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A One-Day Prospective National Observational Study on Sedation-Analgesia of Patients with Brain Injury in French Intensive Care Units: The SEDA-BIP-ICU (Sedation-Analgesia in Brain Injury Patient in ICU) Study. Neurocrit Care 2021; 36:266-278. [PMID: 34331208 DOI: 10.1007/s12028-021-01298-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Accepted: 06/10/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND Sedation/analgesia is a daily challenge faced by intensivists managing patients with brain injury (BI) in intensive care units (ICUs). The optimization of sedation in patients with BI presents particular challenges. A choice must be made between the potential benefit of a rapid clinical evaluation and the potential exacerbation of intracranial hypertension in patients with impaired cerebral compliance. In the ICU, a pragmatic approach to the use of sedation/analgesia, including the optimal titration, management of multiple drugs, and use of any type of brain monitor, is needed. Our research question was as follows: the aim of the study is to identify what is the current daily practice regarding sedation/analgesia in the management of patients with BI in the ICU in France? METHODS This study was composed of two parts. The first part was a descriptive survey of sedation practices and characteristics in 30 French ICUs and 27 academic hospitals specializing in care for patients with BI. This first step validates ICU participation in data collection regarding sedation-analgesia practices. The second part was a 1-day prospective cross-sectional snapshot of all characteristics and prescriptions of patients with BI. RESULTS On the study day, among the 246 patients with BI, 106 (43%) had a brain monitoring device and 74 patients (30%) were sedated. Thirty-nine of the sedated patients (53%) suffered from intracranial hypertension, 14 patients (19%) suffered from agitation and delirium, and 7 patients (9%) were sedated because of respiratory failure. Fourteen patients (19%) no longer had a formal indication for sedation. In 60% of the sedated patients, the sedatives were titrated by nurses based on sedation scales. The Richmond Agitation Sedation Scale was used in 80% of the patients, and the Behavioral Pain Scale was used in 92%. The common sedatives and opioids used were midazolam (58.1%), propofol (40.5%), and sufentanil (67.5%). The cerebral monitoring devices available in the participating ICUs were transcranial Doppler ultrasound (100%), intracranial and intraventricular pressure monitoring (93.3%), and brain tissue oxygenation (60%). Cerebral monitoring by one or more monitoring devices was performed in 62% of the sedated patients. This proportion increased to 74% in the subgroup of patients with intracranial hypertension, with multimodal cerebral monitoring in 43.6%. The doses of midazolam and sufentanil were lower in sedated patients managed based on a sedation/analgesia scale. CONCLUSIONS Midazolam and sufentanil are frequently used, often in combination, in French ICUs instead of alternative drugs. In our study, cerebral monitoring was performed in more than 60% of the sedated patients, although that proportion is still insufficient. Future efforts should stress the use of multiple monitoring modes and adherence to the indications for sedation to improve care of patients with BI. Our study suggests that the use of sedation and analgesia scales by nurses involved in the management of patients with BI could decrease the dosages of midazolam and sufentanil administered. Updated guidelines are needed for the management of sedation/analgesia in patients with BI.
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[The correlation among the Ramsay sedation scale, Richmond agitation sedation scale and Riker sedation agitation scale during midazolam-remifentanil sedation]. Rev Bras Anestesiol 2017; 67:347-354. [PMID: 28412050 DOI: 10.1016/j.bjan.2017.03.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2015] [Accepted: 07/19/2016] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Sedative and analgesic treatment administered to critically ill patients need to be regularly assessed to ensure that previously stated goals are well achieved as the risk of complications of oversedation is minimized. We revised and prospectively tested the Ramsay Sedation Scale (RSS) for interrater reliability and compared it with the Riker Sedation-Agitation Scale (RSAS) and the Richmond Agitation Sedation Scale (RASS) to test construct validity during midazolam-remifentanil sedation. METHODS A convenience sample of ICU patients was simultaneously and independently examined by pairs of trained evaluators by using the revised RSAS, RSS, and RASS. Ninety-two ICU patients were examined a total of 276 times by evaluator pairs. RESULTS The mean patient age was 61.32±18.68years, 45,7% were female (n=42), 54.3% male (n=50). Their APACHE values varied between 3 and 39 with an average of 13.27±7.86 and 75% of the cases were under mechanical ventilation. When classified by using RSS (2.70±1.28), 10.9% were anxious or agitated (RSS1), 68.5% were calm (RSS 2-3), and 20.6% were sedated (RSS 4-6). When classified by using RASS (-0.64±1.58), 20.7% were anxious or agitated (RASS+1 to +4), 63.0% were calm (RASS 0 to -2), and 16.3% were sedated (RASS -3 to -5). When classified by using RSAS (2.63±1.00), 12% were anxious or agitated (RSAS 5-7), 57.6% were calm (RSAS 4), and 30.4% were sedated (RSAS 1-3). RSS was correlated with the RSAS (r=-0.656, p<0.001) and RASS was correlated with the RSAS (r=0.565, p<0.001). RSS was highly correlated with the RASS (r=-0.664, p<0.001). CONCLUSIONS Ramsay is both reliable and valid (high correlation with the RASS and RSAS scales) in assessing agitation and sedation in adult ICU patients.
