Ventilator compliance drives transition from fentanyl to hydromorphone in critically ill patients

The transition from continuous infusion fentanyl to continuous infusion hydromorphone in critically ill patients is motivated by ventilator compliance, better patient-specific pharmacokinetics, and reduction in sedative exposure, according to a study.

A single-centre, prospective, observational analysis was conducted to identify the rationales for the transition from continuous infusion fentanyl to continuous infusion hydromorphone in adult intensive care unit (ICU) patients who were transitioned from fentanyl to hydromorphone.

The primary endpoint was to determine the main reasons for the transition. Secondary endpoints included minor reasons for transition, transition dosing, changes in continuous sedative requirements and level of sedation.

Forty-six patients met the inclusion criteria. Ventilator compliance (28.3 percent) was the major reason for transition, followed by tachyphylaxis or better pain control (19.6 percent) and reduction in sedatives (13.0 percent). For minor reasons, the most common ones were reduction in sedative exposure (47.8 percent), opioid rotation (32.6 percent) and obesity (30.4 percent).

The transition was from a median fentanyl rate of 100 µg/h to 1 mg/h of hydromorphone. A reduction in the percentage of patients requiring the use of continuous sedatives occurred in the 24 hours following transition (p=0.005), but patients were more deeply sedated (p=0.02).

“The 2013 Society of Critical Care Medicine guidelines for the management of pain, agitation and delirium in adult ICU patients recommend intravenous opioids as first-line therapy to treat non-neuropathic pain,” the investigators said. “There is a paucity of literature describing possible benefits of utilizing specific opioids over others in ICU patients.”