Sadra Medical Journal

The Effect of Implementing Pain, Agitation, and Delirium Control Protocol on Outcomes of Critically Ill Patients with a History of Drug Abuse in Intensive Care Units

Document Type : Original Article

Authors

Farid Zand 1
Golnar Sabetian Jahromi 2
Bita Hojatpanah Montazeri 3
Hosseinali Khlaili 4
Mansour Masjedi 5
Naeimeh Assadat Asmarian 6
Fateme Safari 7
Atefe Moradi 7

1 Professor of Critical Care Medicine, Department of Anesthesiology, Anesthesiology and Critical Care Research Center, Shiraz University of Medical Sciences, Shiraz, Iran

2 Associate Professor of Critical Care Medicine, Department of Anesthesiology, Trauma Research Center, Shahid Rajaee (Emtiaz) Hospital, Shiraz University of Medical Sciences, Shiraz, Iran

3 Anesthesiologist, Anesthesiology and Critical Care Research Center, Shiraz University of Medical Sciences, Shiraz, Iran

4 Associate Professor of Neurosurgery, Department of Neurosurgery, Trauma Research Center, Shahid Rajaee (Emtiaz) Trauma Hospital, Shiraz University of Medical Sciences, Shiraz, Iran

5 Associate Professor of Critical Care Medicine, Department of Anesthesiology, Anesthesiology and Critical Care Research Center, Shiraz University of Medical Sciences, Shiraz, Iran

6 PhD of Biostatistics, Anesthesiology and Critical Care Research Center, Shiraz University of Medical Sciences, Shiraz, Iran

7 MSc of nursing, Shahid Rajaee (Emtiaz) Hospital, Shiraz University of Medical Sciences, Shiraz, Iran

https://doi.org/10.30476/smsj.2022.90406.1230
Abstract
Introduction: Drug abuse is a major concern, leading to inappropriate control of pain, agitation, and delirium. In the current study, we aimed to evaluate the effect of implementing Pain, Agitation, and Delirium (PAD) control protocol on the outcomes of critically ill patients with a history of drug abuse in the intensive care unit (ICU).
Methods: In this experimental study, 44 opioid-dependent patients (18 years and older) were included. The pain was assessed by the Behavioral Pain Scale (BPS) per hour, the level of sedation was evaluated by the Richmond Agitation Sedation (RASS) per hour, and Delirium was measured every 8 hours by the Confusion Assessment Method (CAM-ICU). Based on the type and dose of the consumed drug and the way it was used, the dose of methadone was calculated. In addition, possible symptoms of withdrawal syndrome and excessive use were assessed every hour by the intensive care unit nurse.
Results: The ICU stay length was 17 days in the control group and seven days in the intervention group. Patients in the intervention group received lower doses of Methadone and Propofol compared to the control group during 72 hours and lower doses of fentanyl after 48 and 72 hours (p<0.05). In addition, patients with acceptable limits of pain and sedation were significantly more in quantity in the intervention group compared to the control group (p=0.001 and p=0.05, respectively).
Conclusion: Implementing PAD protocol, along with appropriate medical therapy, can greatly help improve the medical care provided by the ICU team. 

