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Casten M, Miller JL, Neely SB, Harkin M, Johnson PN. Variability in opioid conversion calculators in critically ill children transitioned from fentanyl to hydromorphone. Am J Health Syst Pharm 2024; 81:153-158. [PMID: 37880811 DOI: 10.1093/ajhp/zxad270] [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: 10/24/2023] [Indexed: 10/27/2023] Open
Abstract
PURPOSE Opioid conversion calculators (OCCs) are used to convert between opioids. The purpose of this study was to describe the variability in OCC results in critically ill children transitioned from fentanyl to hydromorphone infusions. METHODS This was a descriptive, retrospective study. Seventeen OCCs were identified and grouped into 6 groups (groups 1-6) based on the equianalgesic conversions. The OCCs were used to calculate the hydromorphone rate in critically ill children (<18 years) converted from fentanyl to hydromorphone. Information from a previous study on children stabilized on hydromorphone (defined as the first 24-hour period with no change in the hydromorphone rates, <3 hydromorphone boluses administered, and 80% of State Behavior Scale scores between 0 and -1) were utilized. The primary objective was to compare the median hydromorphone rates calculated using the 17 OCCs. The secondary objective was to compare the percent variability of the OCC-calculated hydromorphone rates to the stabilization rate. RESULTS Seventeen OCCs were applied to data on 28 children with a median age and hydromorphone rate of 2.4 years and 0.08 mg/kg/h, respectively. The median hydromorphone rate calculated using the 17 OCCs ranged from 0.06 to 0.12 mg/kg/h. Group 3 and group 6 OCCs resulted in a calculated hydromorphone rate that was higher than the stabilization rate in 96% and 75% of patients, respectively. Use of group 4 and group 5 OCCs resulted in a calculated hydromorphone rate that was lower than the stabilization rate in 64% and 75% of patients, respectively. CONCLUSION Given the considerable variability of OCCs, caution should be used when applying OCCs to critically ill children.
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Affiliation(s)
- Madison Casten
- University of Oklahoma College of Pharmacy, Oklahoma City, OK, USA
| | - Jamie L Miller
- University of Oklahoma College of Pharmacy, Oklahoma City, OK, USA
| | - Stephen B Neely
- University of Oklahoma College of Pharmacy, Oklahoma City, OK, USA
| | - Maura Harkin
- Oklahoma Children's Hospital at OU Health, Oklahoma City, OK, USA
| | - Peter N Johnson
- University of Oklahoma College of Pharmacy, Oklahoma City, OK, USA
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2
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Maffei MV, Laehn S, Bianchini M, Kim A. Risk Factors Associated With Opioid/Benzodiazepine Iatrogenic Withdrawal Syndrome in COVID-19 Acute Respiratory Distress Syndrome. J Pharm Pract 2023; 36:1362-1369. [PMID: 35930693 PMCID: PMC9357752 DOI: 10.1177/08971900221116178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BackgroundMechanically ventilated COVID-19 acute respiratory distress syndrome (ARDS) patients often receive deeper sedation and analgesia to maintain respiratory compliance and minimize staff exposure, which incurs greater risk of iatrogenic withdrawal syndrome (IWS) and has been associated with worse patient outcomes. Objective: To identify potential risk factors and differences in patient outcomes associated with the development of IWS in COVID-19 ARDS patients. Methods: Retrospective analysis of ventilated COVID-19 ARDS intensive care unit (ICU) patients who received continuous intravenous (IV) analgesia and sedation for ≥5 days from March 2020-May 2021. Patients were classified as IWS and non-IWS based on receipt of scheduled oral sedative/analgesic regimens after cessation of IV therapy. Risk factors were assessed in univariate analyses and multivariable modeling. Results: A total of 115 patients were included. The final multivariable model showed: (1) each additional day of IV opioid therapy was associated with an 8% increase in odds of IWS (95% CI, 1.02-1.14), (2) among sedatives, receipt of lorazepam was associated with 3 times higher odds of IWS (95% CI 1.12-8.15), and (3) each 1-point increase in Simplified Acute Physiology Score (SAPS) II was associated with a 4% reduction in odds of IWS (95% CI 0.93-0.999). Conclusion: Prolonged and high dose exposures to IV opioids and benzodiazepines should be limited when possible. Additional prospective studies are needed to identify modifiable risk factors to prevent IWS.
