessment tools, systematic strategies, and guidelines are essential for the management of opioid withdrawal in opioid naïve patients in intensive care units. The prerequisites for an appropriate management of opioid withdrawal are an accurate and effective communication among critical care nurses and other healthcare professionals involved in patient care. IMPLICATIONS FOR CLINICAL PRACTICE There is a need for a validated assessment tool, systematic strategies, and guidelines for the management of opioid withdrawal in opioid naïve patients in intensive care units. Increased emphasis needs to be placed on the process of identifying iatrogenic opioid withdrawal and improving opioid withdrawal management in the education system and clinical practice.
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Affiliation(s)
- Hedda Bekken Lindberg
- Lovisenberg Diaconal University College, Lovisenberggata 15B, 0456 Oslo, Norway; Department of Cardiothoracic Surgery, Oslo University Hospital, Oslo, Norway.
| | - Simen A Steindal
- Lovisenberg Diaconal University College, Lovisenberggata 15B, 0456 Oslo, Norway; Faculty of Health Studies, VID Specialized University, Oslo, Norway.
| | - Monica Evelyn Kvande
- Lovisenberg Diaconal University College, Lovisenberggata 15B, 0456 Oslo, Norway; Department of Anaesthesiology and Surgery, University Hospital of North Norway, Tromsø, Norway.
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Short A, McPeake J, Andonovic M, McFee S, Quasim T, Leyland A, Shaw M, Iwashyna T, MacTavish P. Medication-related problems in critical care survivors: a systematic review. Eur J Hosp Pharm 2023; 30:250-256. [PMID: 37142386 PMCID: PMC10447966 DOI: 10.1136/ejhpharm-2023-003715] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 04/11/2023] [Indexed: 05/06/2023] Open
Abstract
OBJECTIVES There are numerous, often single centre discussions of assorted medication-related problems after hospital discharge in patients who survive critical illness. However, there has been little synthesis of the incidence of medication-related problems, the classes of medications most often studied, the factors that are associated with greater patient risk of such problems or interventions that can prevent them. METHODS We undertook a systematic review to understand medication management and medication problems in critical care survivors in the hospital discharge period. We searched OVID Medline, Embase, PsychINFO, CINAHL and the Cochrane database (2001-2022). Two reviewers independently screened publications to identify studies that examined medication management at hospital discharge or thereafter in critical care survivors. We included randomised and non-randomised studies. We extracted data independently and in duplicate. Data extracted included medication type, medication-related problems and frequency of medication issues, alongside demographics such as study setting. Cohort study quality was assessed using the Newcastle Ottowa Score checklist. Data were analysed across medication categories. RESULTS The database search initially retrieved 1180 studies; following the removal of duplicates and studies which did not fit the inclusion criteria, 47 papers were included. The quality of studies included varied. The outcomes measured and the timepoints at which data were captured also varied, which impacted the quality of data synthesis. Across the studies included, we found that as many as 80% of critically ill patients experienced medication-related problems in the posthospital discharge period. These issues included inappropriate continuation of newly prescribed drugs such as antipsychotics, gastrointestinal prophylaxis and analgesic medications, as well as inappropriate discontinuation of chronic disease medications, such as secondary prevention cardiac drugs. CONCLUSIONS Following critical illness, a high proportion of patients experience problems with their medications. These changes were present across multiple health systems. Further research is required to understand optimal medicine management across the full recovery trajectory of critical illness. PROSPERO REGISTRATION NUMBER CRD42021255975.
