RESUMO
The management of sedation in critically ill adults poses a unique challenge to clinicians. Dexmedetomidine, an α2 agonist, has a unique mechanism and favorable pharmacokinetics, making it an attractive intravenous option for sedation and delirium in the intensive care unit. However, patients may be at risk for withdrawal with prolonged use, adding to the complexity of sedation and agitation management in this patient population. Enteral α2 agents have the benefit of cost savings and ease of administration, thus playing a role in the ability to decrease intravenous sedative use and prevent dexmedetomidine withdrawal. Clonidine and guanfacine are the two most common enteral α2 agents utilized for this purpose, however, there is a paucity of evidence regarding the comparative benefit between the two agents. The decision to use one vs the other agent should be determined based on their differing pharmacology, pharmacokinetics, and side effect profile. The most effective dosing strategy for these agents is also unknown. Ultimately, more robust literature is required to determine enteral α2 agonists place in therapy. This narrative review evaluates the currently available literature on the use of α2 agonists in critically ill adults with an emphasis on sedation, delirium, and withdrawal.
RESUMO
INTRODUCTION: The 2018 Pain, Agitation/Sedation, Delirium, Immobility, and Sleep guidelines from the Society of Critical Care Medicine recommend opioids as a first-line treatment option for non-neuropathic pain among critically ill adults and prioritize pain management optimization before the administration of sedatives. Although analagosedation is recommended, the downstream effects, such as intensive care unit (ICU)-acquired opioid dependence, are not well described. The purpose of this study is to determine the impact of continuous infusions of opioids for mechanically ventilated patients prescribed opioids on discharge. METHODS: This was a single-center, retrospective chart review of mechanically ventilated patients admitted to the medical ICU at a tertiary medical center from July 1, 2018 to June 30, 2019. The primary objective of this study was to compare the incidence of opioid prescriptions at discharge between those who received opioid infusions versus intermittent administrations. Secondary objectives included risk factors for receiving opioid prescriptions at discharge and readmission within 90 days with an active opioid prescription and/or a diagnosis of opioid use disorder. RESULTS: A total of 100 patients were included. There was no statistically significant difference in the incidence of opioid prescriptions at discharge between the groups (p = 0.933). Only one patient was readmitted within 90 days with documented opioid use disorder and 11 patients with prescription opioids on their home medication list. A best-fit logistic regression model including the type of opioid administration (p = 0.275), length of stay (p = 0.018), and opioid dose (p = 0.137) showed that length of stay was the only significant predictor of discharge opioid prescribing. CONCLUSION: The incidence of opioid prescriptions at discharge for critically ill, mechanically ventilated patients did not differ based on opioid administration strategy. ICU length of stay appears to be a predictive factor of opioid discharge prescriptions.