Fentanyl

[timurx]

This may sound silly and elementary but why does we mess around with using opiates for sedation/analgesia drip? With all the opiate issues, are well not just creating a situation whereby an otherwise opiate naive individual becomes acclimated to having fentanyl on board for weeks at time in the ICU. Not to even mention the "withdrawal" that occurs and wondering why someone is persistently tachycardic. Is the no concern for addiction afterwards to opiates as a result of having so much exposure to this?

Be nice please

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[deleted547339]

This may sound silly and elementary but why does we mess around with using opiates for sedation/analgesia drip? With all the opiate issues, are well not just creating a situation whereby an otherwise opiate naive individual becomes acclimated to having fentanyl on board for weeks at time in the ICU. Not to even mention the "withdrawal" that occurs and wondering why someone is persistently tachycardic. Is the no concern for addiction afterwards to opiates as a result of having so much exposure to this?

Be nice please

What’s your better alternative?

 

[tartesos]

He said be nice.
Now talk noob!l what's your better choice? /jk


Sent from my iPhone using SDN mobile

 

[BigRedBeta]

Of course there's concern, while we as intensivists only have control over the patient within the 4 walls of the ICU, we are still aware that the patient's recovery process extends back home.

Obviously there are competing interests though and we know that other medications (benzos) lead to greater delirium which prolongs ICU stays. Precedex is perhaps more benign but has its own limitations (and I think the data will ultimately show that it still contributes to ICU delirium though not to the same degree). Propofol also has issues and is particularly problematic in children for those of us in the PICU.

The other consideration is that for many of our patients, pain is a significant cause for agitation, so treating that is often worth more bang for your buck than simply trying to sedate the patient into oblivion.

In my experience and I think certain research bears this out, there is an under appreciation for the issues of ventilator dyssynchrony causes in terms of agitation and sedation needs. Maybe that means that neural triggers are the next step forward (I like NAVA a ton...when it works it's fantastic, but getting a patient settled out on it is not always easy. Personally would much prefer to have the option to separate the neural trigger from the ventilatory assist, especially in an non-invasive mode).

Lastly, as someone who loves vents and fully believes that careful selection of vent mode can really make a huge difference in patient's course, the reality is that protocol driven care plans for the RT's to follow allows the ICU to run more smoothly. In a big busy unit, I simply can't take the time to individually craft the perfect vent strategy for a patient when another mode is "good enough". Nevermind that I know my partners who will be working nights or picking up the patient after me won't be as thoughtful and so it's easier to follow the more tried and true path, reserving deviations for the patients who are truly struggling.

 

[Siggy]

Why do we use opiates in vented patients?

Put a finger down your throat. It hurts, right?
Take two benadryl and put a finger down your hurt. Does it hurt less because the benadryl is making you sleepy?

 

[jdh71]

I want an early trach please.

But don't stop the fentanyl, that's just mean.

Also, marijuana brownies into my feeding tube. Don't be a dick.

 

[jdh71]

This may sound silly and elementary but why does we mess around with using opiates for sedation/analgesia drip? With all the opiate issues, are well not just creating a situation whereby an otherwise opiate naive individual becomes acclimated to having fentanyl on board for weeks at time in the ICU. Not to even mention the "withdrawal" that occurs and wondering why someone is persistently tachycardic. Is the no concern for addiction afterwards to opiates as a result of having so much exposure to this?

Be nice please

Patients who get opioid (sorry, pedantic pet peeve, don't mind me) medications for real pain issues in the acute setting don't turn into junkies. It's a good question, but not the kind of thing we worry about because it's just not a real problem.

 

[cbrons]

Patients who get opioid (sorry, pedantic pet peeve, don't mind me) medications for real pain issues in the acute setting don't turn into junkies. It's a good question, but not the kind of thing we worry about because it's just not a real problem.

I thought i was the only one bothered by the constant terminology misuse.

 

[CCMEM]

This may sound silly and elementary but why does we mess around with using opiates for sedation/analgesia drip? With all the opiate issues, are well not just creating a situation whereby an otherwise opiate naive individual becomes acclimated to having fentanyl on board for weeks at time in the ICU. Not to even mention the "withdrawal" that occurs and wondering why someone is persistently tachycardic. Is the no concern for addiction afterwards to opiates as a result of having so much exposure to this?

Be nice please

This is a great question, with no definitive answer yet! My thoughts on this are below, much better are Josh Farkas’s thoughts on this, including a summary of the trials that the SCCM analgesia fist strategy is based on discussed here:

Google: Pulmcrit Fentanyl Infusions, for sedation, the opioid pendulum swings astray? -SDN wouldn’t let me post the link.0


Yes opioid dependence after ICU stay is something I worry about, at least on a theoretical basis, but I have no evidenced based practical solution, yet.

It seems that in general some small subset of patients who are exposed to opiates will become dependent. This has been looked at in an observational fashion amongst ED patients.

Google: NEJM Barnett Opiod prescribing patterns of emergency physicians and risk of long term use. (Sorry can’t post links)


I have not seen a study looking at what portion of ICU patients are still on opiates 6 months after discharge, but that would be really interesting. If anyone knows of a study like this please post link.

I’m my limited practice I have had a few patients who I felt, became opiate dependent in the ICU. They were younger patients who we put on high dose fentanyl for over a week from painful conditions like pancreatitis or poly trauma. Maybe 2 or 3 seemed to become dependent, over the 3 years I have been practicing. These are people who had to be placed on methadone to come off their fentanyl infusions. One possible confounder is that they could have been opiate dependent before the ICU so I can’t say if the fentanyl drip caused a new dependence.

