Incidence and clinical manifestation of iatrogenic opioid withdrawal syndrome in mechanically ventilated patients

Abstract

Objective

The incidence of iatrogenic opioid withdrawal syndrome (IOWS) in mechanically ventilated adults has been questioned in settings driven by analgosedation strategies. This study aimed to describe the incidence, risk factors and clinical impact of IOWS in mechanically ventilated adults.

Methods

This prospective, observational study was performed between 1 January and 31 August 2018. IOWS was identified based on the presence of at least three signs or symptoms according to the Diagnostic and Statistical Manual 5th edition (DSM-5) criteria after opioid discontinuation or rate reduction. Incidence of IOWS, patient characteristics, opioid administration, and the impact of IOWS on the duration of mechanical ventilator and length of stay in the intensive care unit (ICU) were collected.

Results

Thirteen out of 55 patients (23.6%) manifested withdrawal symptoms. Two patients in the non-withdrawal group also developed hypertensive urgency after opioid discontinuation. Patients who received rapid once-daily weaning, especially rate reduction more than 50 µg as fentanyl equivalent per hour, were associated with IOWS. However, there was no statistically significant difference in ventilator-free days and ICU-free days.

Conclusions

These findings showed that approximately one-fourth of mechanically ventilated patients who received opioid infusion experienced IOWS. Monitoring for IOWS is recommended especially in patients who received rapid weaning rate of opioids. Future studies to develop IOWS assessment tools with the change of hemodynamic parameters should be performed.

Trial registration

This trial was registered in ClinicalTrials.gov: identifier NCT03374722, date of registration 15 December 2018.

Keywords:

• Opioids
• withdrawal
• adults
• mechanical ventilator

Transparency

Declaration of funding

This study was supported by the Faculty of Pharmacy, Mahidol University.

Declaration of financial/other relationships

No potential conflict of interest was reported by the authors. CMRO peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Author contributions

All authors meet the International Committee of Medical Journal Editors (ICMJE) criteria for authorship for this article. S.T., P.D. and C.S. were involved in the conception and design of the study. S.T. and V.T. were involved in data collection. S.T., P.D. and C.S. were involved in the analysis, interpretation of the data and drafting of the work. C.S. was responsible for the manuscript correction. All authors approved of the final version of this manuscript.

Suthinee Taesotikul, Pitchaya Dilokpattanamongkol, Viratch Tangsujaritvijit and Chuthamanee Suthisisang

Acknowledgements

We would like to thank Dr. Nuj Tontisirin for technical advice, Dr. Dujrudee Chinwong for statistical expertise and Miss Auranee Trisataya for statistical assistance. We are also grateful to all medical residents and fellows, intensivists, critical care nurses and clinical pharmacists at Ramathibodi Hospital for their assistance in completing the study.