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Affiliation(s)
| | - Joanne McPeake
- The Healthcare Improvement Studies Institute, University of Cambridge, Cambridge, UK
| | - Mark Andonovic
- School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, UK
| | | | - Tara Quasim
- School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, UK
| | - Alastair Leyland
- MRC/CSO Social and Public Health Sciences Unit, University of Glasgow, Glasgow, UK
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Ramin S, Bringuier S, Martinez O, Sadek M, Manzanera J, Deras P, Choquet O, Charbit J, Capdevila X. Continuous peripheral nerve blocks for analgesia of ventilated critically ill patients with multiple trauma: a prospective randomized study. Anaesth Crit Care Pain Med 2023; 42:101183. [PMID: 36496124 DOI: 10.1016/j.accpm.2022.101183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Revised: 12/02/2022] [Accepted: 12/02/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND Sedation of ventilated critically ill trauma patients requires high doses of opioids and hypnotics. We aimed to compare the consumption of opioids and hypnotics, and patient outcomes using sedation with or without continuous regional analgesia (CRA). METHODS Multiple trauma-ventilated patients were included. The patients were randomized to receive an intravenous analgesia (control group) or an addition of CRA within 24h of admission. A traumatic brain injury (TBI) patients group was analyzed. The primary endpoint was the cumulative consumption of sufentanil at 2 days of admission. Secondary endpoints were cumulative and daily consumption of sufentanil and midazolam, duration of mechanical ventilation, intensive care unit (ICU) stay, and safety of CRA management. RESULTS Seventy six patients were analyzed: 40 (67.5% males) in the control group and 36 (72% males) in the CRA group, respectively. The median [IQR] Injury Severity Score was 30.5 [23.5-38.5] and 26.0 [22.0-41.0]. The consumption of sufentanil at 48h was 725 [465-960] μg/48h versus 670 [510-940] μg/48h (p = 0.16). Daily consumption did not differ between the groups except on day 1 when consumption of sufentanil was 360 [270-480] μg vs. 480 [352-535] μg (p = 0.03). Consumptions of midazolam did not differ between the groups. No difference was noted between the groups according to the secondary endpoints. CONCLUSIONS CRA does not decrease significantly sufentanil and midazolam consumption within the first 5 days after ICU admission in multiple trauma-ventilated patients. The use of peripheral nerve blocks in heavily sedated and ventilated trauma patients in the ICU seems safe.
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Affiliation(s)
- Severin Ramin
- Department of Anesthesiology and Critical Care Medicine, Hôpital Lapeyronie, Montpellier, France; OcciTRAUMA Network, Regional Network of Medical Organization and Management for Severe Trauma in Occitanie, France
| | - Sophie Bringuier
- Department of Medical Statistics, CHU Montpellier, University of Montpellier, Montpellier, France
| | - Orianne Martinez
- Department of Anesthesiology and Critical Care Medicine, Hôpital Lapeyronie, Montpellier, France; OcciTRAUMA Network, Regional Network of Medical Organization and Management for Severe Trauma in Occitanie, France
| | - Meriem Sadek
- Department of Anesthesiology and Critical Care Medicine, Hôpital Lapeyronie, Montpellier, France; OcciTRAUMA Network, Regional Network of Medical Organization and Management for Severe Trauma in Occitanie, France
| | - Jonathan Manzanera
- Department of Anesthesiology and Critical Care Medicine, Hôpital Lapeyronie, Montpellier, France; OcciTRAUMA Network, Regional Network of Medical Organization and Management for Severe Trauma in Occitanie, France
| | - Pauline Deras
- Department of Anesthesiology and Critical Care Medicine, Hôpital Lapeyronie, Montpellier, France; OcciTRAUMA Network, Regional Network of Medical Organization and Management for Severe Trauma in Occitanie, France
| | - Olivier Choquet
- Department of Anesthesiology and Critical Care Medicine, Hôpital Lapeyronie, Montpellier, France
| | - Jonathan Charbit
- Department of Anesthesiology and Critical Care Medicine, Hôpital Lapeyronie, Montpellier, France; OcciTRAUMA Network, Regional Network of Medical Organization and Management for Severe Trauma in Occitanie, France
| | - Xavier Capdevila
- Department of Anesthesiology and Critical Care Medicine, Hôpital Lapeyronie, Montpellier, France; OcciTRAUMA Network, Regional Network of Medical Organization and Management for Severe Trauma in Occitanie, France; Inserm U 1298, Neuro Sciences Institute, University of Montpellier, Montpellier, France.
