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Frade-Mera MJ, Arias-Rivera S, Zaragoza-García I, Martí JD, Gallart E, San José-Arribas A, Velasco-Sanz TR, Blazquez-Martínez E, Raurell-Torredà M. The impact of ABCDE bundle implementation on patient outcomes: A nationwide cohort study. Nurs Crit Care 2022; 27:772-783. [PMID: 34994034 DOI: 10.1111/nicc.12740] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Revised: 11/11/2021] [Accepted: 11/30/2021] [Indexed: 12/27/2022]
Abstract
BACKGROUND The ABCDE bundle is a set of evidence-based practices to systematically reduce the risks of sedation, delirium, and immobility in intensive care patients. Implementing the bundle improves clinical outcome. AIMS AND OBJECTIVES To investigate the association between patient outcomes and compliance with bundle components ABC (analgosedation algorithms), D (delirium protocol), and E (early mobilization protocol). DESIGN A Spanish multicentre cohort study of adult patients receiving invasive mechanical ventilation (IMV) for ≥48 h until extubation. METHODS The primary outcome was pain level, cooperation to permit Medical Research Council Scale administration, patient days of delirium, and mobility. The secondary outcome was cumulative drug dosing by IMV days. Tertiary outcomes (ICU days, IMV days, bed rest days, ICU mortality, ICUAW) and independent variables (analgosedation, delirium, early mobilization protocols) were also studied. RESULTS Data were collected from 605 patients in 80 ICUs and 5214 patient days with IMV. Two-thirds of the ICUs studied applied no protocols. Pain was not assessed on 83.6% of patient days. Patient cooperation made scale administration feasible on 20.7% of days. Delirium and immobility were found on 4.2% and 69.9% of days, respectively. Patients had shorter stays in ICUs with bundle protocols and fewer days of IMV in ICUs with delirium and mobilization bundle components (P = 0.006 and P = 0.03, respectively). Analgosedation protocols were associated with more opioid dosing (P = 0.02), and delirium and early mobilization protocols with more propofol (P = 0.001), dexmedetomidine (P = 0.001), and lower benzodiazepine dosing (P = 0.008). CONCLUSIONS The implementation rate of ABCDE bundle components was very low in our Spanish setting, but when implemented, patients had a shorter ICU stay, more analgesia dosing, and lighter sedation. RELEVANCE TO CLINICAL PRACTICE Applying some but not all the bundle components, there is increased analgesia and light sedation drug use, decreased benzodiazepines, and increased patient cooperation and mobility, resulting in a shorter ICU stay and fewer days of IMV.
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Affiliation(s)
- María Jesús Frade-Mera
- Critical Care Department, 12 Octubre University Hospital, Madrid, Spain.,Department of Nursing, Faculty of Nursing, Physiotherapy and Podology, University Complutense of Madrid, Madrid, Spain
| | - Susana Arias-Rivera
- Department of Nursing Management, University Hospital of Getafe, Madrid, Spain.,Research Department, CIBER Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain
| | - Ignacio Zaragoza-García
- Department of Nursing, Faculty of Nursing, Physiotherapy and Podology, University Complutense of Madrid, Madrid, Spain.,Research department (Invecuid), Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), Centro de Actividades Ambulatorias, Madrid, Spain
| | - Joan Daniel Martí
- Cardiovascular Surgery Intensive Care Department, Instituto Clínico Cardiovascular, Clinic University Hospital, Barcelona, Spain
| | - Elisabet Gallart
- Critical Care Department, Vall Hebron University Hospital, Barcelona, Spain
| | - Alicia San José-Arribas
- Department of Nursing, Escola Universitaria d'Infermeria Sant Pau (Hospital de la Santa Creu i Sant Pau), Barcelona, Spain
| | - Tamara Raquel Velasco-Sanz
- Department of Nursing, Faculty of Nursing, Physiotherapy and Podology, University Complutense of Madrid, Madrid, Spain.,Critical Care Department, San Carlos University Hospital, Madrid, Spain
| | | | - Marta Raurell-Torredà
- Department of Fundamental and Medical Surgical Nursing, Faculty of Medicine and Health Sciences, University of Barcelona, Barcelona, Spain
