The changing landscape of ICU sedation

Discordance Between Respiratory Drive and Sedation Depth in Critically Ill Patients Receiving Mechanical Ventilation

OBJECTIVES

In mechanically ventilated patients, deep sedation is often assumed to induce "respirolysis," that is, lyse spontaneous respiratory effort, whereas light sedation is often assumed to preserve spontaneous effort. This study was conducted to determine validity of these common assumptions, evaluating the association of respiratory drive with sedation depth and ventilator-free days in acute respiratory failure.

DESIGN

Prospective cohort study.

SETTING

Patients were enrolled during 2 month-long periods in 2016-2017 from five ICUs representing medical, surgical, and cardiac specialties at a U.S. academic hospital.

PATIENTS

Eligible patients were critically ill adults receiving invasive ventilation initiated no more than 36 hours before enrollment. Patients with neuromuscular disease compromising respiratory function or expiratory flow limitation were excluded.

INTERVENTIONS

Respiratory drive was measured via P0.1, the change in airway pressure during a 0.1-second airway occlusion at initiation of patient inspiratory effort, every 12 ± 3 hours for 3 days. Sedation depth was evaluated via the Richmond Agitation-Sedation Scale. Analyses evaluated the association of P0.1 with Richmond Agitation-Sedation Scale (primary outcome) and ventilator-free days.

MEASUREMENTS AND MAIN RESULTS

Fifty-six patients undergoing 197 bedside evaluations across five ICUs were included. P0.1 ranged between 0 and 13.3 cm H2O (median [interquartile range], 0.1 cm H2O [0.0-1.3 cm H2O]). P0.1 was not significantly correlated with the Richmond Agitation-Sedation Scale (RSpearman, 0.02; 95% CI, -0.12 to 0.16; p = 0.80). Considering P0.1 terciles (range less than 0.2, 0.2-1.0, and greater than 1.0 cm H2O), patients in the middle tercile had significantly more ventilator-free days than the lowest tercile (incidence rate ratio, 0.78; 95% CI, 0.65-0.93; p < 0.01) or highest tercile (incidence rate ratio, 0.58; 95% CI, 0.48-0.70; p < 0.01).

CONCLUSIONS

Sedation depth is not a reliable marker of respiratory drive during critical illness. Respiratory drive can be low, moderate, or high across the range of routinely targeted sedation depth.

The experience of being a couple during an intensive care unit admission

BACKGROUND

In critical care nursing, a trend has been seen towards growing attention to the family experience of critical illness. Despite trends moving towards care of the family as a unit, previous research has focused on individual family members' experience of critical illness. Exploring the life world of the family, especially that of spouses and their interaction, is essential to providing family-centred critical care and has not previously been described.

AIM

To explore the lived experience of being a couple during admission to an intensive care unit.

DESIGN

Data were collected through dyadic semi-structured interviews with four couples who had experienced admission to an intensive care unit. Interviews were audio-taped and transcribed verbatim.

METHOD

Grounded in the phenomenological-hermeneutic tradition, data were analysed using Ricoeur's theory of interpretation, using a method described by Dreyer and Pedersen.

RESULTS

By way of analysis, the life world of being a couple during admission to an intensive care unit was disclosed and divided into themes: For better and for worse; The meaningful proximity; and Being a couple.

CONCLUSION

Although critical illness brings a sudden disruption of a couple's twosomeness, the need to remain, act as and be seen and cared for as a couple persists during admission to an intensive care unit. Therefore, couples need to be cared for as individuals and as a unit, underlining the need to follow trends towards family-centred critical care.

He survived thanks to a non-sedation protocol: Nurses' reflections about caring for critically ill, non-sedated and mechanically ventilated patients

OBJECTIVE

The objective was to explore ICU nurses' experiences of caring for non-sedated, critically ill mechanically ventilated patients, when following a study protocol as part of a clinical trial.

DESIGN

The study had a qualitative design with twelve nurses participating in two focus groups. The interviews were analysed using a thematic approach.

FINDINGS

One overall theme emerged, "Cautious optimism", which suggests positive experiences but with a negative undertone. The most remarkable experiences were related to caring for the patient, but there were some disappointments with regard to the interprofessional teamwork. Three subthemes were identified: 1) Excitement and uncertainty 2) Inspiring but demanding nurse-patient relationship, and 3) Teamwork or working against the tide?

CONCLUSION

The main findings reflect the remarkable and positive aspects of caring for awake and involved mechanically ventilated ICU patients, but also how nurses found it demanding to follow a weakly implemented study protocol that sometimes resulted in deviations from their nursing ethical standards of care. A more strategic implementation plan for the study and improved interprofessional teamwork might have improved their experiences.

Patients' experience of thirst while being conscious and mechanically ventilated in the intensive care unit

BACKGROUND

Because of changes in sedation strategies, more patients in the intensive care unit (ICU) are conscious. Therefore, new and challenging tasks in nursing practice have emerged, which require a focus on the problems that patients experience. Thirst is one such major problem, arising because the mechanical ventilator prevents the patients from drinking when they have the urge to do so. To gain a deeper understanding of the patients' experiences and to contribute new knowledge in nursing care, this study focuses on the patients' experiences of thirst during mechanical ventilation (MV) while being conscious.

AIMS

To explore patients' experience of thirst while being conscious and mechanically ventilated.