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Affiliation(s)
- Melissa Vu Maffei
- Denver Health Medical Center, Denver, CO, USA
- University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, USA
| | | | | | - Andy Kim
- Denver Health Medical Center, Denver, CO, USA
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3
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Morales Castro D, Dresser L, Granton J, Fan E. Pharmacokinetic Alterations Associated with Critical Illness. Clin Pharmacokinet 2023; 62:209-220. [PMID: 36732476 PMCID: PMC9894673 DOI: 10.1007/s40262-023-01213-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/15/2023] [Indexed: 02/04/2023]
Abstract
Haemodynamic, metabolic, and biochemical derangements in critically ill patients affect drug pharmacokinetics and pharmacodynamics making dose optimisation particularly challenging. Appropriate therapeutic dosing depends on the knowledge of the physiologic changes caused by the patient's comorbidities, underlying disease, resuscitation strategies, and polypharmacy. Critical illness will result in altered drug protein binding, ionisation, and volume of distribution; it will also decrease oral drug absorption, intestinal and hepatic metabolism, and renal clearance. In contrast, the resuscitation strategies and the use of vasoactive drugs may oppose these effects by leading to a hyperdynamic state that will increase blood flow towards the major organs including the brain, heart, kidneys, and liver, with the subsequent increase of drug hepatic metabolism and renal excretion. Metabolism is the main mechanism for drug clearance and is one of the main pharmacokinetic processes affected; it is influenced by patient-specific factors, such as comorbidities and genetics; therapeutic-specific factors, including drug characteristics and interactions; and disease-specific factors, like organ dysfunction. Moreover, organ support such as mechanical ventilation, renal replacement therapy, and extracorporeal membrane oxygenation may contribute to both inter- and intra-patient variability of drug pharmacokinetics. The combination of these competing factors makes it difficult to predict drug response in critically ill patients. Pharmacotherapy targeted to therapeutic goals and therapeutic drug monitoring is currently the best option for the safe care of the critically ill. The aim of this paper is to review the alterations in drug pharmacokinetics associated with critical illness and to summarise the available evidence.
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Affiliation(s)
- Diana Morales Castro
- Interdepartmental Division of Critical Care Medicine, Toronto General Hospital, University of Toronto, 585 University Avenue, 9-MaRS, Toronto, ON, M5G 2N2, Canada. .,Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada.