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Hazwani T, Al Ahmady A, Kazzaz Y, Al Smari A, Al Enizy S, Alali H. Implementation of a sedation protocol: a quality improvement project to enhance sedation management in the paediatric intensive care unit. BMJ Open Qual 2022; 11:bmjoq-2021-001501. [PMID: 34980589 PMCID: PMC8724811 DOI: 10.1136/bmjoq-2021-001501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Accepted: 12/21/2021] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Proper sedation is integral to ensuring the safety and comfort of children on mechanical ventilation (MV). Sedation protocols help to achieve this goal and reduce the duration of MV. We have observed varied sedation approaches, sedation score targets and sedative use by our physicians, which were manifested as oversedation and undersedation with associated accidental extubation. Hence, we aimed to implement a standardised sedation protocol and assess its impact on mechanically ventilated paediatric patients. METHODS A multidisciplinary quality improvement team was formed to develop and implement a standardised sedation protocol for mechanically ventilated paediatric patients. COMFORT-Behaviour (COMFORT-B) Scale score was used to assess the sedation targets and define undersedation, oversedation or adequate sedation. Our goal was to achieve adequate sedation during 90% of the sedation period. Based on the model for improvement methodology, we used plan-do-study-act cycles to develop, test and implement the new sedation protocol. RESULTS There was an immediate percentage increase in COMFORT-B Scale scores within the target sedation level, which was associated with a gradual decrease in the need for intermittent sedation doses over sedation infusion in the preimplementation, improvement and control phases (6.3, 4.9 and 3.1 sedation doses/12 hours/patient, respectively) to achieve adequate sedation target. CONCLUSIONS The standardisation of sedation protocols was safe and efficient, and improved the sedation quality in mechanically ventilated paediatric patients.
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Affiliation(s)
- Tarek Hazwani
- Department of Pediatrics, Ministry of the National Guard - Health Affairs, Riyadh, Saudi Arabia .,College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia.,King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Arwa Al Ahmady
- Nursing Service, Ministry of the National Guard - Health Affairs, Riyadh, Saudi Arabia
| | - Yasser Kazzaz
- Department of Pediatrics, Ministry of the National Guard - Health Affairs, Riyadh, Saudi Arabia.,College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia.,King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Abeer Al Smari
- College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia.,Pharmaceutical Care Services, Ministry of the National Guard - Health Affairs, Riyadh, Saudi Arabia
| | - Seham Al Enizy
- Nursing Service, Ministry of the National Guard - Health Affairs, Riyadh, Saudi Arabia
| | - Hamza Alali
- Department of Pediatrics, Ministry of the National Guard - Health Affairs, Riyadh, Saudi Arabia.,King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
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Taran Z, Namadian M, Faghihzadeh S, Naghibi T. The Effect of Sedation Protocol Using Richmond Agitation-Sedation Scale (RASS) on Some Clinical Outcomes of Mechanically Ventilated Patients in Intensive Care Units: a Randomized Clinical Trial. J Caring Sci 2019; 8:199-206. [PMID: 31915621 PMCID: PMC6942649 DOI: 10.15171/jcs.2019.028] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2018] [Accepted: 10/11/2018] [Indexed: 12/17/2022] Open
Abstract
Introduction: Providing for patients’ comfort and reducing their pain is one of the important tasks of health care professionals in the Intensive Care Unit (ICU). The current study was conducted to determine the effect of a protocol using a Richmond Agitation-Sedation Scale (RASS) on some clinical outcomes of patients under mechanical ventilation (MV) in 2017. Methods: This single-blind clinical trial was conducted on 79 traumatic patients in the ICU who were randomly allocated into the intervention (N=40) and the control groups (N=39). The sedation was achieved, using a sedation protocol in the intervention group and the routine care in the control group. The clinical outcomes of the patients (duration of MV, length of staying in ICU, final outcome) were measured. As the participants had different lengths of MV and staying in ICU, the data were restructured, and were analyzed, using proper statistical methods. Results: The patients’ level of sedation in the intervention group was significantly closer to the ideal score of RASS (-1 to +1). The duration of MV was significantly reduced in the intervention group, and the length of stay in the ICU was also significantly shorter. There was no difference in terms of final outcome. The ICU cost in the control group was twice as high as the cost in of the intervention group. Conclusion: The applied sedation protocol in this study would provide better sedation and could consequently lead to significantly better clinical outcomes, and the cost of caring as a result.