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13
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DeJesus J, Shah NR, Franco-Mesa C, Walters ET, Palackic A, Wolf SE. Risk factors for opioid use disorder after severe burns in adults. Am J Surg 2023; 225:400-407. [PMID: 36184330 DOI: 10.1016/j.amjsurg.2022.09.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 09/09/2022] [Accepted: 09/18/2022] [Indexed: 11/01/2022]
Abstract
INTRODUCTION Risk factors for opioid dependence amongst burn patients have not been well-explored compared to other surgical fields. METHODS The TrinetX database was queried for patients diagnosed with opioid use disorder (OUD) after thermal or chemical burn. Propensity score matching was performed. Opioid and non-opioid analgesia use, ICU care, surgery, and comparative risks among common opiates were examined using descriptive and univariate regression models, including odds ratios. Subgroup analysis evaluated the impact of multimodal analgesia. RESULTS Odds of receiving IV opioids for acute analgesia (p = <0.0001, OR = 1.80, CI = 1.45-2.25), undergoing surgery (p = <0.0001, OR = 1.58, CI = 1.26-1.98), and ICU care (p = <0.0001, OR = 3.60, CI = 2.00-3.83) after burn injury were higher in patients who developed OUD. Patients receiving multimodal therapy within 24 hours of admission had lower odds of developing OUD (OR = 0.74, CI = 2.76-4.68, p = 0.0001) and chronic pain (OR = 0.89, CI = 0.78-1.00, p = 0.05) regardless of TBSA. CONCLUSION Patients who developed opioid use disorder following burn injury had higher odds of receiving opioid exclusive pain management, more frequent surgery, ICU care.
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Affiliation(s)
- Jana DeJesus
- Department of Surgery, University of Texas Medical Branch, 301 University Blvd., Galveston, TX, 77555, USA.
| | - Nikhil R Shah
- Department of Surgery, University of Texas Medical Branch, 301 University Blvd., Galveston, TX, 77555, USA.
| | - Camila Franco-Mesa
- Department of Surgery, University of Texas Medical Branch, 301 University Blvd., Galveston, TX, 77555, USA.
| | - Elliot T Walters
- Department of Surgery, University of Texas Medical Branch, 301 University Blvd., Galveston, TX, 77555, USA.
| | - Alen Palackic
- Department of Surgery, University of Texas Medical Branch, 301 University Blvd., Galveston, TX, 77555, USA; Division of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery, Medical University of Graz, Graz, 8036, Austria.
| | - Steven E Wolf
- Department of Surgery, University of Texas Medical Branch, 301 University Blvd., Galveston, TX, 77555, USA.
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Abstract
OBJECTIVES: The association between opioid therapy during critical illness and persistent opioid use after discharge is understudied relative to ICU opioid exposure and modifiable risk factors. Our objectives were to compare persistent opioid use after discharge among patients with and without chronic opioid use prior to admission (OPTA) and identify risk factors associated with persistent use. DESIGN: Retrospective cohort study. SETTING: Medical, trauma/surgical, or neurologic ICU at an academic hospital. PARTICIPANTS: Adult patients surviving hospital admission. INTERVENTIONS: Opioid use during the ICU and post-ICU stays. MEASUREMENTS AND MAIN RESULTS: The primary outcome was persistent opioid use accounting for greater than 70% of days 4–6 months after discharge. Among 2,975 included patients, 257 (8.6%) were classified as OPTA, and 305 (10.2%) persistently filled opioid prescriptions, including 186/257 (72%) OPTA and 119/2,718 (4.4%) with no chronic opioid fills prior to admission. Among all patients, OPTA was strongly associated with persistent opioid use (odds ratio, 57.2 [95% CI, 41.4–80.0]). Multivariable logistic regression revealed that male sex, surgical procedure, and ICU opioid-free days were associated with reduced persistent opioid use for OPTA patients. Age and ICU opioid-free days were associated with reduced persistent opioid use for non-OPTA patients. Total ICU opioid dose and dose per day of ICU exposure were not associated with persistent use for either group. CONCLUSIONS: In this mixed cohort of ICU patients, 10.2% persistently filled opioid prescriptions 4–6 months after discharge. Although ICU opioid doses were not associated with persistent use, duration of ICU opioid administration is a modifiable risk factor that may reduce persistent opioid use after critical illness.