| | - Linda Dresser
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
| | - John Granton
- Interdepartmental Division of Critical Care Medicine, Toronto General Hospital, University of Toronto, 585 University Avenue, 9-MaRS, Toronto, ON, M5G 2N2, Canada.,Department of Medicine, Toronto General Hospital, University of Toronto, Toronto, ON, Canada
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine, Toronto General Hospital, University of Toronto, 585 University Avenue, 9-MaRS, Toronto, ON, M5G 2N2, Canada.,Department of Medicine, Toronto General Hospital, University of Toronto, Toronto, ON, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
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4
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Ma C, Zhao D, Hu X, Li C, Zhang J, Zhang Y, Yuan L. Perioperative Effects of Hydromorphone in Gynecological Laparoscopic Surgery under General Anesthesia. INT J PHARMACOL 2022. [DOI: 10.3923/ijp.2022.534.542] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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5
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Smith K, Wang M, Abdukalikov R, McAullife A, Whitesell D, Richard J, Sauer W, Quaye A. Pain Management Considerations in Patients with Opioid Use Disorder Requiring Critical Care. J Clin Pharmacol 2021; 62:449-462. [PMID: 34775634 DOI: 10.1002/jcph.1999] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Accepted: 11/07/2021] [Indexed: 11/07/2022]
Abstract
The opioid epidemic has resulted in increased opioid-related critical care admissions, presenting challenges in acute pain management. Limited guidance exists in the management of critically ill patients with opioid use disorder (OUD). This narrative review provides the intensive care unit (ICU) clinician with guidance and treatment options, including non-opioid analgesia, for patients receiving medications for opioid use disorder (MOUD) and for patients actively misusing opioids. Verification and continuation of the patient's outpatient MOUD regimen, specifically buprenorphine and methadone formulations, assessment of pain and opioid withdrawal, and treatment of acute pain with non-opioid analgesia, nonpharmacologic strategies, and short-acting opioids as needed, are all essential to adequate management of acute pain in patients with OUD. A multidisciplinary approach to treatment and discharge planning in patients with OUD may be beneficial to engage patients with OUD early in their hospital stay to prevent withdrawal, stabilize their OUD, and to reduce the risk of unplanned discharge and other associated morbidity. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Kathryn Smith
- Department of Pharmacy, Maine Medical Center, 22 Bramhall St, Portland, ME, 04102, USA
| | - Michelle Wang
- Department of Pharmacy, Beth Israel Deaconess Medical Center, 330 Brookline Ave, Boston, MA, 02215, USA
| | - Ruslan Abdukalikov
- Department of Anesthesiology and Perioperative Medicine, Maine Medical Center, 22 Bramhall St, Portland, ME, 04102, USA
| | - Amy McAullife
- Department of Psychiatry, Maine Medical Center, 22 Bramhall St, Portland, ME, 04102, USA
| | - Dena Whitesell
- Department of Psychiatry, Maine Medical Center, 22 Bramhall St, Portland, ME, 04102, USA
| | - Janelle Richard
- Department of Anesthesiology and Perioperative Medicine, Maine Medical Center, 22 Bramhall St, Portland, ME, 04102, USA
| | - William Sauer
- Department of Anesthesiology and Perioperative Medicine, Maine Medical Center, 22 Bramhall St, Portland, ME, 04102, USA.,Spectrum Healthcare Partners, 324 Gannett Dr, Suite 200, South Portland, ME, 04106, USA.,Department of Critical Care, Maine Medical Center, 22 Bramhall St, Portland, ME, 04102, USA
| | - Aurora Quaye
- Department of Anesthesiology and Perioperative Medicine, Maine Medical Center, 22 Bramhall St, Portland, ME, 04102, USA.,Spectrum Healthcare Partners, 324 Gannett Dr, Suite 200, South Portland, ME, 04106, USA
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Dreucean D, Harris JE, Voore P, Donahue KR. Approach to Sedation and Analgesia in COVID-19 Patients on Venovenous Extracorporeal Membrane Oxygenation. Ann Pharmacother 2021; 56:73-82. [PMID: 33882694 DOI: 10.1177/10600280211010751] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
OBJECTIVE To describe clinically pertinent challenges of managing sedation in COVID-19 patients on venovenous extracorporeal membrane oxygenation (VV-ECMO) and describe considerations for enhanced safety and efficacy of pharmacological agents used. DATA SOURCES A PubMed search was performed using the following search terms: ECMO, ARDS, sedation, COVID-19, coronavirus, opioids, analgesia, fentanyl, hydromorphone, morphine, oxycodone, methadone, ketamine, propofol, dexmedetomidine, clonidine, benzodiazepines, midazolam, lorazepam, and diazepam. STUDY SELECTION AND DATA EXTRACTION Relevant clinical and pharmacokinetic studies were considered. All studies included were published between January 1988 and March 2021. DATA SYNTHESIS Patients with acute respiratory distress syndrome secondary to COVID-19 may progress to requiring VV-ECMO support. Agents frequently used for sedation and analgesia in these patients have been shown to have significant adsorption to ECMO circuitry, leading to possible diminished clinical efficacy. Use of hydromorphone-based analgesia has been associated with improved clinical outcomes in patients on VV-ECMO. However, safety and efficacy regarding use of other agents in this patient population remains an area of further research. RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE This review addresses clinical challenges associated with sedation management in COVID-19 patients requiring VV-ECMO support and provides potential strategies to overcome these challenges. CONCLUSIONS Historically, sedation and analgesia management in patients requiring ECMO support have posed a challenge for bedside clinicians given the unique physiological and pharmacokinetic changes in this patient population. A multimodal strategy to managing analgesia and sedation should be used, and the use of enteral agents may play a role in reducing parenteral agent requirements.
