B55-24 Impact of Analgesia-First Sedation Protocol on Morphine Milligram Equivalents Received by Adult Mechanically Ventilated Patients in the CCU

Abstract Introduction Mechanical ventilation can include the use of analgesics and sedation medications to manage pain, agitation, and assist with ventilator compliance. During the process over-sedation can increase the incidence of Critical Care Unit (CCU) delirium, post-traumatic stress disorder, mortality, and prolonged ventilation, thereby also increasing the risk of pneumonia. Long-term or high-dose opioid use can also increase the risk of developing opioid dependence, tolerance, addiction, and other physiological conditions. Objectives To investigate whether the adoption of a structured analgesia-first sedation protocol can decrease morphine milligram equivalents (MMEs) of analgesics during a CCU stay. Secondarily, to review the impact of the protocol on episodes of delirium and adverse events. Methods A pre-/post- study based on an intent-to-treat design was used to examine the implementation of an analgesia-first sedation protocol as standard care. The change was implemented in the CCUs at two Midwestern hospitals in the United States within the same health system. Distribution differences in hourly MMEs between sample groups were examined using quantile regression (i.e., tau = 10% to 90% by 10%). The model included stabilized inverse propensity score weights to balance baseline covariates (i.e., age, body mass index, sex, and comorbidity status). Results The study sample included 202 patients with 109 (54%) in the pre-group and 93 (46%) in the post-group period. Across both time periods 40% of patients were female, median BMI values were 29, and median patient ages were in the 60’s. There were no marked differences in hourly MMEs for most quantile values, with the largest difference seen at the highest quantile value (Figure); specifically, post-intervention patients in the 90th percentile received 8.9 (95% CI: -22.4, -0.7) fewer MMEs per hour during their CCU stay relative to the pre-group. Documented delirium incidence was higher at 24-hours post-extubation in the post-group (31% vs 51%; delta: 21%, 95% CI: 4%, 37%). Models failed to reveal any significant difference in delirium incidence at 48-hours post-extubation (28% vs 43%; delta 15%, 95% CI: -1, 32%) or adverse events related to sedation between periods. Adverse events (i.e., all tube removals, including self-extubating, chest tube removal, etc.) occurred in 6% of patients pre- vs. 9% post-intervention (delta: 3% (95% CI: -4%, 3%)). Conclusions Study findings demonstrate that an analgesia-first sedation protocol is effective at reducing the number of mechanically ventilated patients receiving high doses of opioids. While important, additional research is still required to better understand its impact on all patient outcomes. This abstract is funded by: None