Keywords

Agitation
Delirium
Intensive care unit (ICU)
Opium
Pain
  1. Noohi S, Azar M, Behzadi AH, Sedaghati M, Panahi SA, Dehghan N, et al. A Comparative Study of Characteristics and Risky Behaviors Among the Iranian Opium and Opium Dross Addicts. Journal of Addiction Medicine. 2011; 5(1): 74-8.
  2. de Wit M, Wan SY, Gill S, Jenvey WI, Best AM, Tomlinson J, et al. Prevalence and impact of alcohol and other drug use disorders on sedation and mechanical ventilation: a retrospective study. BMC anesthesiology. 2007; 7(1): 3.
  3. Suchyta M, Hopkins R, Beck C, Jephson A. Prevalence of alcohol abuse, drug abuse and psychiatric disorders in icu patients. Am J Resp Crit Care Med. 2006; 3: A737.
  4. Tetrault JM, O'Connor PG. Substance Abuse and Withdrawal in the Critical Care Setting. Critical Care Clinics. 2008; 24(4): 767-88.
  5. Tollisen KH, Bjerva M, Hadley CL, Dahl GT, Högvall LM, Sandvik L, et al. Substance abuse-related admissions in a mixed Norwegian intensive care population. Acta Anaesthesiologica Scandinavica.n/a(n/a).
  6. Ahmadi J, Fallahzadeh H, Salimi A, Rahimian M, Salehi V, Khaghani M, et al. Analysis of opium use by students of medical sciences. Journal of Clinical Nursing. 2006; 15(4): 379-86.
  7. McCabe S. Substance Use and Abuse in Trauma: Implications for Care. Critical Care Nursing Clinics. 2006; 18(3): 371-85.
  8. Amato L, Davoli M, Minozzi S, Ferroni E, Ali R, Ferri M. Methadone at tapered doses for the management of opioid withdrawal. The Cochrane Library. 2013.
  9. Fard GS, Zand F, Khalili F. Implementation of a protocol to control pain, agitation and delirium in the patients admitted to intensive care unit with opioid drug dependency: A feasibility study. BIOMEDICAL RESEARCH-INDIA. 2017;28:3666-71.
  10. Drew DJ, Marie BJS. Pain in critically ill patients with substance use disorder or long-term opioid use for chronic pain. AACN advanced critical care. 2011; 22(3): 238-54.
  11. Tan CM, Camargo M, Miller F, Ross K, Maximous R, Yung P, et al. Impact of a nurse engagement intervention on pain, agitation and delirium assessment in a community intensive care unit. BMJ Open Qual. 2019; 8(3): e000421-e.
  12. Robinson BR, Mueller EW, Henson K, Branson RD, Barsoum S, Tsuei BJ. An analgesia–delirium–sedation protocol for critically ill trauma patients reduces ventilator days and hospital length of stay. Journal of Trauma and Acute Care Surgery. 2008; 65(3): 517-26.
  13. Pisani MA, Murphy TE, Araujo KL, Slattum P, Van Ness PH, Inouye SK. Benzodiazepine and opioid use and the duration of ICU delirium in an older population. Critical care medicine. 2009; 37(1): 177.
  14. Ouimet S, Kavanagh BP, Gottfried SB, Skrobik Y. Incidence, risk factors and consequences of ICU delirium. Intensive care medicine. 2007; 33(1): 66-73.
  15. Sessler CN, Varney K. Patient-focused sedation and analgesia in the ICU. Chest. 2008 Feb 1;133(2):552-65.
  16. Skrobik Y, Ahern S, Leblanc M, Marquis F, Awissi DK, Kavanagh BP. Protocolized intensive care unit management of analgesia, sedation, and delirium improves analgesia and subsyndromal delirium rates. Anesthesia & Analgesia. 2010; 111(2): 451-63.
  17. Barr J, Fraser GL, Puntillo K, Ely EW, Gélinas C, Dasta JF, et al. Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit. Critical care medicine. 2013; 41(1): 263-306.
  18. Arroyo-Novoa CM, Figueroa-Ramos MI, Puntillo KA. Occurrence and Practices for Pain, Agitation, and Delirium in Intensive Care Unit Patients. P R Health Sci J. 2019; 38(3): 156-62.
  19. Coleman EA, Honeycutt G, Ogden B, McMillan DE, O'Sullivan PS, Light K, et al. Assessing substance abuse among health care students and the efficacy of educational interventions. Journal of Professional Nursing. 1997; 13(1): 28-37.
