Critical Care Medicine: May 2016 - Volume 44 - Issue 5 - p
973–980
Zeiler, FA et al
Objective: To characterize analgesic administration in
neurocritical care. Design: ICU pharmacy database analgesic delivery audits
from five countries. A 31-question analgesic agent survey was constructed,
validated, and e-distributed in four countries. Setting: International
multicenter neuro-ICU database audit and electronic survey. Patients: Six ICUs
provided individual, anonymized analgesic delivery data in primary neurological
diagnosis patients. Prescriber surveys were disseminated by neurocritical care
societies. Interventions: None. Measurements and Main Results: Analgesic
delivery data from 173 patients in French, Canadian, American, and Australian
and New Zealand ICUs suggest that acetaminophen/paracetamol is the most common
first-line analgesic (49.1% of patients); opiates are the “second line” in
31.5% of patients; however, 33% patients received no second agent. In the 2.3%
with demyelinating disease, gabapentin was the most likely second analgesic
(50.0%). Third-line analgesics were scarce across sites and neuropathologies.
Few national or regional differences were found. The analgesic preference
rankings noted by the 95 international physicians who completed the survey
matched the audits. However, self-reported analgesic prescription rates were
much higher than pharmacy records indicate, with self-reported prescribing of
both acetaminophen/paracetamol and opiates in 97% of patients and gabapentin in
45% of patients. Third-line analgesic variability appeared to be driven by
neuropathology; ibuprofen was preferred for traumatic brain injury,
postcraniotomy, and thromboembolic stroke patients, whereas
gabapentin/pregabalin were favored in subarachnoid hemorrhage, intracranial
hemorrhage, spine, demyelinating disease, and epileptic patients. Conclusions:
Opiates and acetaminophen are preferred analgesic agents, and gabapentin is a
contextual third choice, in neurocritically ill patients. Other agents are
rarely prescribed. The discordance in physician self-reports and objective
audits suggest that pain management optimization studies are warranted.
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