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15
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Bedene A, Lijfering WM, Arbous MS, Rosendaal FR, Dahan A, van Dorp ELA. Association between prescription opioid use and unplanned intensive care unit admission and mortality in the adult population of the Netherlands: a registry study. Br J Anaesth 2022; 129:254-262. [PMID: 35752474 DOI: 10.1016/j.bja.2022.05.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Revised: 05/11/2022] [Accepted: 05/14/2022] [Indexed: 11/02/2022] Open
Abstract
BACKGROUND Opioid overdoses are increasing in the Netherlands, and there may be other harms associated with prescription opioid use. We investigated the relationship between prescription opioid use and unplanned ICU admission and death. METHODS This is an analysis of linked government registries of the adult Dutch population (age ≥18 years) alive on January 1, 2018. The co-primary outcomes were ICU admission and death up to 1 year. Crude event rates and event-specific adjusted hazard rates (aHRs) with 95% confidence intervals (CIs) were calculated using multivariable analysis for people with and without exposure to an opioid prescription. RESULTS We included 13 813 173 individuals, of whom 32 831 were admitted to the ICU and 152 259 died during the 1 year follow-up. Rates of ICU admission and death amongst people who reimbursed an opioid prescription were 5.87 and 62.2 per 1000 person-years, and rates of ICU admission and death in those without a prescription were 2.03 and 6.34, respectively. Exposed individuals had a higher rate of both ICU admission (aHR 2.53; 95% CI: 2.45-2.60) and death (aHR 7.11; 95% CI: 7.02-7.19) compared with unexposed individuals. Both outcomes were more frequent amongst prescription opioid users across a range of subgroups. CONCLUSIONS The rate of ICU admission and death was higher amongst prescription opioid users than non-users in the full cohort and in subgroups. These findings represent an important public health concern.
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Affiliation(s)
- Ajda Bedene
- Department of Anesthesiology, Leiden University Medical Center, Leiden, the Netherlands; Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Willem M Lijfering
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
| | - M Sesmu Arbous
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands; Department of Intensive Care, Leiden University Medical Center, Leiden, the Netherlands
| | - Frits R Rosendaal
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Albert Dahan
- Department of Anesthesiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Eveline L A van Dorp
- Department of Anesthesiology, Leiden University Medical Center, Leiden, the Netherlands; Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands.
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16
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Lamey PS, Landis DM, Nugent KM. Iatrogenic opioid withdrawal syndromes in adults in intensive care units: a narrative review. J Thorac Dis 2022; 14:2297-2308. [PMID: 35813766 PMCID: PMC9264079 DOI: 10.21037/jtd-22-157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Accepted: 05/12/2022] [Indexed: 11/08/2022]
Abstract
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.
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Affiliation(s)
- Patrice S Lamey
- The Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Dylan M Landis
- The Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Kenneth M Nugent
- The Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, TX, USA
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17
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Naloxegol to Prevent Constipation in ICU Adults Receiving Opioids: A Randomized Double-Blind Placebo-Controlled Pilot Trial. Crit Care Res Pract 2022; 2022:7541378. [PMID: 35356796 PMCID: PMC8958087 DOI: 10.1155/2022/7541378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Accepted: 03/01/2022] [Indexed: 11/29/2022] Open
Abstract
Background Constipation is frequent in critically ill adults receiving opioids. Naloxegol (N), a peripherally acting mu-receptor antagonist (PAMORA), may reduce constipation. The objective of this trial was to evaluate the efficacy and safety of N to prevent constipation in ICU adults receiving opioids. Methods and Patients. In this single-center, double-blind, randomized trial, adults admitted to a medical ICU receiving IV opioids (≥100 mcg fentanyl/day), and not having any of 17 exclusion criteria, were randomized to N (25 mg) or placebo (P) daily randomized to receive N (25mg) or placebo (P) and docusate 100 mg twice daily until ICU discharge, 10 days, or diarrhea (≥3 spontaneous bowel movement (SBM)/24 hours) or a serious adverse event related to study medication. A 4-step laxative protocol was initiated when there was no SBM ≥3 days. Results Only 318 (20.6%) of the 1542 screened adults during the 1/17–10/19 enrolment period met all inclusion criteria. Of these, only 19/381 (4.9%) met all eligibility criteria. After 7 consent refusals, 12 patients were randomized. The study was stopped early due to enrolment futility. The N (n = 6) and P (n = 6) groups were similar. The time to first SBM (N 41.4 ± 31.7 vs. P 32.5 ± 25.4 hours, P = 0.56) was similar. The maximal daily abdominal pressure was significantly lower in the N group (N 10 ± 4 vs. P 13 ± 5, P = 0.002). The median (IQR) daily SOFA scores were higher in N (N 7 (4, 8) vs. P 4 (3, 5), P < 0.001). Laxative protocol use was similar (N 83.3% vs. P 66.6%; P = 0.51). Diarrhea prevalence was high but similar (N 66.6% vs. P 66.6%; P = 1.0). No patient experienced opioid withdrawal. Conclusions Important recruitment challenges exist for ICU trials evaluating the use of PAMORAs for constipation prevention. Despite being underpowered, our results suggest time to first SBM with naloxegol, if different than P, may be small. The effect of naloxegol on abdominal pressure, SOFA, and the interaction between the two requires further research.
