Patterns of prescribing and administering drugs for agitation and pain in patients in a surgical intensive care unit

OBJECTIVES: To describe the variety of medications prescribed along with the doses administered and routes of administration, and to delineate the clarity of orders written and the accuracy of transcription of drugs used for sedation, anxiety, pain, and neuromuscular blockade in a surgical intensive care unit (ICU). DESIGN: A prospective, observational study of drug-related information collected from forms used by physicians and nurses. SETTING: Three adult surgical ICUs at an academic medical center. Patients were admitted to a surgical service and co-managed by the surgical ICU team and primary surgical service. PATIENTS: Consecutive patients admitted to all of these units from September 1992 to January 1993. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Information on prescribing and administering sedatives, analgesics, and neuromuscular blocking drugs was obtained from data collected on 221 patients. A total of 202 (91%) patients received, on average, 1.9 +/- 1.4 study drugs (range 0 to 9) in a wide variety of combinations. There were 2,103 total doses administered from 448 drug orders. Ninety percent of study drug orders were written for administration on an "as-needed" basis; in 42% of these orders, the indication for use was not specified. On average, only 27% of the maximal allowable daily dose was administered; this number ranged from 15% for hydromorphone to 77% for chlordiazepoxide. Morphine sulfate, the most commonly prescribed drug, was ordered primarily for intravenous administration in 84% of patients. Morphine sulfate was prescribed using 19 different doses (written as a range of doses) and 13 different dosing intervals. Transcription discrepancies were observed in 17% of orders. In 2.7% of doses, the actual dose that was administered could not be determined. CONCLUSIONS: A wide variety of sedatives and analgesics are frequently used in surgical ICU patients. These agents are often ordered on an "as-needed" basis using a range of doses, sometimes without adequate directions about the indication for their use. Daily doses received are significantly less than their maximum allowable daily doses. Orders for these medications are sometimes transcribed and charted incorrectly. In contrast, neuromuscular blocking agents are not commonly prescribed. Future studies are needed to improve order writing of these agents, and to determine the criteria used by physicians and nurses in the selection and administration of these agents, the outcomes of therapy, and the most cost-effective regimen.