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Comparative Analysis of Sedation and Analgesia Requirements in Trauma Patients Presenting with a Positive Drug Toxicology Screen
Friday April 25, 2025 11:20am - 11:35am EDT
Athena H
    • Title: Comparative Analysis of Sedation and Analgesia Requirements in Trauma Patients Presenting with a Positive Drug Toxicology Screen 
    • Authors: Sydney Kermeen, Sarah Alimenti, Michael Honaker, Kenji Leonard, and Emily Whitehead
    • Objective: Compare analgesia and sedation requirements in trauma patients requiring intubation after presenting with a positive urine drug screen (UDS) and/or serum ethanol level to patients presenting with a negative toxicology screen.
    • Self Assessment Question: True or False: Due to impaired drug metabolism and increased drug tolerance, trauma patients acutely intoxicated with amphetamine, cocaine, PCP, MDMA, or ethanol may have higher opioid requirements during mechanical intubation?
    • Background: Pre-injury illicit substance use and intoxication are predictors of ICU admission and increased analgesia and sedation requirements in patients admitted to the hospital following traumatic injuries. Literature evaluating analgesia and sedation in patients presenting with a positive toxicology screen is limited and further research is warranted to guide treatment.
    • Methods: This was a single-center, retrospective, observational study including adult patients admitted to the surgical intensive care unit (SICU) who were intubated for at least 48 hours following a trauma and presented with either a positive urine drug screen (UDS) for cannabinoids, cocaine, amphetamines, phencyclidine, ecstasy and/or elevated serum ethanol level within the first 24 hours of admission.  Patients were excluded if they had withdrawal of care or were transferred out of the SICU within 48 hours of admission, utilized short acting opiates for at least 30 days or long-acting opiates as a home medication, had a pre-diagnosed psychiatric illness, or utilized pentobarbital, chemical paralysis, or extracorporeal membrane oxygenation during the study period. The control group included patients presenting with both a negative UDS and serum ethanol level. There were two comparator groups: group 1 with both a positive UDS and serum ethanol level, and group 2 with a positive UDS and negative serum ethanol level. The primary outcome was median daily dose of opioid requirements in morphine milligram equivalents until extubation, transfer from SICU, or 30 days. Some of the secondary outcomes included mean daily benzodiazepine use, mean daily dose of continuous sedation, utilization of adjunctive analgesia and sedation agents, length of mechanical ventilation, average daily pain scores, and percentage of time within goal sedation.
    • Results: A total of 151 patients were included in the analysis, with 50 patients each in the UDS(-)/EtOH(-) and USD(+)/(-) groups and 51 patients in the UDS(+)/EtOH(+) group. Baseline characteristics and patient demographics between groups were similar between groups. There were no differences in median daily MME, LME, dexmedetomidine, or ketamine use between groups; however, intoxicated patients in the UDS(+)/EtOH(+) and UDS(+)/EtOH(-) used a significantly higher median dose of propofol (30.9 [21.5, 36.7] and 33.9 [22.7, 50.0]  vs 33.9 [13.7, 33.6] mcg/kg/min). UDS(+)/EtOH(+) and UDS(+)/EtOH(-) groups also used more adjunctive agents (66.7 % and 82.0% vs 46.0%, p=0.0008) and ERAS medications (45% and 47% vs 46%, p=0.0028). Additionally, intoxicated patients achieved lower RASS levels on continuous sedation compared to non-intoxicated patients (-1 [-2.0, 1.0] and -1 [-2.0, 1.0] vs -2 [-2.8, 1.0]). Of note, the incidence of mortality was higher in the non-intoxicated group (7% and 1% vs 11%, p=0.0101). There were no differences in duration of intubation, BPS scores, ICU LOS, hospital LOS, self extubation, or trach placement.
    • Conclusion: Mechanically-ventilated patients with a positive UDS and/or serum ethanol level may not have higher MME or LME requirements. However, multimodal adjunctive analgesia and sedation methods may be warranted.

       sydney.kermeen@ecuhealth.org


Moderators
avatar for Maggie Goode

Maggie Goode

Critical Care Pharmacist, Mobile Infirmary Medical Center
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Presenters
avatar for Sydney Kermeen

Sydney Kermeen

PGY2 Critical Care Resident, ECU Health Medical Center
Sydney Kermeen is originally from Memphis, Tennessee. She received her Bachelor of Science in Chemical Engineering from Christian Brothers University and attended The University of Tennessee Health Science Center College of Pharmacy where she received her Bachelor of Science in Pharmaceutical... Read More →
Evaluators
MM
Friday April 25, 2025 11:20am - 11:35am EDT
Athena H
  Critical Care/Emergency Medicine (CCM), ECU Health Medical Center
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