Iatrogenic Withdrawal Syndrome due to Opioids in Critically Ill Patients: a Multicenter Prospective Obeservationnal Study
CCCF ePoster library. Williamson D. Nov 1, 2016; 150959; 78 Disclosure(s): Investigator-initiated research grant from Pfizer
Prof. David Williamson
Prof. David Williamson
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Topic: Retrospective or Prospective Cohort Study

Iatrogenic Withdrawal Syndrome due to Opioids in Critically Ill Patients: a Multicenter Prospective Obeservationnal Study

Wang, Pan Pan1; Huang, Elaine1; Feng, Xue; Bray1, Charles-André1; Perreault, Marc2,3; Rico, Philippe4,5; Bellemare, Patrick4,5; Murgoi, Paul3; Gélinas C6; Lecavalier, A7; Jayaraman, Dev7; Frenette, Anne Julie1,2; Willamson, David1,2   

1Pharmacy department, Hôpital du Sacré-Coeur de Montréal, Montréal, Québec, Canada;
2Faculté de Pharmacie, Université de Montréal, Montréal, Québec, Canada;
3Pharmacy department, McGill University Health Center, Montréal, Québec, Canada;
4Critical Care department, Hôpital du Sacré-Coeur de Montréal, Montréal, Québec, Canada;
5Faculté de Médecine, Université de Montréal, Montréal, Québec, Canada;
6Ingram School of Nursing, McGill University; Centre for Nursing Research and Lady Davis Institute, Jewish General Hospital, Montréal, Québec, Canada;
7Department of Critical Care Montreal General Hospital, McGill University Health Center, Montréal, Québec, Canada;

Grant acknowledgements:
The study was supported by an unrestricted educational grant form Hospira Inc.


Introduction: Opioids and benzodiazepines are frequently used in the intensive care unit (ICU) to treat pain, agitation and facilitate mechanical ventilation. Regular use and prolonged exposure to opioids in the ICU patients followed by abrupt tapering or cessation may lead to iatrogenic withdrawal syndrome (IWS). IWS is well described in the paediatric but no prospective study has yet evaluated the adult ICU population.
Objective: The objective of this study was to determine the incidence of iatrogenic withdrawal syndrome (IWS) caused by opioids in the critically ill adult population.
Methods: WAAICUP-1, a multicenter prospective cohort, included 54 critically ill patients. The study was conducted at two level-1 trauma ICUs in Montreal, Quebec, Canada. Patients were enrolled between February 2015 and September 2015. Participants were eligible if they were 18 years and older, were mechanically ventilated and had received more than 72 hours of regular intermittent or continuous infusion of opioids. Patients were excluded if they were unable to speak English or French, had physical communication barriers, suffered from severe brain injury defined as Glasgow Coma Scale (GCS) of 8 or less, or moderate brain injury (GCS 9 to 12) with elevated intracranial pressure (ICP > 20 mmHg requiring osmotherapy). Other exclusion criteria included imminent and predictable death, active neurological condition such as status epilepticus, encephalopathy, chronic substance abuse (chronic alcohol use defined as ≥ 2 drinks per day and/or ≥ 14 drinks per week for men and 9 drinks per week for women, regular use of heroin, GHB, cocaine or amphetamines), chronic use of opioids prior to ICU admission, spinal cord injury, and extubation during the first 72 hours. For each enrolled patient and per each opioid weaning episode, presence of IWS was assessed by a qualified ICU physician or senior resident according to the 5th edition of Diagnostic and Statistical Manual of Mental Disorders (DSM-V) criteria for opioid withdrawal.
Results: The population consisted mostly of males (74.1%) with a mean age of 50 years. The mean APACHE II score was 23 upon ICU admission. The overall incidence of IWS was 16.7% (95% CI, 6-27). Potential risk factors of IWS included higher doses and longer exposure to opioid. The median cumulative opioid dose prior to weaning was higher in patients with IWS (245.72 mcg/kg vs. 169.39 mcg/kg, fentanyl equivalent). Patients with IWS were also exposed to opioids for a longer period of time as compared to patients without IWS (151 hours vs.125 hours). [PPW2] However, these results were not statistically significant.
Conclusions: IWS was frequently observed in mechanically ventilated, critically ill ICU patients. Further studies are needed to confirm these preliminary results.


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