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Harkin M, Miller JL, Lim SY, Neely SB, Walsh CK, Johnson PN. Conversion From Continuous Infusion Fentanyl to Continuous Infusion Hydromorphone in the Pediatric Intensive Care Unit. Ann Pharmacother 2021; 55:1439-1446. [DOI: 10.1177/10600280211003170] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
Background: Opioid rotations from fentanyl to hydromorphone may reduce opioid/sedative exposure in critically ill children. Objective: The primary objective was to determine the conversion percentage from fentanyl to hydromorphone infusions using equianalgesic conversions (0.1 mg fentanyl = 1.5 mg hydromorphone). Secondary objectives included identification of the median time and hydromorphone rate at stabilization (defined as the first 24-hour period no hydromorphone rates changed, 80% of State Behavioral Scale [SBS] scores between 0 and −1, and <3 hydromorphone boluses administered). Additional outcomes included a comparison of opioid/sedative requirements on the day of conversion versus the three 24-hour periods prior to conversion. Methods: This retrospective study included children <18 years old converted from fentanyl to hydromorphone infusions over 6.3 years. Linear mixed models were used to determine if the mean cumulative opioid/sedative dosing differed from the day of conversion versus three 24-hour periods prior to conversion. Results: A total of 36 children were converted to hydromorphone. The median conversion percentage of hydromorphone was 86% of their fentanyl dose (interquartile range [IQR] = 67-100). The median hydromorphone rate at stabilization was 0.08 mg/kg/h (IQR = 0.05-0.1). Eight (22%) were stabilized on their initial hydromorphone rate; 8 (22%) never achieved stabilization. Patients had a significant decrease in opioid dosing on the day of conversion versus the 24-hour period prior to conversion but no changes in sedative dosing following conversion. Conclusion and Relevance: A median 14% fentanyl dose reduction was noted when transitioning to hydromorphone. Further exploration is needed to determine if opioid rotations with hydromorphone can reduce opioid/sedative exposure.
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Affiliation(s)
- Maura Harkin
- Oklahoma Children’s Hospital at OU Health, Oklahoma City, OK, USA
| | - Jamie L. Miller
- University of Oklahoma College of Pharmacy, Oklahoma City, OK, USA
| | - Sin Yin Lim
- University of Wisconsin School of Pharmacy, Madison, WI, USA
| | - Stephen B. Neely
- University of Oklahoma College of Pharmacy, Oklahoma City, OK, USA
| | | | - Peter N. Johnson
- University of Oklahoma College of Pharmacy, Oklahoma City, OK, USA
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Evaluation of Hypertriglyceridemia in Critically Ill Patients With Coronavirus Disease 2019 Receiving Propofol. Crit Care Explor 2021; 3:e0330. [PMID: 33490957 PMCID: PMC7808527 DOI: 10.1097/cce.0000000000000330] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
Objectives To report the prevalence of, and evaluate risk factors for, the development of hypertriglyceridemia (defined as a serum triglyceride level of > 400 mg/dL) in patients with coronavirus disease 2019 who received propofol. Design Single-center, retrospective, observational analysis. Setting Brigham and Women's Hospital, a tertiary academic medical center in Boston, MA. Patients All ICU patients who with coronavirus disease 19 who received propofol between March 1, 2020, and April 20, 2020. Interventions None. Measurements and Main Results The major outcome of this analysis was to report the prevalence of, and risk factors for, the development of