Sedation and analgesia needs in methamphetamine intoxicated patients: much ado about nothing

Background: Methamphetamine (M) is a widely used, powerful sympathomimetic drug that produces significant CNS stimulation. Its use is associated with psychiatric disorders, abnormal brain chemistry, and cardiovascular disease. Pre-hospital M use is associated with increased intubation, intensive care unit admission, and hospital length of stay. The purpose of this study was to determine the influence of acute M use on analgesia and sedation requirements in mechanically ventilated trauma patients. Methods: This single center retrospective cohort study included injured adult patients (≥16 years) admitted to the trauma intensive care unit (TICU) between 2016 and 2018 who were mechanically ventilated and had a urine drug screen (UDS) completed. The primary outcome was the median sedation and total analgesia administered during the first 48 hours of TICU admission, expressed as propofol, dexmedetomidine, lorazepam, and morphine equivalents. Secondary endpoints included the median Richmond Agitation Sedation Scale (RASS) score, median Critical Pain Observation Tool (CPOT) score, ventilator days, length of stay, in-hospital mortality, and discharge disposition. Results: A total of 245 patients were included in the final analysis (53 M+ and 192 M-). The patients were mostly men (78%) and sustained blunt trauma (89%) with a median age of 35 (IQR 26-52) years and median ISS of 11 (IQR 4-24). A M+ UDS was associated with increased morphine requirements, defined as greater than the cohort median of 1.91 mg/kg, during the first 12 hours of admission on the univariable analysis (OR 2.03; 95% CI, 1.07-3.82). There was no difference in median propofol (M+ 30 mcg/kg/min vs. M- 30 mcg/kg/min, p=0.58) or total morphine equivalents (M+ 5.42 mg/kg s. M- 3.89 mg/kg, p=0.30) over 48 hours between M+ and M- groups to achieve similar RASS and CPOT scores. Conclusion: To achieve the same level of pain control and depth of sedation, intubated TICU patients with a M+ UDS do not require more analgesia and sedation than patients with a M- UDS during the first 48 hours of admission.