Professor of Pharmacy Practice Massachusetts College of Pharmacy, Massachusetts
Introduction: There is a paucity of data comparing opioid analgesia in critically ill patients receiving mechanical ventilation (MV). The SCCM PADIS guidelines suggest fentanyl or hydromorphone for most MV patients needing analgesia, but few studies compare patient-centered outcomes with infusions of these agents. We evaluated the difference between continuous fentanyl and hydromorphone infusions in MV patients, hypothesizing that fentanyl would be associated with increased 28-day MV-free survival.
Methods: This IRB-approved, single-center, retrospective cohort study evaluated adult MV patients with a SAS goal of 3-4 admitted to an intensive care unit at a community-based teaching hospital. Patients received either a hydromorphone or fentanyl infusion for analgesia during MV from May 2022 to May 2023. The primary endpoint was MV-free survival within 28 days of intubation. Secondary endpoints included cumulative and hourly opioid dose during MV expressed in fentanyl equivalents, duration of MV, and time within goal pain score and sedation score during MV. Chi-square tests were used for categorical data and Kruskal-Wallis tests were used for continuous data. Data were analyzed using RStudio.
Results: A total of 239 patients were included with 145 receiving fentanyl and 94 receiving hydromorphone. Baseline characteristics were similar between the groups with a median age of 66 years, weight of 78 kg, and 33% were female. More patients in the hydromorphone group had a diagnosis of chronic pain at baseline (60% vs 45%, p = 0.04). Median 28-day MV-free survival was 22 days for the fentanyl group compared to 21 days for the hydromorphone group (p = 0.37). Median cumulative fentanyl-equivalent opioid dose during MV was higher in patients given fentanyl infusions compared to hydromorphone-treated patients (4269 mcg (IQR 1823–8155 mcg) and 2448 mcg (IQR 1012–4926 mcg) (p < 0.001), respectively). Fentanyl-treated patients received a higher hourly average dose (56 mcg/hr (IQR 41-75 mcg/hr) and 37 mcg/hr (IQR 29-51 mcg/hr) (p < 0.001), respectively). Duration of MV and time at goal pain and sedation score were similar between groups.
Conclusions: Fentanyl infusions in MV patients resulted in similar 28-day MV-free survival, but hydromorphone was associated with a significant reduction in opioid exposure.