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Affiliation(s)
- Zahra Taran
- Department of Nursing, Nursing & Midwifery School, Zanjan University of Medical Sciences, Zanjan, Iran
| | - Masoumeh Namadian
- Social Determinants of Health Research Center, Zanjan University of Medical Sciences, Zanjan, Iran
| | - Soghrat Faghihzadeh
- Department of Epidemiology and Biostatistics, School of Medicine, Zanjan University of Medical Sciences, Zanjan, Iran
| | - Taraneh Naghibi
- Department of Anesthesiology and Critical Care Medicine, School of Medicine, Zanjan University of Medical Sciences, Zanjan, Iran
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4
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Maison O, Tardy C, Offrey JM, Boselli E, Piriou V, Parat S, Allaouchiche B. Compliance with sedation analgesia protocols: Do clinical pharmacists have an impact? J Clin Pharm Ther 2019; 45:59-64. [PMID: 31660644 DOI: 10.1111/jcpt.13023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Revised: 06/27/2019] [Accepted: 07/17/2019] [Indexed: 12/01/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVES The agreement between prescribed sedation objectives and sedation pump syringe rate adaptation is not optimal. Delays in adjustment of sedation doses are associated with an increased patient length of stay in the intensive care unit. Our objectives were to assess compliance with the approved sedation protocol and to evaluate the impact of a clinical pharmacist daily controlling sedation and analgesia scores and pump syringe rates on patients' outcomes in a critical care unit. METHODS Prospective before/after study involving 60 adult patients divided into two groups (non-intervention and intervention groups) who received mechanical ventilation and continuous infusions of sedative and analgesic drugs in an intensive care unit. In both groups, data were collected daily in 30 mechanically ventilated patients receiving a sedation/analgesia regimen during a 3-month period according to a standardized protocol. A pharmacist was in charge of intervening with physicians when the local sedation analgesia protocol was not followed. RESULTS AND DISCUSSION There were no significant differences between the groups in terms of demographic characteristics except a higher proportion of men in the intervention group (70% vs 40%, P = .019). In the control group, sedation and analgesia objectives were not prescribed in more than half the cases. Pharmacist intervention reduced sedation duration (5 [2-11] vs 2 [1-5.5] days, P = .019). The cumulative delay in adaptation of the sedation analgesia electric syringe pump was significantly decreased in the intervention group (8 [0-29.5] vs 28.5 hours [11.1-68.4], P = .034). Total doses of sedatives (midazolam, propofol) and analgesics (sufentanil, remifentanil) per patient were decreased in the intervention group compared to the control group (respectively, P = .24, P = .0009, P = .0013 and P = .0007). CONCLUSIONS Pharmacist intervention can decrease the sedation duration and the total dose of sedation medications and reinforce adherence to sedation/analgesia guidelines.
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Affiliation(s)
- Ophélie Maison
- Pharmacy, Groupement Hospitalier Sud, Pierre-Benite, France
| | - Cléa Tardy
- Pharmacy, Groupement Hospitalier Sud, Pierre-Benite, France
| | | | - Emmanuel Boselli
- Intensive care unit, Centre Hospitalier Pierre Oudot de Bourgoin-Jallieu, Bourgoin-Jallieu, France
| | - Vincent Piriou
- Intensive care unit, Groupement Hospitalier Sud, Pierre-Benite, France
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Kaplan JB, Eiferman DS, Porter K, MacDermott J, Brumbaugh J, Murphy CV. μImpact of a nursing-driven sedation protocol with criteria for infusion initiation in the surgical intensive care unit. J Crit Care 2018; 50:195-200. [PMID: 30553990 DOI: 10.1016/j.jcrc.2018.11.029] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Revised: 11/06/2018] [Accepted: 11/28/2018] [Indexed: 11/29/2022]
Abstract
PURPOSE Analgesia and sedation protocols (ASPs) reduce duration of mechanical ventilation (MV) in the medical intensive care unit (ICU), but data in the surgical ICU (SICU) are limited. The objective of this study was to determine the impact of a nursing-driven ASP with criteria for infusion initiation in the SICU. MATERIALS AND METHODS A single-center, retrospective study compared ventilator-free days at day 28 from start of MV (VFD28) before and after ASP implementation. Secondary endpoints included cumulative opioid and sedative requirements, level of sedation, incidence of delirium, SICU and hospital length of stay. RESULTS One hundred thirty two patients were included (66 per group). The protocol group had greater VFD28 compared to the control group (21 vs. 14.5 days, p = .04). Lower rates of benzodiazepine (42.4% vs. 84.8%, p < .001) and opioid (24.2 vs. 78.8, p < .001) infusion use occurred in the protocol group, resulting in lower cumulative doses per ventilator-day through day 7. The protocol group had more documented sedation scores within target range. There were no differences in ICU delirium, SICU or hospital length of stay. CONCLUSIONS A nursing-driven ASP with criteria for infusion initiation in mechanically-ventilated SICU patients may increase ventilator-free time, maintain patients at the target sedation goal, and reduce opioid and benzodiazepine utilization.
