Abstract Introduction Prolonged, high-dose opioid infusions in mechanically ventilated patients are independently associated with delirium, development of opioid tolerance, and risk of iatrogenic withdrawal once discontinued. Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in the ICU recommend minimizing continuous opioid infusions to reduce these risks. However, compliance with these recommendations has not been widely evaluated. We hypothesized that continuous fentanyl use remains high, and daily doses increase as patients are on prolonged infusions. Methods This retrospective cohort study evaluated adult patients receiving mechanically ventilation for ≥24 hours at a tertiary care medical intensive care unit (ICU) from 01/02/2015 - 07/06/2025. Electronic health record medication administration data were extracted to analyze patterns of IV fentanyl use. We evaluated the proportion of patient-ventilator-days with fentanyl infusions and the median daily fentanyl infusion dose. Among patients receiving 48 hours of continuous fentanyl infusion, total daily dose was calculated in mcg per 24 hours and stratified into quartiles based on common infusion rates, ranging from daily average 50 mcg/hr (1-1199 mcg/day) to average 150 mcg/hr (3600 mcg/day). McNemar’s test was used to compare the proportion of patients on high-dose (3600 mcg/day) fentanyl infusions on day 1 vs day 7, among those receiving at least 7 days. Results Among 14,698 medical ICU patients mechanically ventilated for ≥24 hours, 77.6% (11,406) received any fentanyl infusion. The median duration of mechanical ventilation was 2.8 days (IQR 1.5-5.9), with fentanyl infusions given on 56.1% of 84,740 total patient-ventilator-days. Among patient-ventilator days that received fentanyl infusions, the median daily dose was 1,617 (IQR 757-2849) mcg/day, equivalent to a daily average continuous rate of 67.4 mcg/hr. Among 1,776 patients on at least 7 days of continuous fentanyl, 16.4% were on high dose (3600 mcg/day) on fentanyl infusion day 1, and 23.8% were on high dose on day 7 (McNemar’s χ² = 37.91, p 0.01). Figure 1 demonstrates proportion of patients on fentanyl dose quartiles per day of infusion. Conclusion In this large study of mechanically ventilated patients, 75% of patients ever received a fentanyl infusion. Among patients who received prolonged mechanical ventilation and fentanyl infusions, the proportion who received high dose fentanyl increased with time. This suggests opportunities to improve adherence to guideline recommendations for minimizing continuous opioid infusions. Additional work is warranted to identify patients on prolonged high dose infusions and promote implementation of opioid-sparing strategies among these mechanically ventilated patients. This abstract is funded by: NIH T32-HL007749-33
Hechtman et al. (Fri,) studied this question.