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Chanques G, Garnier O, Carr J, Conseil M, de Jong A, Rowan CM, Ely EW, Jaber S. The CAM-ICU has now a French "official" version. The translation process of the 2014 updated Complete Training Manual of the Confusion Assessment Method for the Intensive Care Unit in French (CAM-ICU.fr). Anaesth Crit Care Pain Med 2017; 36:297-300. [PMID: 28365244 DOI: 10.1016/j.accpm.2017.02.003] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2016] [Accepted: 02/21/2017] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Delirium is common in Intensive-Care-Unit (ICU) patients but under-recognized by bed-side clinicians when not using validated delirium-screening tools. The Confusion-Assessment-Method for the ICU (CAM-ICU) has demonstrated very good psychometric properties, and has been translated into many different languages though not into French. We undertook this opportunity to describe the translation process. MATERIAL AND METHODS The translation was performed following recommended guidelines. The updated method published in 2014 including introduction letters, worksheet and flowsheet for bed-side use, the method itself, case-scenarios for training and Frequently-Asked-Questions (32 pages) was translated into French language by a neuropsychological researcher who was not familiar with the original method. Then, the whole method was back-translated by a native English-French bilingual speaker. The new English version was compared to the original one by the Vanderbilt University ICU-delirium-team. Discrepancies were discussed between the two teams before final approval of the French version. RESULTS The entire process took one year. Among the 3692 words of the back-translated version of the method itself, 18 discrepancies occurred. Eight (44%) lead to changes in the final version. Details of the translation process are provided. CONCLUSIONS AND RELEVANCE The French version of CAM-ICU is now available for French-speaking ICUs. The CAM-ICU is provided with its complete training-manual that was challenging to translate following recommended process. While many such translations have been done for other clinical tools, few have published the details of the process itself. We hope that the availability of such teaching material will now facilitate a large implementation of delirium-screening in French-speaking ICUs.
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Affiliation(s)
- Gérald Chanques
- Department of anaesthesia and critical care medicine, university of Montpellier Saint-Éloi hospital, Montpellier, France; PhyMedExp, university of Montpellier, Inserm U1046, CNRS UMR 9214, Montpellier, France.
| | - Océane Garnier
- Department of anaesthesia and critical care medicine, university of Montpellier Saint-Éloi hospital, Montpellier, France
| | - Julie Carr
- Department of anaesthesia and critical care medicine, university of Montpellier Saint-Éloi hospital, Montpellier, France
| | - Matthieu Conseil
- Department of anaesthesia and critical care medicine, university of Montpellier Saint-Éloi hospital, Montpellier, France
| | - Audrey de Jong
- Department of anaesthesia and critical care medicine, university of Montpellier Saint-Éloi hospital, Montpellier, France; PhyMedExp, university of Montpellier, Inserm U1046, CNRS UMR 9214, Montpellier, France
| | - Christine M Rowan
- Department of medicine, division of allergy, pulmonary, and critical care medicine, and the center for health services research, Vanderbilt university school of medicine, Nashville, Tennessee, USA
| | - E Wesley Ely
- Department of medicine, division of allergy, pulmonary, and critical care medicine, and the center for health services research, Vanderbilt university school of medicine, Nashville, Tennessee, USA; Geriatric research education clinical center (GRECC), department of veterans affairs, Tennessee valley healthcare system, Nashville, Tennessee, USA
| | - Samir Jaber
- Department of anaesthesia and critical care medicine, university of Montpellier Saint-Éloi hospital, Montpellier, France; PhyMedExp, university of Montpellier, Inserm U1046, CNRS UMR 9214, Montpellier, France
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Baars JH. Utilisation du réflexe RIII pour l’évaluation de la profondeur de l’analgo-sédation en réanimation. Neurophysiol Clin 2016. [DOI: 10.1016/j.neucli.2016.05.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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Efficacy and safety of sedation with dexmedetomidine in critical care patients: A meta-analysis of randomized controlled trials. Anaesth Crit Care Pain Med 2016; 35:7-15. [DOI: 10.1016/j.accpm.2015.06.012] [Citation(s) in RCA: 80] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2015] [Revised: 06/02/2015] [Accepted: 06/17/2015] [Indexed: 12/16/2022]