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Affiliation(s)
- Justin B Kaplan
- Department of Pharmacy, The Ohio State University Wexner Medical Center, 410 W. 10th Avenue, Columbus, OH 43210, USA
| | - Daniel S Eiferman
- Department of Surgery, Division of Critical Care, Trauma, and Burn, The Ohio State University Wexner Medical Center, 410 W. 10th Avenue, Columbus, OH 43210, USA
| | - Kyle Porter
- Center for Biostatistics, Department of Biomedical Informatics, College of Medicine, The Ohio State University, 1800 Cannon Drive, Columbus, OH 432101, USA
| | - Jennifer MacDermott
- Center for Quality and Education, The Ohio State University Wexner Medical Center, 410 W. 10th Avenue, Columbus, OH 43210, USA
| | - Jessica Brumbaugh
- The Ohio State University College of Pharmacy, 217 Lloyd M Parks Hall, 500 W. 12th Avenue, Columbus, OH 43210, USA
| | - Claire V Murphy
- Department of Pharmacy, The Ohio State University Wexner Medical Center, 410 W. 10th Avenue, Columbus, OH 43210, USA.
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Interprofessional Implementation of a Pain/Sedation Guideline on a Trauma Intensive Care Unit. J Trauma Nurs 2017; 23:156-64. [PMID: 27163223 DOI: 10.1097/jtn.0000000000000205] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Trauma patients experience pain and agitation during their hospitalization. Many complications have been noted both in the absence of symptom management and the in presence of oversedation/narcotization. To combat noted untoward effects of pain and sedation management, an interprofessional team convened to develop a pain and sedation guideline for use in a trauma intensive care unit. Guideline development began with a comprehensive review of the literature. With the input of unit stakeholders, a nurse-driven analgosedation guideline was implemented for a 6-month trial. During this time, unit champions were integral to successful trial execution. Outcome measurement included patient and unit outcomes, nursing satisfaction, and a pre- and postimplementation patient comparison. Following implementation, unit length of stay decreased by 4.16% and there was a 17.81% decrease in average time on the ventilator following the initiation of weaning. Patient reports of nurse sensitivity and responsiveness to pain increased from 93.7 to 94.9. Nurses reported satisfaction with the practice change and improvements in care. In comparing pre- and postimplementation patient data, there was a significant decrease in mean analgesic treatment duration and an increase in the use of antipsychotics for delirium management. Following the trial period, this guideline was permanently adopted across the adult critical care service. The development of a nurse-driven analgosedation guideline was noted to be both feasible and successful.
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7
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Dreyfus L, Javouhey E, Denis A, Touzet S, Bordet F. Implementation and evaluation of a paediatric nurse-driven sedation protocol in a paediatric intensive care unit. Ann Intensive Care 2017; 7:36. [PMID: 28341980 PMCID: PMC5366991 DOI: 10.1186/s13613-017-0256-7] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2016] [Accepted: 03/08/2017] [Indexed: 12/02/2022] Open
Abstract
Background Optimal sedation and analgesia is a challenge in paediatric intensive care units (PICU) because of difficulties in scoring systems and specific metabolism inducing tolerance and withdrawal. Excessive sedation is associated with prolonged mechanical ventilation and hospitalisation. Adult and paediatric data suggest that goal-directed sedation algorithms reduce the duration of mechanical ventilation. We implemented a nurse-driven sedation protocol in a PICU and evaluated its impact. Methods We conducted a before and after protocol implementation study in a population of children aged 0–18 years who required mechanical ventilation for at least 24 h between January 2013 and March 2015. After the protocol implementation in January 2014, nurses managed analgesia and sedation following an algorithm that included the COMFORT behaviour scale (COMFORT-B). Duration of mechanical ventilation was the primary outcome; secondary outcomes were total doses and duration of medications, PICU length of stay, incidence of ventilator-associated pneumonia, and occurrence of withdrawal symptoms. Pre–post analysis followed with segmented regression analysis of interrupted time series was used to assess the effect of protocol. Results A total of 200 children were analysed, including 107 before implementation and 93 children after implementation of the protocol. After implementation of the protocol, the total number of COMFORT-B scores per day of mechanical ventilation significantly increased from 3.9 ± 2.5 times during the pre-implementation period to 6.6 ± 3.5 times during the post-implementation period (p < 10−3). Mean duration of mechanical ventilation tended to be lower in the post-implementation period (8.3 ± 7.3 vs 6.6 ± 5.6 days, p = 0.094), but changes in either the trend per trimester from pre-implementation to post-implementation (p = 0.933) or the immediate change after implementation (p = 0.923) were not significant with segmented regression analysis. No significant change between pre- and post-implementation was shown for total dose of sedatives, withdrawal symptoms, agitation episodes, or unplanned endotracheal extubations. Conclusions These results were promising and suggested that implementation of a nurse-driven sedation protocol in a PICU was feasible. Evaluation of sedation and analgesia was better after the protocol implementation; duration of mechanical ventilation and occurrence of withdrawal symptoms tended to be reduced. Electronic supplementary material The online version of this article (doi:10.1186/s13613-017-0256-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Lélia Dreyfus
- Service de réanimation pédiatrique, Hospices Civils de Lyon - Hôpital Femme Mère Enfant, 59, Boulevard Pinel, 69500, Bron, France.
