Survey of critical care pharmacists on sedation and analgesia practices in adult and pediatric patients receiving continuous neuromuscular blocking agents

Abstract

Introduction There is a lack of recommendations regarding sedation/analgesia practices for patients receiving continuous or frequent boluses of neuromuscular blocking agents (NMBAs), which may cause variation among different clinical practice sites. Objectives The primary objective of this study was to determine critical care pharmacist's perceptions and practices regarding sedation/analgesia for patients receiving NMBAs and to compare sedation/analgesia regimens among adult and pediatric populations. Methods A 10‐question survey was provided to critical care pharmacists regarding practice site, comfort using NMBAs, and monitoring practices. Respondents could select all sedation/analgesia regimens they commonly see, would recommend, and would consider inappropriate. Responses from adult and pediatric pharmacists were compared. Results Of the 2435 pharmacists who received the survey, 192 (7.9%) completed the survey. Most respondents practiced in the United States (97.9%), cared for adult patients (60.7%), and worked in a medical intensive care unit (ICU) (81.3%). Most respondents reported monitoring sedation depth (82.6%) with vitals (49%) and bispectral index (30.3%) being the most common methods. The most commonly observed regimens were continuous infusion (CI) benzodiazepine and CI opioid (n = 114, 66.7%), followed by propofol and CI opioid (n = 104, 60.8%). These were also the most commonly recommended regimens (n = 102, 59.6%; n = 108, 63.2%), respectively. Most respondents would not recommend monotherapy regimens. Dexmedatomidine was utilized and recommended significantly more by pediatric pharmacists while propofol was utilzied and recommended more by adult pharmaicsts. Regimens deemed inappropriate were similar between adult and pediatric pharmacists except for dexmedetomidine‐containing regimens which significantly more adult pharmacists deemed inappropriate. Conclusion Despite a lack of guideline recommendations, use of combination therapy with sedation/analgesia was frequently reported; however, the choice of sedation agent was variable. Given concern with the inability to achieve deep sedation with dexmedetomidine and a high response rate recommending/utilizing dexmedetomidine, further research is needed to guide recommendations for providing appropriate sedation/analgesia to patients receiving NMBAs.

Continuing excellence in critical care pharmacy practice, education, and advocacy

“…Critical care pharmacist participation on the multidisciplinary team has also demonstrated considerable benefits in areas such as anticoagulation, 9,10 antimicrobial therapy, 11 pain, agitation and sleep management, 12–14 and overall medication safety 15 . The ICU Liberation Campaign represents bundled interventions conducted by an interdisciplinary team, including a critical care pharmacist that has been associated with improvement in survival, ICU length of stay, and ICU readmission 16 .…”

“…Interpreting complicated pharmacokinetics/pharmacodynamics using advanced therapeutic drug monitoring, 5 evaluation of patient clinical status and organ function, 6 or the ordering and utilization of procedures or laboratory assays to provide optimal pharmacotherapy are now common practice for most critical care pharmacists. 7,8 Critical care pharmacist participation on the multidisciplinary team has also demonstrated considerable benefits in areas such as anticoagulation, 9,10 antimicrobial therapy, 11 pain, agitation and sleep management, [12][13][14] and overall medication safety. 15 The ICU Liberation Campaign represents bundled interventions conducted by an interdisciplinary team, including a critical care pharmacist that has been associated with improvement in survival, ICU length of stay, and ICU readmission.…”