Iatrogenic Withdrawal Syndrome (IWS) in adult intensive care: a survey of UK healthcare professionals

Eadie, Rebekah, Blackwood, Bronagh, Kalk, Nicola J., Hadfield, Daniel, Dempster, Martin, McAuley, D.F. and McKenzie, Cathrine (2024) Iatrogenic Withdrawal Syndrome (IWS) in adult intensive care: a survey of UK healthcare professionals. European Society of Intensive Care Medicine: LIVES2024, spain, Barcelona, United Kingdom. 05 - 09 Oct 2024. (Submitted)

Abstract

Introduction: intravenous (IV) sedation and opioids are administered to intensive care unit (ICU) patients for anxiety, pain, and somnolence in mechanical ventilation. However, prolonged exposure to high medication doses places patients at significant risk of IWS upon abrupt cessation or rapid tapering of medications.1-3 IWS encompasses a combination of autonomic dysregulation, central nervous system arousal, and gastro-intestinal symptoms. It is associated with adverse clinical outcomes that include prolonged mechanical ventilation, psychological distress, longer hospital and ICU stay, higher morbidity, and elevated healthcare costs.4,5 There are increasing reports of IWS in ICU adults, but how it is recognised by healthcare professionals is less established.

Objective: to determine ICU healthcare professionals’ perspective on incidence, detection and research in IWS in IV sedation and opioid use in adult ICU.
Methods: The survey was registered as a service evaluation without the need for ethics. An online survey was piloted (Survey Monkey), revised and distributed via various professional societies of Irish and UK ICU community, addiction psychiatrists and social media. The survey was open for 16 weeks from 5 February 2023 with reminders sent for completion. Data was analysed using descriptive statistics.

Results: 246 responses were received from ICU health care professionals including nurses 32% (79/246); pharmacists 30% (75/246); medical doctors (consultant-level) 27% (66/246); medical (other) 7% (17/246); allied health professionals 2% (5/246) and other 2% (4/246). Overall, 90% (221/246) indicated that IWS was a clinically important issue for adults in ICU and 80% (198/246) felt that a validated IWS screening tool would be useful for clinical practice. 24% (59/246) reported they were familiar with strategies for prevention and/or treatment of IWS and 13% (31/246) had IWS guidelines available in their ICU. 89% (218/246) stated that there is a need to improve clinical guidance for identification, prevention and treatment of IWS in dult ICUs. With 90% (220/246) reporting that more research is needed to understand the incidence and impact of IWS in adult ICUs.

Conclusion: ICU professionals surveyed indicated that IWS was very common in their clinical practice and a majority reported the need for further guidance to identify and treat IWS. The absence of IWS screening tools, coupled with a lack of understanding regarding prevalence and treatment strategies, indicates a significant gap in clinical knowledge. Given the clinical importance; we strongly recommend further research and development to bridge these critical gaps and provide clinical guidelines.

References:
1.Cammarano WB, Pittet JF, Weitz S, et al.: Acute withdrawal syndrome related to the administration of analgesic and sedative medications in adult intensive care unit patients [Internet]. Crit Care Med 1998; 26:676–684. doi: 10.1097/00003246-199804000-00015.
2.Wang PP, Huang E, Feng X, et al.: Opioid-associated iatrogenic withdrawal in critically ill adult patients: a multicenter prospective observational study. Ann Intensive Care 2017; 7:88
3.Sneyers B, Duceppe MA, Frenette AJ, et al.: Strategies for the Prevention and Treatment of Iatrogenic Withdrawal from Opioids and Benzodiazpeines in Critically Ill Neonates, Children and Adults: A Systematic Review of Clinical Studies. Drugs. 2020 Aug;80(12):1211-1233. doi: 10.1007/s40265-020-01338-4. PMID: 32592134; PMCID: PMC7317263.
4.Arroyo-Novoa CM, Figueroa-Ramos MI et al.: Opioid and Benzodiazepine Withdrawal Syndromes in Trauma ICU Patients: a prospective Exploratory study. Criritcal Care Exploration 2020; 2:e0089
5.Capilnean A, Martone A, Rosu VA, et al.: Validation of the Withdrawal Assessment Tool-1 in Adult Intensive Care Patients [Internet]. Am J Crit Care 2019; 28:361–369Available from: https://www.ncbi.nlm.nih.gov/pubmed/31474606

Grant acknowledgment:
Rebekah Eadie - 2021 HSC Research and Development Bridging Scheme-Predoctoral Support (Ref EAT/5665/21).
Cathrine McKenzie: Research Leader Program, Southampton

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Contributors

Author: Cathrine McKenzie

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