Nicotine Replacement Therapy Does Not Increase Mortality in Critically Ill Smokers in the ICU

Deborah Brauser

January 15, 2010

January 15, 2010 (Miami Beach, Florida) — Nicotine replacement therapy (NRT) is not associated with increased hospital mortality in critically ill active smokers, according to a new observational study from the Mayo Clinic.

Lead author Rodrigo Cartin-Ceba, MD, senior associate consultant and instructor of medicine at the Mayo Clinic in Rochester, Minnesota, reported the results during an oral presentation here at the Society of Critical Care Medicine (SCCM) 39th Critical Care Congress.

He said that NRT is often given to smokers admitted to the intensive care unit (ICU) to prevent their withdrawal. "However, the safety of NRT in the critically ill has not been very well studied, and current data are controversial."

In fact, "only 1 previous study evaluated the risks and benefits of this intervention in [this population], and that study had several methodological limitations. Therefore, no firm conclusions have been drawn," said Dr. Cartin-Ceba.

For this study, his team sought to investigate the impact of NRT on critically ill patients, including hospital mortality (primary outcome), delirium, and cumulative doses of sedation, and analgesia (secondary outcomes).

A total of 330 active smokers older than 18 years of age were evaluated, and 174 received NRT upon admission to the Mayo Clinic ICU.

No Increased Mortality, But More Delirium

Results showed that NRT was not associated with increased hospital mortality after adjustment for severity of disease, pack-years of smoking, and do-not-resuscitate status upon ICU admission (odds ratio, 1.6; 95% confidence interval, 0.6 - 4.1; P = .35).

A total of 14 patients from the group receiving NRT (7.8%) died, as did 10 patients from the non-NRT group (6.3%) — a difference that was not statistically significant (P = .595).

However, the NRT group did experience significantly more delirium than the non-NRT group (average ICU days, 169 [23%] vs 75 [13.1%]; .001).

"What surprised us the most [about our findings] was the fact that patients on NRT developed more delirium than smokers not treated with NRT," said Dr. Cartin-Ceba. "One of the thoughts behind using NRT is to prevent the withdrawal symptoms from nicotine addiction."

In addition, the patients receiving NRT required higher cumulative doses of narcotics and benzodiazepines during their stay in the ICU than did the other group.

"The decision to use NRT in critically ill patients should be balanced between the risks and benefits for every individual patient," said Dr. Cartin-Ceba. However, "all efforts should be made to help smokers quit, including the adoption of nonpharmacological interventions." He noted that a randomized controlled trial is now needed to really evaluate these risks and benefits.

An Interesting First Step

"I think the investigators tapped into a very interesting topic. Even though there are supposedly fewer people smoking, I still think this is something we need to address," said session comoderator Christa Schorr, RN, MSN, FCCM, director of critical care databases for research and quality improvement at Cooper University Medical Center in Camden, New Jersey.

Ms. Schorr, who was not involved with this study, said that most of the time, clinicians don't necessarily think about nicotine replacement in the ICU patient population. "So the fact that they implemented this study was, I think, certainly a good idea. The protocol was first implemented by the physicians and, in this particular study, the [NRT] was implemented by the nursing staff," she added.

However, she was concerned that mortality was the study's primary outcome. "This seemed to me to be a difficult thing to measure, and I don't know if that was really going to be impacted by the [NRT] or not. Several of us in the [SCCM] session were interested in other things that play a part in length of stay, such as delirium. And those on NRT did actually have more episodes of delirium than those that were not. [I wonder whether that] was that because of the [NRT] or was it the particular patient population. I think expanding their focus on this topic in the future is something that would be very helpful."

She added that it also would have been interesting if the investigators had delved more into the various patient groups, such as whether they had diabetes or cardiac disease, to see if those things were affected by NRT.

"Overall, it's a very interesting first step and I think they're touching on something that will prove helpful, especially if they keep expanding on their data collection," concluded Ms. Schorr.

Dr. Cartin-Ceba and Ms. Schorr have disclosed no relevant financial relationships.

Society of Critical Care Medicine (SCCM) 39th Critical Care Congress: Abstract 18. Presented January 10, 2010.

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