DESIGN

This hermeneutic study used qualitative interviews of 12 patients.

METHOD

Data were analyzed based on content analysis. Interviews were conducted between September and October 2014 in two large ICUs in Denmark.

RESULT

Four themes relating to the patients' experiences of thirst during MV were identified: a paramount thirst, a different sense in the mouth, deprivation of the opportunity to quench thirst and difficulties associated with thirst.

CONCLUSION

Patients associate feelings of desperation, anxiety and powerlessness with the experience of thirst. These feelings have a negative impact on their psychological well-being. A strategy in the ICU that includes no sedation for critically ill patients in need of MV introduces new demands on the nurses who must care for patients who are struggling with thirst.

RELEVANCE TO CLINICAL PRACTICE

This study shows that despite several practical attempts to relieve thirst, it remains a paramount problem for the patients. ICU nurses need to increase their focus on issues of thirst and dry mouth, which are two closely related issues for the patients. Communication may be a way to involve the patients, recognize and draw attention to their problem.

Strategies to Prevent Ventilator-Associated Pneumonia in Acute Care Hospitals: 2014 Update

Previously published guidelines are available that provide comprehensive recommendations for detecting and preventing healthcare-associated infections (HAIs). The intent of this document is to highlight practical recommendations in a concise format to assist acute care hospitals in implementing and prioritizing strategies to prevent ventilator-associated pneumonia (VAP) and other ventilator-associated events (VAEs) and to improve outcomes for mechanically ventilated adults, children, and neonates. This document updates "Strategies to Prevent Ventilator-Associated Pneumonia in Acute Care Hospitals," published in 2008. This expert guidance document is sponsored by the Society for Healthcare Epidemiology of America (SHEA) and is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America (IDSA), the American Hospital Association (AHA), the Association for Professionals in Infection Control and Epidemiology (APIC), and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise. The list of endorsing and supporting organizations is presented in the introduction to the 2014 updates.

Propofol detection and quantification in human blood: the promise of feedback controlled, closed-loop anesthesia

The performance of a membrane-coated voltammetric sensor for propofol (2,6-diisopropylphenol) has been characterized in long term monitoring experiments using an automated flow analytical system (AFAS) and by analyzing human serum and whole blood samples by standard addition. It is shown that the signal of the membrane-coated electrochemical sensor for propofol is not influenced by the components of the pharmaceutical formulation of propofol (propofol injectable emulsion). The current values recorded with the electrochemical propofol sensor in buffer solutions and human serum samples spiked with propofol injectable emulsion showed excellent correlation with the peak heights recorded with an UV-Vis detector during the HPLC analysis of these samples (R(2) = 0.997 in PBS and R(2) = 0.975 in human serum). However, the determination of propofol using the electrochemical method is simpler, faster and has a better detection limit (0.08 ± 0.05 μM) than the HPLC method (0.4 ± 0.2 μM). As a first step towards feedback controlled closed-loop anesthesia, the membrane-coated electrochemical sensor has been implemented onto surface of an intravenous catheter. The response characteristics of the membrane-coated carbon fiber electrode on the catheter surface were very similar to those seen using a macroelectrode.

Strategies to prevent ventilator-associated pneumonia in acute care hospitals: 2014 update

Previously published guidelines are available that provide comprehensive recommendations for detecting and preventing healthcare-associated infections (HAIs). The intent of this document is to highlight practical recommendations in a concise format to assist acute care hospitals in implementing and prioritizing strategies to prevent ventilator-associated pneumonia (VAP) and other ventilator-associated events (VAEs) and to improve outcomes for mechanically ventilated adults, children, and neonates. This document updates “Strategies to Prevent Ventilator-Associated Pneumonia in Acute Care Hospitals,” published in 2008. This expert guidance document is sponsored by the Society for Healthcare Epidemiology of America (SHEA) and is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America (IDSA), the American Hospital Association (AHA), the Association for Professionals in Infection Control and Epidemiology (APIC), and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise. The list of endorsing and supporting organizations is presented in the introduction to the 2014 updates.

Nurses' experiences of caring for critically ill, non-sedated, mechanically ventilated patients in the Intensive Care Unit: a qualitative study

OBJECTIVE

The objective was to explore nurses' experiences of caring for non-sedated, critically ill patients requiring mechanical ventilation.

DESIGN AND SETTING

The study had a qualitative explorative design and was based on 13 months of fieldwork in two intensive care units in Denmark where a protocol of no sedation is implemented. Data were generated during participant observation in practice and by interviews with 16 nurses. Data were analysed using thematic interpretive description.

FINDINGS

An overall theme emerged: "Demanding, yet rewarding". The demanding aspects of caring for more awake intubated patients included unpredictability, ambiguous needs and complex actions, while the rewarding aspects included personal interaction. Three sub-themes were identified: (i) caring for and with the patient, (ii) negotiating relational and instrumental care and (iii) managing physical and emotional closeness.

CONCLUSION

Despite the complexity of care, nurses preferred to care for more awake rather than sedated patients and appreciated caring for just one patient at a time. The importance of close collaboration between nurses and doctors to ensure patient comfort during mechanical ventilation was valued. Caring for more awake non-sedated patients required the nurses to act at the interface between ambiguous possibilities and needs, which was perceived as both demanding and rewarding.