18 The Risks of Sedation and Pain Control in the ICU: Can Increased Sedation Lead to Over-Resuscitation and More Hypotension?

Abstract

Abstract Introduction Pain control and sedation of burn patients is a complex and necessary aspect of initial care and resuscitation. Each patient’s pain experience is unique. Balancing pain needs with obtundation and hemodynamic changes can be difficult, even for experienced clinicians. We hypothesize that in the first 48 hours of ICU admission, increased sedation in burned patients will be associated with increased resuscitation and hemodynamic instability. Methods A 6-year (2014–19) retrospective review of our hospital’s burn database collected patients admitted to the ICU with greater than 20% TBSA burns. In the first 48 hours of admission, we compared total amounts of sedation/pain medications (morphine milligram equivalents (MME), propofol, dexmedetomidine, benzodiazepines) given with total resuscitation and hemodynamic data. A linear regression model was chosen to determine if higher amounts of sedation/pain medication could predict greater resuscitation and episodes of hypotension (MAP < 65). Results 208 patients were included with median age, %TBSA, and resuscitation of 43 years (0–99), 31% (20–93), and 3.3 ml/kg/%TBSA (0.13–19.05), respectively. The majority of our patients were white (80%) males (68%). Patients received a combination of MMEs (99% of patients), propofol (31%), dexmedetomidine (11%), and benzodiazepines (73%). Using a multivariable linear regression model, we found associations between total MMEs given and greater resuscitation (95% CI: 0.15–0.54, p=0.01) as well as number of hypotensive events (95% CI: 1.57–2.7, p< 0.001) in the first 48 hours of admission. No associations were noted with other sedative medications when comparing the number of hypotensive events and increased resuscitation. Conclusions While acute pain and sedation management is crucial in treating critically-ill burn patients, it often becomes routine. We find that pain management is not without physiological consequences and should be carefully monitored during resuscitation.