| | - Etienne Javouhey
- Service de réanimation pédiatrique, Hospices Civils de Lyon - Hôpital Femme Mère Enfant, 59, Boulevard Pinel, 69500, Bron, France.,Université Claude-Bernard Lyon 1, 69008, Lyon, France
| | - Angélique Denis
- Pôle information médicale évaluation recherche, Hospices Civils de Lyon, 162 avenue Lacassagne Bâtiment A, 69003, Lyon, France
| | - Sandrine Touzet
- Pôle information médicale évaluation recherche, Hospices Civils de Lyon, 162 avenue Lacassagne Bâtiment A, 69003, Lyon, France.,HESPER EA 7425, Université Claude Bernard Lyon 1, 69008, Lyon, France
| | - Fabienne Bordet
- Service de réanimation pédiatrique, Hospices Civils de Lyon - Hôpital Femme Mère Enfant, 59, Boulevard Pinel, 69500, Bron, France
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Frade-Mera MJ, Regueiro-Díaz N, Díaz-Castellano L, Torres-Valverde L, Alonso-Pérez L, Landívar-Redondo MM, Muñoz-Pasín R, Terceros-Almanza LJ, Temprano-Vázquez S, Sánchez-Izquierdo-Riera JÁ. [A first step towards safer sedation and analgesia: A systematic evaluation of outcomes and level of sedation and analgesia in the mechanically ventilated critically ill patient]. ENFERMERIA INTENSIVA 2016; 27:155-167. [PMID: 26803376 DOI: 10.1016/j.enfi.2015.10.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2015] [Accepted: 10/19/2015] [Indexed: 10/22/2022]
Abstract
INTRODUCTION Safe analgesia and sedation strategies are necessary in order to avoid under or over sedation, as well as improving the comfort and safety of critical care patients. OBJECTIVES To compare and contrast a multidisciplinary protocol of systematic evaluation and management of analgesia and sedation in a group of critical care patients on mechanical ventilation with the usual procedures. MATERIALS AND METHODS A cohort study with contemporary series was conducted in a tertiary care medical-surgical ICU February to November during 2013 and 2014. The inclusion criteria were mechanical ventilation ≥ 24h and use of sedation by continuous infusion. Sedation was monitored using the Richmond agitation-sedation scale or bispectral index, and analgesia were measured using the numeric rating scale, or behavioural indicators of pain scale. The study variables included; mechanical ventilation time, weaning time, ventilation support time, artificial airway time, continuous sedative infusion time, daily dose and frequency of analgesic and sedative drug use, hospital stay, and ICU and hospital mortality, Richmond agitation-sedation scale, bispectral index, numeric rating scale, and behavioural indicators of pain scale measurements. Kruskal Wallis and Chi2, and a significance of p<.05 were used. RESULTS The study included 153 admissions, 75 pre-intervention and 78 post-intervention, with a mean age of 55.7±13 years old, and 67% men. Both groups showed similarities in age, reason for admission, and APACHE. There were non-significant decreases in mechanical ventilation time 4 (1.4-9.2) and 3.2 (1.4-8.1) days, respectively; p= 0.7, continuous sedative infusion time 6 (3-11) and 5 (3-11) days; p= 0.9, length of hospital stay 29 (18-52); 25 (14-41) days; p= 0.1, ICU mortality (8 vs. 5%; p= 0.4), and hospital mortality (10.6 vs. 9.4%: p= 0.8). Daily doses of midazolam and remifentanil decreased 347 (227-479) mg/day; 261 (159-358) mg/day; p= 0.02 and 2175 (1427-3285) mcg/day; 1500 (715-2740) mcg/day; p= 0.02, respectively. There were increases in the use of remifentanil (32% vs. 51%; p= 0.01), dexmedetomidine (0 vs.6%; p= 0.02), dexketoprofen (60 vs. 76%; p= 0.03), and haloperidol (15 vs.28%; p= 0.04). The use of morphine decreased (71 vs. 54%; p= 0.03). There was an increase in the number of measurements and Richmond agitation-sedation scale scores 6 (3-17); 21 (9-39); p< 0.0001, behavioural indicators of pain scale 6 (3-18); 19(8-33); p< 0.001 and numeric rating scale 4 (2-6); 8 (6-17); p< 0.0001. CONCLUSIONS The implementation of a multidisciplinary protocol of systematic evaluation of analgesia and sedation management achieved an improvement in monitoring and adequacy of dose to patient needs, leading to improved outcomes.