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Sedation in French intensive care units: a survey of clinical practice. Ann Intensive Care 2013; 3:24. [PMID: 23937955 PMCID: PMC3751696 DOI: 10.1186/2110-5820-3-24] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2013] [Accepted: 06/10/2013] [Indexed: 12/03/2022] Open
Abstract
Background Sedation is used frequently for patients in intensive care units who require mechanical ventilation, but oversedation is one of the main side effects. Different strategies have been proposed to prevent oversedation. The extent to which these strategies have been adopted by intensivists is unknown. Methods We developed a six-section questionnaire that covered the drugs used, modalities of drug administration, use of sedation scales and procedural pain scales, use of written local procedures, and targeted objectives of consciousness. In November 2011, the questionnaire was sent to 1,078 intensivists identified from the French ICU Society (SRLF) database. Results The questionnaire was returned by 195 intensivists (response rate 18.1%), representing 135 of the 282 ICUs (47.8%) listed in the French ICU society (SRLF) database. The analysis showed that midazolam and sufentanil are the most frequently used hypnotics and opioids, respectively, administered in continuous intravenous (IV) infusions. IV boluses of hypnotics without subsequent continuous IV infusion are used occasionally (in <25% of patients) by 65% of intensivists. Anxiolytic benzodiazepines (e.g., clorazepam, alprazolam), hydroxyzine, and typical neuroleptics, via either an enteral or IV route, are used occasionally by two thirds of respondents. The existence of a written, local sedation management procedure in the ICU is reported by 55% of respondents, 54% of whom declare that they use it routinely. Written local sedation procedures mainly rely on titration of continuous IV hypnotics (90% of the sedation procedures); less frequently, sedation procedures describe alternative approaches to prevent oversedation, including daily interruption of continuous IV hypnotic infusion, hypnotic boluses with no subsequent continuous IV infusion, or the use of nonhypnotic drugs. Among the responding intensivists, 98% consider eye opening, either spontaneously or after light physical stimulation, a reasonable target consciousness level in patients with no severe respiratory failure or intracranial hypertension. Conclusions Despite a low individual response rate, the respondents to our survey represent almost half of the ICUs in the French SRLF database. The presence of a written local sedation procedure, a cornerstone of preventing oversedation, is reported by only half of respondents; when present, it is used in for a limited number of patients. Sedation procedures mainly rely on titration of continuous IV hypnotics, but other strategies to limit oversedation also are included in sedation procedures. French intensivists no longer consider severely altered consciousness a sedation objective for most patients.
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Skrobik Y, Chanques G. The pain, agitation, and delirium practice guidelines for adult critically ill patients: a post-publication perspective. Ann Intensive Care 2013; 3:9. [PMID: 23547921 PMCID: PMC3622614 DOI: 10.1186/2110-5820-3-9] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2012] [Accepted: 02/13/2013] [Indexed: 02/08/2023] Open
Abstract
The recently published Clinical Practice Guidelines for the Management of Pain, Agitation, and Delirium in Adult Patients in the Intensive Care Unit differ from earlier guidelines in the following ways: literature searches were performed in eight databases by a professional librarian; psychometric validation of assessment scales was considered in their recommendation; discrepancies in recommendation votes by guideline panel members are available in online supplements; and all recommendations were made exclusively on the basis of evidence available until December of 2010. Pain recognition and management remains challenging in the critically ill. Patient outcomes improve with routine pain assessment, use of co-analgesics and administration as well as dose adjustment of opiates to patient needs. Thoracic epidurals help ease patients undergoing abdominal aortic surgery. Little data exists to guide clinicians as to the type or dose of co-analgesics; no opiate choice is associated with better patient outcomes. Lighter or no sedation is beneficial, and interruption is desirable in patients who require deep sedation for specific pathologic states. Delirium screening is probably useful; no treatment modality can be unequivocally recommended, and the benefit of prophylaxis is established only for early mobilization. The details of these recommendations, as well as more recent publications that complement the guidelines, are provided in this commentary.
