The analgesia-first sedation approach is crucial to adequate pain management in critically ill oncology patients on mechanical ventilation. The approach ensures adequate pain management, and avoids oversedation and delirium, according to a study presented at the 2016 ASCO Quality Care Symposium.1
More than 60% of patients with cancer experience chronic pain. Furthermore, pain assessment is challenging in oncology patients on mechanical ventilation due to sedation. As a result, pain is often undertreated. This study sought to determine the need for a nurse driven pain-sedation protocol in ventilated oncology patients.
The Society of Critical Care Medicine (SCCM) recommends managing pain with intermittent bolus doses rather than continuous infusions; however, appropriate doses and means of titration are vague, which means patients are at risk for over-sedation, prolonged ventilation, and delirium.
For this retrospective study, the researchers collected data on analgesics, sedatives, dosing, and duration of mechanical ventilation from 51 mechanically ventilated oncology patients admitted to hospital between December 2013 and June 2015. Sedative titration was evaluated relative to analgesics administered by the nursing staff.
Results showed that 94% of patients received fentanyl at an average rate of 142 mcg/hr (3413 mcg/day); 57% of patients received midazolam at an average rate of 1.25 mg/hr, while 54% of patients received propofol (15.5 mcg/hr). Use of sedatives and analgesics was determined to be concurrent.
In addition, sedative doses were increased without prior adjustment of analgesics in 49% of patients, implicating that pain was not addressed. Nurse neurologic assessment of oversedated patients was associated with longer duration of mechanical ventilation (9.7 days).
The researchers conclude that this study demonstrates the need for a structured pain-sedation protocol to reduce oversedation, adequately treat pain, and potentially decrease delirium and prolonged mechanical ventilation.
1. Kennedy M, Bullick D, Barniak S, McGovern J, Patel T, Hoag J. Reducing pain, agitation and delirium to optimize outcomes in mechanically ventilated critically ill oncology patients. J Clin Oncol. 2016;34(suppl7S):Abstract 233.