Encore Presentations
Sunday, November 12, 2023
12:45 PM–02:15 PM
Abstract
ESICM Abstract 2022
International Analgesia and Sedation Weaning and Withdrawal Practices in Critically Ill Adults: The AduLt iatrogEnic withdRawal sTudy in the ICU (ALERT-ICU)
Scott Bolesta, PharmD; Lisa Burry, PharmD; Marc M. Perreault, PharmD, MSc, Céline Gélinas, RN, PhD; Kathryn E. Smith, PharmD; Federico Carini, MD; Rebekah Eadie, MPharm, MSc; Katrianna Saltarelli, PharmD Candidate; Jennifer Mitchell, PharmD Candidate; Jamie Harpel, PharmD Candidate; Ryan Stewart, PharmD Candidate; Richard R. Riker MD; Gilles L. Fraser, PharmD; Brian L. Erstad, PharmD, on behalf of the ALERT-ICU study investigators
Introduction
Iatrogenic withdrawal syndrome (IWS) from opioids and sedatives in critically ill patients has a reported prevalence of 32% to 68% (Curley et al., 2015; Cammarano et al., 1998). It is associated with prolonged mechanical ventilation and ICU stay (Amigoni et al., 2017; Cammarano et al., 1998); however, little is known about practices utilized to monitor, assess, prevent or treat IWS.
Objectives
Describe analgesia and sedation weaning and withdrawal practices in critically ill adults.
Methods
We conducted an international, prospective, observational, one-day point prevalence study. Professional networks, listservs, a study website, and social media were used for study site recruitment. The study was determined to be exempt by the Wilkes University Institutional Review Board. Study sites obtained local research ethics approval, and selected a data collection date between June 1 and September 30, 2021 for each of their participating ICUs. Patients aged 18 years and older in the ICU on the data collection date were included, and those receiving parenteral analgesics or sedatives during the previous 24 hours had demographic, medication, and outcomes data collected for that time period using Research Electronic Data Capture (REDCap). The primary outcome was the proportion of patients weaned from continuous parenteral analgesics and sedatives using an institution-defined standardized approach. Secondary outcomes included proportion of patients assessed for IWS using a standardized approach, proportion receiving continuous analgesics and sedatives, and weaning and IWS practices. Descriptive and comparative statistical analyses were performed using IBM SPSS Statistics version 28.0.0 (Armonk, New York). Parametric and non-parametric tests were used according to level of measurement, data distribution and assumptions. An alpha less than 5% demonstrated statistical significance.
Results
Data were collected at 87 hospitals in 229 ICUs from 11 countries on 2402 patients. More than half the hospitals (56%) were located in the United States and United Kingdom, 61% were academic medical centers, and 68% of participating ICUs were using a closed practice model and had a mean of 19 (SD ± 9) beds. Most patients (55%) were from the United States and continuous parenteral analgesics or sedatives were administered in the previous 24 hours in 1506 (63%) patients. The mean age of patients who received continuous parenteral analgesics or sedatives was 56 (SD ± 16) years, 38% were female, 41% were admitted primarily for respiratory disease, and 30% were COVID-19 PCR positive. On the day of data collection, the median duration of ICU stay for these patients was 6 (IQR; 12) days, 31% had active ARDS, and 74% were on mechanical ventilation. Among these patients 521 (34%) were admitted to 90 (39%) ICUs with a weaning protocol, and 97 (6%) patients to 23 (10%) ICUs with a withdrawal protocol. By the day of data collection, a weaning protocol for analgesia-sedation was utilized in 176 (12%) and withdrawal protocol in 9 (0.6%) patients in these ICUs. In ICUs with a weaning protocol 20 (22%) initiate the protocol < 24 hours after starting continuous analgesics or sedatives, 12 (13%) 24 to < 72 hours, and 11 (12%) ? 72 hours, but the majority (52%) do not specify. A validated tool is used to determine the degree of weaning in 48 (53%) ICUs, absolute dose reduction in 22 (24%), and percent reduction in 23 (26%). Significantly more ICUs with a withdrawal protocol initiate weaning 72 to < 96 hours after analgesia-sedation initiation (40% vs 0%; p < 0.001), and use an absolute (30% vs. 7%; p = 0.003) and percent (39% vs. 7%; p < 0.001) dose reduction for weaning compared to ICUs without a withdrawal protocol.
Conclusions
Although two-thirds of patients received continuous parenteral analgesics or sedatives, a small proportion were weaned and assessed for withdrawal from these agents using a standardized approach. A little over one-third of patients were admitted to an ICU with a weaning protocol, and about 1 in 20 to an ICU with a withdrawal protocol.
References
Amigoni A, Mondardini MC, Vittadello I, Zaglia F, Rossetti E, Vitale F, et al. Withdrawal Assessment Tool-1 Monitoring in PICU: A Multicenter Study on Iatrogenic Withdrawal Syndrome. Pediatr Crit Care Med 2017;18:e86–91.
Cammarano WB, Pittet JF, Weitz S, Schlobohm RM, Marks JD. Acute withdrawal syndrome related to the administration of analgesic and sedative medications in adult intensive care unit patients. Crit Care Med 1998;26:676–84.
Curley MAQ, Wypij D, Watson RS, Grant MJC, Asaro LA, Cheifetz IM, et al. Protocolized sedation vs usual care in pediatric patients mechanically ventilated for acute respiratory failure: A randomized clinical trial. JAMA - J Am Med Assoc 2015;313:379–89.
Grant Acknowledgement
Supported by funding from a Wilkes University Provost Research and Scholarship Grant.
Presenting Author
Scott Bolesta PharmD, BCPS, FCCP, FCCM
Wilkes UniversityAuthors
Lisa Burry PharmD, PhD
Mount Sinai Hospital
Federico Carini MD
University of Toronto
Gilles Fraser PharmD
Maine Medical Center (Ret.)
Celine Gelinas RN, PhD
McGill Uinversity
Jamie Harpel PharmD
Wilkes University
Jennifer Mitchell PharmD
Veterans Affairs Medical Center
Marc Perreault PharmD, MSc
University of Montreal,
Katrianna Pranga-Saltarelli PharmD
Baptist Memorial Health Care
Rebekah Eadie MPharm, MSc
Ulster Hospital
Brian Erstad PharmD
The University of Arizona College of Pharmacy
Richard Riker MD
Maine Medical Center
Kathryn Smith PharmD
Maine Medical Center
Ryan Stewart Doctor of Pharmacy Candidate
Wilkes University