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Affiliation(s)
- Yoanna Skrobik
- Soins Intensifs, Hôpital Maisonneuve Rosemont, Montréal, QC H1T 2M4, Canada
| | - Gerald Chanques
- Intensive Care and Anaesthesiology Department (DAR), Saint Eloi Hospital, Montpellier University Hospital, 80, Avenue Augustin Fliche, Montpellier cedex 5, 34295, France
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De Jonghe B, Constantin JM, Chanques G, Capdevila X, Lefrant JY, Outin H, Mantz J. Physical restraint in mechanically ventilated ICU patients: a survey of French practice. Intensive Care Med 2012; 39:31-7. [PMID: 23064500 DOI: 10.1007/s00134-012-2715-9] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2011] [Accepted: 07/18/2012] [Indexed: 10/27/2022]
Abstract
PURPOSE To characterize the perceived utilization of physical restraint (PR) in mechanically ventilated intensive care unit (ICU) patients and to identify clinical and structural factors influencing PR use. METHODS A questionnaire was personally handed to one intensivist in 130 ICUs in France then collected on-site 2 weeks later. RESULTS The questionnaire was returned by 121 ICUs (response rate, 93 %), 66 % of which were medical-surgical ICUs. Median patient-to-nurse ratio was 2.8 (2.5-3.0). In 82 % of ICUs, PR is used at least once during mechanical ventilation in more than 50 % of patients. In 65 % of ICUs, PR, when used, is applied for more than 50 % of mechanical ventilation duration. Physical restraint is often used during awakening from sedation and when agitation occurs and is less commonly used in patients receiving deep sedation or neuromuscular blockers or having severe tetraparesis. In 29 % of ICUs, PR is used in more than 50 % of awake, calm and co-operative patients. PR is started without written medical order in more than 50 % of patients in 68 % of ICUs, and removed without written medical order in more than 50 % of patients in 77 % of ICUs. Only 21 % of ICUs have a written local procedure for PR use. CONCLUSIONS This survey in a country with a relatively high patient-to-nurse ratio shows that PR is frequently used in patients receiving mechanical ventilation, with wide variations according to patient condition. The common absence of medical orders for starting or removing PR indicates that these decisions are mostly made by the nurses.
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Affiliation(s)
- Bernard De Jonghe
- Réanimation Médico-Chirurgicale, Centre Hospitalier de Poissy, 10 rue du Champ Gaillard, 78300, Poissy, France.
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[How to easily and efficiently implement a quality improvement project regarding sedation-analgesia in Intensive care unit?]. ACTA ACUST UNITED AC 2012; 31:767-9. [PMID: 22959169 DOI: 10.1016/j.annfar.2012.08.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Chanques G, Conseil M, Coisel Y, Carr J, Jung B, Jaber S. Sédation-analgésie en réanimation : arrêt quotidien par les médecins ou gestion continue par les infirmières. MEDECINE INTENSIVE REANIMATION 2012. [DOI: 10.1007/s13546-012-0511-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Quintard H, Philip I, Ichai C. French survey on current use of ultrasound in the critical care unit: ECHOREA. ACTA ACUST UNITED AC 2011; 30:e69-73. [PMID: 21978478 DOI: 10.1016/j.annfar.2011.05.012] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2011] [Accepted: 05/16/2011] [Indexed: 10/16/2022]
Abstract
INTRODUCTION Over the last ten years, ultrasound became standard procedure in the intensive care unit (ICU). STUDY DESIGN A national survey to evaluate the use of this technique in French ICUs. METHODS Three hundred and twenty-seven units were contacted from the listing of the Société de réanimation de langue française (SRLF). A survey containing 20 questions addressing the availability, the training for, and the use of ultrasound was sent to the ICUs. Collection of data took place over a period of three months. RESULTS We received 132 completed surveys out of the 327 sent out (40%). Seventy-nine percent of the public community and private centers and 94% of the university centers had an available device in the unit. Forty percent of the units carried out five to ten examinations per week. Seventy-two percent had staff trained in echocardiography. Fifty-five percent used association of monitoring techniques for the haemodynamic assessment of patients with shock. Only 73% carried out formalized reports after examination. In more than 80%, the echocardiograph was also used for the evaluation of other organs. CONCLUSION Ultrasound, and particularly echocardiography, has taken on a more prominent role in the routine assessment of critically ill patients. The availability of equipment and of training has increased over the last ten years, but the demand for training in this area remains strong. This French survey confirms this technique became the "extension of the hand" of the intensivist in ICU.
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Affiliation(s)
- H Quintard
- Réanimation médicochirurgicale, faculté de médecine, hôpital Saint-Roch, CHU de Nice, université de Nice Sophia-Antipolis, 5, rue Pierre-Dévoluy, 06000 Nice, France.
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Vinatier I. Le bien-être du patient en réanimation — Comment l’améliorer ? MEDECINE INTENSIVE REANIMATION 2011. [DOI: 10.1007/s13546-010-0136-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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