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18
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Moran BL, Myburgh JA, Scott DA. The complications of opioid use during and post-intensive care admission: A narrative review. Anaesth Intensive Care 2022; 50:108-126. [PMID: 35172616 DOI: 10.1177/0310057x211070008] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
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.
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Affiliation(s)
- Benjamin L Moran
- Critical Care Program, The George Institute of Global Health, Sydney, Australia.,Department of Intensive Care, 90112Gosford Hospital, Gosford Hospital, Gosford, Australia.,Department of Anaesthesia and Pain Medicine, Gosford Hospital, Gosford, Australia.,School of Medicine and Public Health, University of Newcastle, Callaghan, Australia
| | - John A Myburgh
- Critical Care Program, The George Institute of Global Health, Sydney, Australia.,Faculty of Medicine, 7800University of New South Wales, University of New South Wales, Kensington, Australia.,St George Hospital, Kogarah, Australia
| | - David A Scott
- Department of Anaesthesia and Acute Pain Medicine, St Vincent's Hospital, Fitzroy, Australia.,Department of Critical Care, University of Melbourne, Parkville, Australia
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19
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Sutton S, McCrobie TR, Kovacevic MR, Dube KM, Szumita PM, Herod K, Bezio A, Choi H, Duprey MS, Zeballos J, Devlin JW. Impact of the 2018 Society of Critical Care Medicine Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Guidelines on Nonopioid Analgesic Use and Related Outcomes in Critically Ill Adults After Major Surgery. Crit Care Explor 2021; 3:e0564. [PMID: 34723188 PMCID: PMC8549685 DOI: 10.1097/cce.0000000000000564] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
We compared ICU nonopioid analgesic use, opioid use, and pain before and after Pain, Agitation/Sedation, Delirium, Immobility, and Sleep guideline publication at one academic center among critically ill adults receiving an opioid infusion and greater than or equal to 24 hours of mechanical ventilation after major surgery. The 2017 (n = 77) and 2019 (n = 57) groups were similar at baseline. The 2019 (vs 2017) patients were more likely to receive scheduled IV/oral acetaminophen (84% vs 69%; p = 0.05), less likely to receive a lidocaine patch (33% vs 50%; p = 0.05), and just as likely to receive ketamine (4% vs 3%; p = 1.0), an nonsteroidal anti-inflammatory drug (7% vs 3%; p = 0.26), or gabapentin/pregabalin (16% vs 9%; p = 0.23). Daily average opioid exposure (in IV morphine milligram equivalent) was not different (70 [42–99] [2017] vs 78 mg [49–109 mg]; p = 0.94). The 2019 (vs 2017) group spent more ICU days with severe pain (p = 0.04). At our center, Pain, Agitation/Sedation, Delirium, Immobility, and Sleep guideline publication had little effect on nonopioid analgesic or opioid prescribing practices in critically ill surgical adults.
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Affiliation(s)
- Spencer Sutton
- Department of Pharmacy, Boston Medical Center, Boston, MA
| | | | - Mary R Kovacevic
- Department of Pharmacy, Brigham and Women's Hospital, Boston, MA
| | - Kevin M Dube
- Department of Pharmacy, Brigham and Women's Hospital, Boston, MA
| | - Paul M Szumita
- Department of Pharmacy, Brigham and Women's Hospital, Boston, MA
| | - Kyle Herod
- School of Pharmacy, Northeastern University, Boston, MA
| | - Aaron Bezio
- School of Pharmacy, Northeastern University, Boston, MA
| | - Hannah Choi
- School of Pharmacy, Northeastern University, Boston, MA
| | | | - Jose Zeballos
- Division of Anesthesiology, Brigham and Women's Hospital, Boston, MA
| | - John W Devlin
- School of Pharmacy, Northeastern University, Boston, MA.,Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, MA
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