Kevin Dube, BCCCP, BCPS, PharmD
Clinical Pharmacy Specialist
Brigham & Women's Hospital
Boston, Massachusetts
Disclosure information not submitted.
Mary Kovacevic, BCCCP, BCPS, PharmD
Clinical Pharmacy Specialist
Brigham & Women's Hospital
Boston, Massachusetts
Disclosure information not submitted.
Matthew Duprey, BCCCP, PharmD, PhD
Investigator
Northeastern University
Providence, Rhode Island
Disclosure information not submitted.
Paul Szumita, PharmD, FASHP
Director, Clinical Pharmacy Services
Brigham & Women's Hospital, United States
Disclosure information not submitted.
Spencer Sutton, PharmD
PGY 2 Pharmacy Resident, Infectious Disease
Boston Medical Center, United States
Disclosure information not submitted.
Trevor McCrobie, n/a
Pharmacy Student
Northeastern University, United States
Disclosure information not submitted.
Jose Zeballos, MD
Director of the Post-Operative Pain Service
Brigham and Women's Hospital, United States
Disclosure information not submitted.
John Devlin, BCCCP, PharmD, MCCM
Professor
Northeastern University
Boston, Massachusetts, United States
Disclosure information not submitted.
Title: Association between non-opioid analgesic use and opioid exposure in critically ill surgical adults
Introduction:
PADIS guidelines recommend a multimodal, non-opioid analgesic (NOA) strategy to reduce ICU opioid use after surgery. However, the association between daily individual NOA use and ICU opioid exposure in critically ill, postsurgical adults remains unclear. We hypothesized that the scheduled use of acetaminophen (A), a gabapentinoid (G), ketamine (K), lidocaine (L), or an NSAID (N) each are associated with reduced next-day ICU opioid use in critically ill adults after major surgery.
Methods:
This IRB-approved, quasi-experimental study evaluated consecutive adults undergoing major surgery and admitted to a surgical ICU at one academic center during both 2017 and 2019 who required continuously-infused opioids and mechanical ventilation ≥24 hrs. Patients taking chronic opioids [≥100 mg morphine equivalents (MME)] or ≥3 scheduled NOAs pre-ICU were excluded. Only SICU days of opioid (IV and/or PO) use were included in the analysis. Using repeated-measures multivariate linear regression models, and adjusting for baseline (i.e., age, gender, BMI, SOFA, home opioid use, surgery site, year) and daily ICU (i.e., peak CPOT, nerve block use, and mechanical ventilation use) factors known to influence ICU opioid use, we evaluated the association between NOA (i.e., A, G, K, L, & N) use on one SICU day and total opioid exposure on the next SICU day.
Results:
The 134 patients (63±15 yr, SOFA 9[7-11]) primarily underwent major abdominal (45%) or cardiothoracic (38%) surgery and stayed in the SICU 7[5-13] days. An opioid was administered on 1341/1650 (81%) of SICU days at an average dose of 66[42-96] MME. Among these opioid days, ≥1 NOA was administered on 874/1341 (65%): A 55%, L 24%, G 7%, K 1.2%, and N 1%. After controlling for all variables, no NOA was significantly associated with a next-SICU day reduction in opioid (MME) use (A -9.5, p=0.60; L -3.4, p=0.87; G -19.4; p=0.69; K -24.1, p=0.78; and N -9.2, p=0.90). Results did not change when moderate pain (vs. peak CPOT) was used.
Conclusions:
Individual NOAs shown in studies to reduce ICU opioid use have primarily evaluated non-critically ill patients and those who transition through the ICU quickly. Controlled studies are needed to evaluate the effect of NOAs, both alone and in combination, on ICU opioid use in postsurgical adults who are critically ill.