Opioid and Benzodiazepine Iatrogenic Withdrawal Syndrome in Patients in the Intensive Care Unit

Abstract

Iatrogenic withdrawal syndrome is an increasingly recognized issue among adult patients in the intensive care unit. The prolonged use of opioids and benzodiazepines during the intensive care unit stay and preexisting disorders associated with their use put patients at risk of developing iatrogenic withdrawal syndrome. Although research to date is scant regarding iatrogenic withdrawal syndrome in adult patients in the intensive care unit, it is important to recognize and adequately manage iatrogenic withdrawal syndrome in order to prevent possible negative outcomes during and after a patient’s intensive care unit stay. This article discusses in depth 8 studies of iatrogenic withdrawal syndrome among adult patients in the intensive care unit. It also addresses important aspects of opioid and benzodiazepine iatrogenic withdrawal syndrome, including prevalence, risk factors, and assessment and considers its prevention and management.

Analgesia and sedation in patients with ARDS

“…Opioids with fast-onset, dose-dependent effects, and ability to reduce excessive respiratory drive remain the analgesic mainstay in ARDS [46]. However, they are not without adverse effects: (1) immunosuppression, (2) drug accumulation resulting in prolonged sedation and respiratory depression that may affect ventilator liberation, (3) tolerance within 48 h, (4) withdrawal signs after discontinuation [47], (5) hyperalgesia and chronic pain syndromes with prolonged use, and (6) ileus potentially resulting in increased abdominal pressure and subsequent worsening of respiratory mechanics. Although not rigorously evaluated in ARDS, non-opioid analgesics (e.g., paracetamol, ketamine, and nefopam) used in a multimodal fashion, may reduce opioid use and their Time to offset can be prolonged for hour-days in patients receiving high-dose infusions for > 3 days, particularly in the face of obesity, end-stage renal disease, and/or end-stage liver disease Risk of hypokalemia, hypernatremia, hypochloremic metabolic alkalosis side effects, but also improve pain control in critically ill adults [2,48].…”

Incidence patterns of nervous system diseases after carbon monoxide poisoning: a retrospective longitudinal study in South Korea from 2012 to 2018

“…However, considering the SIR of common neurological diseases according to the history of admission to the ICU, the risks of neurological diseases after CO poisoning were not always higher in the ICU admitted group than in the non-ICU admitted group. Because of the withdrawal of sedatives or analgesics after the period of intensive treatment (e.g., mechanical ventilation and invasive monitoring in the ICU), the risk of disorders of initiating and maintaining sleep in the ICU admitted group might be higher [ 25 ]. In addition, anoxic brain injury is also a typical sequela after CO poisoning, along with cardiac arrest, and it is assumed that anoxic brain injury could occur frequently in patients who are in a severe enough condition to be admitted to the ICU after CO poisoning [ 13 ].…”

“…Because of the withdrawal of sedatives or analgesics after the period of intensive treatment (e.g., mechanical ventilation and invasive monitoring in the ICU), the risk of disorders of initiating and maintaining sleep in the ICU admitted group might be higher. 25 In addition, anoxic brain injury is also a typical sequela after CO poisoning, along with cardiac arrest, and it is assumed that anoxic brain injury could occur frequently in patients who are in a severe enough condition to be admitted to the ICU after CO poisoning. 13 Nevertheless, in patients who were not admitted to the ICU, the risk of developing tension-type headache and post-zoster neuralgia was higher than in the patient group admitted to the ICU, as well as in the general population.…”

Clinical Utility of the Behavioral Pain Assessment Tool in Patients Admitted in the Intensive Care Unit

“…Owing to opioid crisis and opioid withdrawal syndrome, further research is needed to study the impact of implementation of BPAT to guide pain assessment and management in either adjusting the opioid daily dosages or efficacy of an opioid-sparing ICU protocol. 29 , 30 …”