Michelle Horng, BCCCP, PharmD
Clinical Pharmacy Specialist - Critical Care
University of Texas MD Anderson Cancer Center
Houston, Texas
Disclosure information not submitted.
Nirmala Manjapacha
Research Assistant
The University of Texas MD Anderson Cancer Center, United States
Disclosure information not submitted.
Courtney Magoun, RN
Nurse Manager
University of Texas MD Anderson Cancer Center, United States
Disclosure information not submitted.
Joseph Nates, MBA, MD
Professor, Deputy Chair, Director ICUs
University of Texas MD Anderson Center
Bellaire, Texas, United States
Disclosure information not submitted.
Rekha Silas, RN
Nurse Manager
University of Texas MD Anderson Cancer Center, United States
Disclosure information not submitted.
Kimberly Turner, PA-C
Physician Assistant
MD Anderson Cancer Care Center, United States
Disclosure information not submitted.
Benisco Voltaire, RT
Respiratory Therapist
The University of Texas MD Anderson Cancer Center, United States
Disclosure information not submitted.
Joshua Botdorf, DO
Assistant Professor
University of Texas MD Anderson Cancer Center, Texas, United States
Disclosure information not submitted.
Title: A Multidisciplinary Approach to Reduce Opioid Use in Mechanically Ventilated Solid Cancer Patients
Introduction: Continuous infusion opioids used to facilitate mechanical ventilation can lead to over-sedation and poor outcomes. Multimodal pharmacotherapy decreases use of opioid and sedative agents, but can be difficult to implement in an oncologic patient population with multiple considerations (e.g., bleed risk, antipyretic avoidance). This study utilized a multidisciplinary approach to reduce the use of intravenous continuous infusion opioids (CIO) in mechanically ventilated solid tumor patients in the medical intensive care unit (MICU).
Methods: This quality improvement study was conducted at a tertiary oncology center with a multidisciplinary team of physicians, nurses, a respiratory therapist, an advance practice provider, and a clinical pharmacist. We performed process analysis to identify causes contributing to patient exposure to opioids and developed a multimodal analgesia-first algorithm in accordance to institutional and societal pain guidelines. A supplemental guidance document outlined strategies and common adverse effects for use of non-opioid analgesia, and co-analgesics for neuropathic and chronic pain syndromes. Verbal and disseminated education were presented to members of each discipline. Solid tumor patients admitted to the MICU and intubated for > 48 hours were included in the study.
Results: A total of 111 patients were included; 37 from pre-algorithm (pR-a; October 2019 to February 2020), and 74 from post-algorithm (pO-a; Sept 2020 to April 2021) implementation. There was no difference in baseline hospital or ICU length of stay, or duration of intubation. No difference was seen in percent of time in severe pain (14% + 12 vs 13% + 11, p=0.561) or use of multimodal analgesia administration (32% vs 38%, p=0.366) in the pR-a and pO-a groups, respectively. Use of CIO drips decreased from 91.9% to 79.7% (p=0.082), the percent of oral morphine milligram equivalents derived from CIO drips decreased from 90% to 77% (p=0.064), and the usage of intermittent opioids increased from 21.6% to 36.5% (p = 0.083) in the pR-a and pO-a groups, respectively.
Conclusions: A team-based multimodal approach to pain control in intubated solid tumor patients reduced exposure to continuous opioid infusion therapy while maintaining adequate pain control.