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24.08.2020 | Systematic Review

Pain management during the withholding and withdrawal of life support in critically ill patients at the end-of-life: a systematic review and meta-analysis

verfasst von: Andres Laserna, Alejandro Durán-Crane, María A. López-Olivo, John A. Cuenca, Cosmo Fowler, Diana Paola Díaz, Yenny R. Cardenas, Catherine Urso, Keara O’Connell, Clara Fowler, Kristen J. Price, Charles L. Sprung, Joseph L. Nates

Erschienen in: Intensive Care Medicine | Ausgabe 9/2020

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Abstract

Purpose

To review and summarize the most frequent medications and dosages used during withholding and withdrawal of life-prolonging measures in critically ill patients in the intensive care unit.

Methods

We searched PubMed, EMBASE, the Cochrane Database of Systematic Reviews, and the Virtual Health Library from inception through March 2019. We considered any study evaluating pharmaceutical interventions for pain management during the withholding or withdrawing of life support in adult critically ill patients at the end-of-life. Two independent investigators performed the screening and data extraction. We pooled data on utilization rate of analgesic and sedative drugs and summarized the dosing between the moment prior to withholding or withdrawal of life support and the moment before death.

Results

Thirteen studies met inclusion criteria. Studies were conducted in the United States (38%), Canada (31%), and the Netherlands (31%). Eleven studies were single-cohort and twelve had a Newcastle–Ottawa Scale score of less than 7. The mean age of the patients ranged from 59 to 71 years, 59–100% were mechanically ventilated, and 47–100% of the patients underwent life support withdrawal. The most commonly used opioid and sedative were morphine [utilization rate 60% (95% CI 48–71%)] and midazolam [utilization rate 28% (95% CI 23–32%)], respectively. Doses increased during the end-of-life process (pooled mean increase in the dose of morphine: 2.6 mg/h, 95% CI 1.2–4).

Conclusions

Pain control is centered on opioids and adjunctive benzodiazepines, with dosages exceeding those recommended by guidelines. Despite consistency among guidelines, there is significant heterogeneity among practices in end-of-life care.

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Titel: Pain management during the withholding and withdrawal of life support in critically ill patients at the end-of-life: a systematic review and meta-analysis
verfasst von: Andres Laserna
Alejandro Durán-Crane
María A. López-Olivo
John A. Cuenca
Cosmo Fowler
Diana Paola Díaz
Yenny R. Cardenas
Catherine Urso
Keara O’Connell
Clara Fowler
Kristen J. Price
Charles L. Sprung
Joseph L. Nates
Publikationsdatum: 24.08.2020
Verlag: Springer Berlin Heidelberg
Erschienen in: Intensive Care Medicine / Ausgabe 9/2020
Print ISSN: 0342-4642
Elektronische ISSN: 1432-1238
DOI: https://doi.org/10.1007/s00134-020-06139-7

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Pain management during the withholding and withdrawal of life support in critically ill patients at the end-of-life: a systematic review and meta-analysis