title: The use of opioids and sedatives and time until death after withdrawing mechanical ventilation and vasoactive drugs in a dutch intensive care unit.
abstract: BACKGROUND
  We studied the frequency of withdrawal of mechanical ventilation (MV) and/or vasoactive agents (VAs), the time until death, and dosages of opioids and sedatives in a Dutch academic intensive care unit (ICU), and compared these practices with international observations in this field.
  
  
  METHODS
  Retrospective data were collected from the electronic and paper files of all patients who died after withdrawal of treatment in a Dutch ICU between October 2006 and February 2007.
  
  
  RESULTS
  In this period, 471 patients were admitted to the ICU, of whom 88 died (18%). In 60 of these patients (68%), MV and/or VAs were withdrawn. This group represented 13% of the total ICU population. Of the 60 patients for whom MV and/or VAs were withdrawn, 54 (90%) died after withdrawal of MV (with or without VAs). Six (10%) died after withdrawal of VAs only, 33 (55%) after withdrawal of MV in combination with VAs, and 21 (35%) after withdrawal of MV only. Death occurred after withdrawal of MV in combination with VAs after a median of 30 minutes (interquartile range [IQR], 10-195 minutes). When only MV was discontinued, the median time until death was 50 minutes (IQR, 15-530 minutes). When only VAs were withdrawn, patients died after a median of 45 minutes (IQR, 20-715 minutes). Ten patients (17%) did not receive opioids or sedatives in their last hours. Fifty patients received opioids in their last hours. Fentanyl, with a median dosage at time of death of 100 μg/h, was the most frequently used opioid. Forty (80%) of the 50 patients mentioned above received some kind of sedative until death. In the MV withdrawal group, 34 of the 54 patients (63%) received sedatives in the last hours of their lives: 16 (27%) received midazolam (median, 10 mg/h), 12 (22%) propofol (median, 160 mg/h), and 6 (11%) lorazepam (2.0 mg/h). Sedatives were administered to all patients in whom only VAs were withdrawn.
  
  
  CONCLUSIONS
  Dutch patients who die in the ICU, or die after discharge from the ICU, die after MV and/or VAs are withdrawn. When treatments are withdrawn, death follows within 1 hour in most patients, which is a reflection of the severity of illnesses. At least 80% of patients receive opioids, and 67% receive sedatives until death. Fentanyl is the most used opioid, whereas midazolam is the most used sedative. Dosages of opioids and sedatives did not significantly exceed the ranges described as usual in the international literature.
authors.affiliation: Department of Intensive Care Medicine, Erasmus MC Rotterdam, PO Box 2040, 3000 CA Rotterdam, The Netherlands. j.epker@erasmusmc.n
authors.forename: Jelle L
authors.initials: JL
authors.lastname: Epker
authors.forename: Jan
authors.initials: J
authors.lastname: Bakker
authors.forename: Erwin J O
authors.initials: EJ
authors.lastname: Kompanje
mesh_terms: D000368:Aged; D000701:Analgesics, Opioid / Q000627:therapeutic use*; D005260:Female; D017052:Hospital Mortality / Q000639:trends; D006801:Humans; D006993:Hypnotics and Sedatives / Q000627:therapeutic use*; D007362:Intensive Care Units / Q000639:trends; D008297:Male; D008875:Middle Aged; D009426:Netherlands / Q000453:epidemiology; D012121:Respiration, Artificial / Q000401:mortality* / Q000639:trends; D012189:Retrospective Studies; D013997:Time Factors; D028761:Withholding Treatment / Q000639:trends
chemical_list: D000701:Analgesics, Opioid; D006993:Hypnotics and Sedatives