(1354) Improving Opioid Sedation for Intubated Patients in the Medical Intensive Care Unit (iOSIP-MICU)

Introduction: Implementation of PADIS guidelines and the A-F Bundle requires team efforts and site-specific adaptations. In our Medical ICU, a multidisciplinary team proposed two interventions. First, a mandatory nightly rounding policy was implemented to address the lack of defined avenue for communicating vent weaning plans between physician team, RNs and RTs. Second, to address the number of patients receiving high-dose fentanyl infusions, education efforts were directed at RNs and physicians. The ordering and use of PRN fentanyl boluses was encouraged, to ameliorate fentanyl’s long context-sensitive half-time and to avoid the development of tolerance, both of which may tend to cause prolonged sedation, leading to failed SBTs and longer duration of mechanical ventilation.

Methods: We used historical baseline data in the two months prior to the study period, for each patient ventilator-day recording doses and routes of fentanyl given, frequency of SATs and SBTs, and total duration of mechanical ventilation (n=295). The same data was obtained at 3 months (n=126) and 6 months (n=141). Comparisons were performed using Fisher’s exact test and Wilcoxon rank-sum test. Events for each patient ventilator-day were considered independently, with no corrections for multiple comparisons.

Results: The mean percent of total fentanyl given as boluses increased from 14% at baseline to 33% at Month 3 (p < 0.01) and 42% at Month 6 (p < 0.01). Mean total dose of fentanyl per 24 hours decreased from baseline of 628 mcg (IQR 0-924) to 495 at Month 3 (IQR 0-600, p=0.16) and 330 at Month 6 (IQR 0-219, p< 0.01). While not statistically significant, there was a trend toward decreased mean duration of mechanical ventilation, from 72h at baseline (IQR 20-87) to 55h (IQR 20-67) at Month 3 (p=0.48) and 44h (IQR 16-60) at Month 6 (p=0.13). The rates of daily SATs and SBTs were not significantly different.

Conclusions: Mandatory nightly rounding and education efforts emphasizing the use of PRN fentanyl boluses resulted in a significant decrease in the mean total dose of fentanyl received and the proportion given as a bolus, which coincided with a trend toward decreased mean duration of mechanical ventilation. Further work is needed to clarify whether the use of different routes of fentanyl affects patient-centered outcomes.