Reducing pain, agitation and delirium to optimize outcomes in mechanically ventilated critically ill oncology patients.

Abstract

233 Background: Greater than 60% of cancer patients experience chronic pain which is heightened in critical illness. Optimal pain assessment is challenging in the critically ill leading to under treatment due to sedation during mechanical ventilation (MV). The Society of Critical Care Medicine (SCCM) favors treating pain with intermittent boluses rather than continuous infusions; however,appropriate analgesic doses and means of titration are elusive leading to over sedation, prolonged ventilation, and delirium. Utilization of protocols promotes better nursing assessment of sedation-delirium scores which reduce the use of sedatives. The purpose of this study was to assess the need for a nurse driven pain-sedation protocol in ventilated oncology patients. Methods: This retrospective study included 51 mechanically ventilated oncology patients admitted between12/2013 and 6/2015. The analgesics, sedatives, dosing and duration of MV were collected. Sedative titration was evaluated relative to analgesics used by nursing staff. Results: Fentanyl was administered in 94% of patients, an average rate of 142mcg/hr (3413mcg/day) significantly higher than rates of 43mcg/hr). Midazolam was administered at an average rate of 1.25mg/hr in 57%, while 54% received propofol (15.5mcg/hr), demonstrating concurrent use of sedatives and analgesics. In 49%, sedatives were increased without prior adjustment of analgesics indicating that pain was unaddressed and undertreated. In the setting of over-sedation nursing neurological assessment was difficult and associated with prolonged duration of MV (9.7 days). Conclusions: Guidelines recommend “analgesia-first sedation” to promote use of analgesic agents over sedatives to treat pain and agitation and reduce undertreating pain. This becomes crucial in the oncology population. This study demonstrates inconsistencies with guidelines and further supports the need for a structured pain-sedation protocol to decrease over-sedation, adequately treat pain and potentially decrease delirium and prolonged MV. Subsequently, a protocol has been developed which will be implemented after education has been provided to the multidisciplinary team.