In the patients who I know are already opiate dependent, like IV drug abusers I have frequently needed to place them on methadone to come off fentanyl. I’m not sure if there is a better strategy for these guys but would love to hear the groups thougts.

I’ve found found a wide range of tolerance to having an endotracheal tube. There are some people who can sit up reading the newpaper intubated with no pain, and others who violently fight against the tube (or ventilator).

There is a trial of no sedation in ICU patients, but I’m not aware of opiates vs Tylenol or opiates vs analgesia dosed ketamine.

I am sure we are harming some patients with opiates in the ICU, but I’m not sure there is a better evidenced based alternative yet; uncontrolled pain certainly leads to delirium, PTSD post ICU depression, probably longer ventilator and ICU stays.

Maybe remifentanyl would be better? Maybe analgesia dosed ketamine would be better? We really need good data on analgesia for mechanical ventilation; so far Fentanyl infusions are an evidence free zone. (as far as I’m aware)

 

[Siggy]

It seems that in general some small subset of patients who are exposed to opiates will become dependent.

I've wondered the same thing... but can you become dependent on a substance that you never really knew you received? Going through withdraw? Sure... but if you don't make connection that drug X caused feeling/sensation Y, I don't know if you can get actual dependence.

 

[engineeredout]

I want an early trach please.

But don't stop the fentanyl, that's just mean.

Also, marijuana brownies into my feeding tube. Don't be a dick.

Damn well better be whisky autoflush with my tube feedings.

 

[RNthenDoc]

I hate seeing people tortured over the fear of this epidemic.

Granny Ethel isn’t going to buy any illicit horse down the street after we give her a sniff of the good stuff while her lungs recover from the flu A her antixer great-grandkid gave her.

Judicious use of opioids is smart, but jeezy Petes, is the ICU the time to be stingy?

 

[deleted875186]

Agreed, give me opioids if I’m tuned in te ICU. I think the bigger problem is many ICUs don’t do a proper sedation holiday and truely try to decrease sedation.

Does anyone try rotating opioids? I’ve seen so many patients end up on 300 mcg/hr fentanyl and have often wondered if it’s worth it to switch to hydromorphone and back again after a certain amount of time.

Ketamine works excellent, and has a very short context sensitive half time close to propofol.

 

[WheezyBaby]

Agreed, give me opioids if I’m tuned in te ICU. I think the bigger problem is many ICUs don’t do a proper sedation holiday and truely try to decrease sedation.

Does anyone try rotating opioids? I’ve seen so many patients end up on 300 mcg/hr fentanyl and have often wondered if it’s worth it to switch to hydromorphone and back again after a certain amount of time.

Ketamine works excellent, and has a very short context sensitive half time close to propofol.

Not that I have a lot of experience, but I generally rotate opioids coming up on a week of being on one if requirements are going up

 

[nimbus]

This is a great question, with no definitive answer yet! My thoughts on this are below, much better are Josh Farkas’s thoughts on this, including a summary of the trials that the SCCM analgesia fist strategy is based on discussed here:

Google: Pulmcrit Fentanyl Infusions, for sedation, the opioid pendulum swings astray? -SDN wouldn’t let me post the link.0


Yes opioid dependence after ICU stay is something I worry about, at least on a theoretical basis, but I have no evidenced based practical solution, yet.

It seems that in general some small subset of patients who are exposed to opiates will become dependent. This has been looked at in an observational fashion amongst ED patients.

Google: NEJM Barnett Opiod prescribing patterns of emergency physicians and risk of long term use. (Sorry can’t post links)


I have not seen a study looking at what portion of ICU patients are still on opiates 6 months after discharge, but that would be really interesting. If anyone knows of a study like this please post link.

I’m my limited practice I have had a few patients who I felt, became opiate dependent in the ICU. They were younger patients who we put on high dose fentanyl for over a week from painful conditions like pancreatitis or poly trauma. Maybe 2 or 3 seemed to become dependent, over the 3 years I have been practicing. These are people who had to be placed on methadone to come off their fentanyl infusions. One possible confounder is that they could have been opiate dependent before the ICU so I can’t say if the fentanyl drip caused a new dependence.

In the patients who I know are already opiate dependent, like IV drug abusers I have frequently needed to place them on methadone to come off fentanyl. I’m not sure if there is a better strategy for these guys but would love to hear the groups thougts.

I’ve found found a wide range of tolerance to having an endotracheal tube. There are some people who can sit up reading the newpaper intubated with no pain, and others who violently fight against the tube (or ventilator).

There is a trial of no sedation in ICU patients, but I’m not aware of opiates vs Tylenol or opiates vs analgesia dosed ketamine.

I am sure we are harming some patients with opiates in the ICU, but I’m not sure there is a better evidenced based alternative yet; uncontrolled pain certainly leads to delirium, PTSD post ICU depression, probably longer ventilator and ICU stays.

Maybe remifentanyl would be better? Maybe analgesia dosed ketamine would be better? We really need good data on analgesia for mechanical ventilation; so far Fentanyl infusions are an evidence free zone. (as far as I’m aware)

Problem with remi is that even short infusions in the operating room are associated with OIH.

Ketamine and propofol together make a nice general anesthetic.