hypertriglyceridemia in patients with coronavirus disease 19 who received propofol. Minor outcomes included the development of acute pancreatitis and description of propofol metrics. Of the 106 patients that were included, 60 (56.6%) developed hypertriglyceridemia, with a median time to development of 46 hours. A total of five patients had clinical suspicion of acute pancreatitis, with one patient having confirmatory imaging. There was no difference in the dose or duration of propofol in patients who developed hypertriglyceridemia compared with those who did not. In the patients who developed hypertriglyceridemia, 35 patients (58.5%) continued receiving propofol for a median duration of 105 hours. Patients who developed hypertriglyceridemia had elevated levels of inflammatory markers. Conclusions Hypertriglyceridemia was commonly observed in critically ill patients with coronavirus disease 2019 who received propofol. Neither the cumulative dose nor duration of propofol were identified as a risk factor for the development of hypertriglyceridemia. Due to the incidence of hypertriglyceridemia in this patient population, monitoring of serum triglyceride levels should be done frequently in patients who require more than 24 hours of propofol. Many patients who developed hypertriglyceridemia were able to continue propofol in our analysis after reducing the dose.
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Adams CD, Altshuler J, Barlow BL, Dixit D, Droege CA, Effendi MK, Heavner MS, Johnston JP, Kiskaddon AL, Lemieux DG, Lemieux SM, Littlefield AJ, Owusu KA, Rouse GE, Thompson Bastin ML, Berger K. Analgesia and Sedation Strategies in Mechanically Ventilated Adults with COVID‐19. Pharmacotherapy 2020; 40:1180-1191. [DOI: 10.1002/phar.2471] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
- Christopher D. Adams
- Department of Pharmacy Practice and Administration Ernest Mario School of Pharmacy Piscataway New JerseyUSA
| | - Jerry Altshuler
- Department of Pharmacy Hackensack Meridian JFK Medical Center Edison New JerseyUSA
| | - Brooke L. Barlow
- Department of Pharmacy Services University of Kentucky HealthCare Lexington KentuckyUSA
| | - Deepali Dixit
- Department of Pharmacy Practice and Administration Ernest Mario School of Pharmacy Piscataway New JerseyUSA
| | - Christopher A. Droege
- Department of Pharmacy UC Health – University of Cincinnati Medical Center Cincinnati OhioUSA
| | - Muhammad K. Effendi
- Department of Pharmacy Practice and Administration Ernest Mario School of Pharmacy Piscataway New JerseyUSA
| | - Mojdeh S. Heavner
- Department of Pharmacy Practice University of Maryland School of Pharmacy Baltimore MarylandUSA
| | - Jackie P. Johnston
- Department of Pharmacy Practice and Administration Ernest Mario School of Pharmacy Piscataway New JerseyUSA
| | - Amy L. Kiskaddon
- Department of Pharmacy Johns Hopkins All Children's Hospital St. Petersburg FloridaUSA
| | - Diana G. Lemieux
- Department of Pharmacy Services Yale New Haven Hospital New Haven ConnecticutUSA
| | - Steven M. Lemieux
- Department of Pharmacy Practice and Administration University of Saint Joseph Hartford ConnecticutUSA
| | - Audrey J. Littlefield
- Department of Pharmacy New York‐Presbyterian Hospital/Weill Cornell Medical Center New York New YorkUSA
| | - Kent A Owusu
- Department of Pharmacy Services Yale New Haven Hospital New Haven ConnecticutUSA
| | - Ginger E. Rouse
- Department of Pharmacy Services Yale New Haven Hospital New Haven ConnecticutUSA
| | | | - Karen Berger
- Department of Pharmacy New York‐Presbyterian Hospital/Weill Cornell Medical Center New York New YorkUSA
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