  20. Mansouri P, Javadpour S, Zand F, Ghodsbin F, Sabetian G, Masjedi M, et al. Implementation of a protocol for integrated management of pain, agitation, and delirium can improve clinical outcomes in the intensive care unit: A randomized clinical trial. Journal of Critical Care. 2013; 28(6): 918-22.
  21. Luetz A, Balzer F, Radtke FM, Jones C, Citerio G, Walder B, et al. Delirium, sedation and analgesia in the intensive care unit: a multinational, two-part survey among intensivists. PloS one. 2014; 9(11): e110935-e.
  22. Penuela MC, Law M, Chung H-O, Faught BE, Tsang JLY. Impact of a multifaceted and multidisciplinary intervention on pain, agitation and delirium management in a Canadian community intensive care unit: a quality improvement study protocol. CMAJ Open. 2019; 7(2): E430-E4.
  23. Pandharipande PP, Patel MB, Barr J. Management of pain, agitation, and delirium in critically ill patients. Pol Arch Med Wewn. 2014; 124(3): 114-23.
  24. Fischer F, Lange K, Klose K, Greiner W, Kraemer A. Barriers and Strategies in Guideline Implementation-A Scoping Review. Healthcare (Basel). 2016; 4(3): 36.
  25. Devlin JW, Fong JJ, Howard EP, Skrobik Y, McCoy N, Yasuda C, et al. Assessment of delirium in the intensive care unit: nursing practices and perceptions. American Journal of Critical Care. 2008; 17(6): 555-65.
  26. Barnes-Daly MA, Phillips G, Ely EW. Improving Hospital Survival and Reducing Brain Dysfunction at Seven California Community Hospitals: Implementing PAD Guidelines Via the ABCDEF Bundle in 6,064 Patients. Crit Care Med. 2017; 45(2): 171-8.
  27. Schiavenato M, Craig KD. Pain assessment as a social transaction: beyond the “gold standard”. The Clinical journal of pain. 2010; 26(8): 667-76.
  28. Davidson JE, Harvey MA, Bemis-Dougherty A, Smith JM, Hopkins RO. Implementation of the Pain, Agitation, and Delirium Clinical Practice Guidelines and Promoting Patient Mobility to Prevent Post-Intensive Care Syndrome. Critical Care Medicine. 2013; 41(9): S136-S45.
  29. Skrobik Y, Chanques G. The pain, agitation, and delirium practice guidelines for adult critically ill patients: a post-publication perspective. Annals of intensive care. 2013 Dec;3(1):1-9.-.
  30. Georgiou E, Hadjibalassi M, Lambrinou E, Andreou P, Papathanassoglou ED. The impact of pain assessment on critically ill patients’ outcomes: a systematic review. BioMed research international. 2015 Oct 19;2015.
  31. Sessler CN, Gosnell MS, Grap MJ, Brophy GM, O'neal PV, Keane KA, et al. The Richmond Agitation–Sedation Scale: validity and reliability in adult intensive care unit patients. American journal of respiratory and critical care medicine. 2002; 166(10): 1338-44.
  32. Fard GS, Zand F, Khalili F. Implementation of a protocol to control pain, agitation and delirium in the patients admitted to intensive care unit with opioid drug dependency: A feasibility study. BIOMEDICAL RESEARCH-INDIA. 2017;28:3666-71.
  33. Robinson BRH, Mueller EW, Henson K, Branson RD, Barsoum S, Tsuei BJ. An Analgesia–Delirium–Sedation Protocol for Critically Ill Trauma Patients Reduces Ventilator Days and Hospital Length of Stay. Journal of Trauma and Acute Care Surgery. 2008; 65(3): 517-26.
  34. Brattebø G, Hofoss D, Flaatten H, Muri AK, Gjerde S, Plsek PE. Effect of a scoring system and protocol for sedation on duration of patients' need for ventilator support in a surgical intensive care unit. Bmj. 2002; 324(7350): 1386-9.
  35. Brook AD, Ahrens TS, Schaiff R, Prentice D, Sherman G, Shannon W, et
    Effect of a nursing-implemented sedation protocol on the duration of mechanical ventilation. Critical care medicine. 1999; 27(12): 2609-15.
  36. Radtke FM, Heymann A, Franck M, Maechler F, Drews T, Luetz A, et al. How to implement monitoring tools for sedation, pain and delirium in the intensive care unit: an experimental cohort study. Intensive Care Medicine. 2012; 38(12): 1974-81.
Sadra Medical Journal
Volume 10, Issue 1
January 2022
Pages 23-36

Home

Guide for Authors

Submit Manuscript

Guide for Reviewers

Contact Us