(924) Evaluation of Intravenous Opioid Exchange in Critically Ill Intubated Patients

Introduction: Opioids are the foundation of analgosedation in the ICU. Although evidence is limited, an opioid exchange may mitigate tolerance and opioid induced hyperalgesia in patients requiring prolonged intubation. This study seeks to evaluate the impact of opioid exchange on morphine milligram equivalent (MME) requirements in intubated patients.

Methods: This retrospective analysis was conducted at an academic medical center in adult ICU patients who were intubated for at least five days and changed from a fentanyl infusion to a hydromorphone infusion. Pertinent exclusion criteria was intubation for more than 24 hours at an outside facility prior to transfer. The primary outcome was total daily MME requirements during 0-24 and 24-48 hours before and after the change. Secondary outcomes were percentage of Critical Care Pain Observation Tool (CPOT) scores less than 2, median Richmond Agitation-Sedation Scale (RASS) scores, and sedative requirements during the same time periods.

Results: A total of 61 patients were identified for inclusion. The majority of patients were medical admissions (72%) and the median APACHE II score was 25. Day 7 was the median day of intubation that the change took place. There was a significantly lower median total daily MME during 24 and 48 hours after the exchange compared to 24 and 48 hours before (826 and 864 vs 1365 and 1373, respectively [p < 0.0001 for all comparisons]). There was a significant difference in median percentage of CPOT scores less than 2 at 48 hours after the exchange (100 [100, 100]) compared to 24 hours before (100 [69, 100]) (p=0.0002). There were no differences in median RASS scores. Dexmedetomidine, ketamine, and propofol requirements were similar between time intervals. In patients that received benzodiazepines during 24 (n=25) and 48 hours (n=24) after the exchange, requirements increased compared to 24 hours before (116mg vs 50mg [p=0.0009] and 119mg vs 60mg [p=0.0046], respectively).

Conclusions: In patients requiring prolonged ventilation more than 5 days, changing from fentanyl based analgosedation to hydromorphone reduced total MME requirements 24 and 48 hours after the exchange. Sedative requirements were similar with the exception of increased benzodiazepine requirements.