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Affiliation(s)
- M J Frade-Mera
- UCI Polivalente, Hospital Universitario 12 de Octubre, Madrid, España.
| | - N Regueiro-Díaz
- UCI Polivalente, Hospital Universitario 12 de Octubre, Madrid, España
| | - L Díaz-Castellano
- UCI Polivalente, Hospital Universitario 12 de Octubre, Madrid, España
| | - L Torres-Valverde
- UCI Polivalente, Hospital Universitario 12 de Octubre, Madrid, España
| | - L Alonso-Pérez
- UCI Polivalente, Hospital Universitario 12 de Octubre, Madrid, España
| | | | - R Muñoz-Pasín
- UCI Polivalente, Hospital Universitario 12 de Octubre, Madrid, España
| | - L J Terceros-Almanza
- Servicio de Medicina Intensiva, Hospital Universitario 12 de Octubre, Madrid, España
| | - S Temprano-Vázquez
- Servicio de Medicina Intensiva, Hospital Universitario 12 de Octubre, Madrid, España
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Abstract
PURPOSE OF REVIEW There is recognition that the use of sedative drugs in critically ill patients is potentially harmful, particularly in relation to ICU delirium and clinical outcomes. In that context, there is an increasing interest in maintaining light sedation, the use of non-gamma-aminobutyric acid agonist agents and antipsychotics. RECENT FINDINGS The sedative drugs currently available have limitations relating to duration of action, cost or variability in response. Recent reviews and meta-analyses comparing sedatives in ICU patients differ in their findings depending on whether trials in elective cardiac surgical patients are included. Dexmedetomidine does appear to reduce the number of ventilator days in the less sick critically ill patient. There is currently no evidence to support the routine use of antipsychotics in ICU patients to prevent or treat delirium, although they will reduce agitation and they appear to be well tolerated when used in the critically ill patient. Sedation protocols and early mobilization reduce the use of sedative drugs and improve some outcomes but are challenging to implement in practice. SUMMARY The bedside clinician needs to balance the need to sedate the patient and maintain life-saving support, while keeping their patient responsive, cooperative and pain free.
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10
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Impact of Sedation on Cognitive Function in Mechanically Ventilated Patients. Lung 2015; 194:43-52. [PMID: 26559680 DOI: 10.1007/s00408-015-9820-9] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2015] [Accepted: 10/30/2015] [Indexed: 10/22/2022]
Abstract
The practice of sedation dosing strategy in mechanically ventilated patient has a profound effect on cognitive function. We conducted a comprehensive review of outcome of sedation on mental health function in critically ill patients on mechanical ventilation in the intensive care unit (ICU). We specifically evaluated current sedative dosing strategy and the development of delirium, post-traumatic stress disorders (PTSDs) and agitation. Based on this review, heavy dosing sedation strategy with benzodiazepines contributes to cognitive dysfunction. However, outcome for mental health dysfunction is mixed in regard to newer sedatives agents such as dexmedetomidine and propofol. Moreover, studies that examine the impact of sedatives for persistence of PTSD/delirium and its long-term cognitive and functional outcomes for post-ICU patients are frequently underpowered. Most studies suffer from low sample sizes and methodological variations. Therefore, larger randomized controlled trials are needed to properly assess the impact of sedation dosing strategy on cognitive function.
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11
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Stewart ML. Interruptions in enteral nutrition delivery in critically ill patients and recommendations for clinical practice. Crit Care Nurse 2015; 34:14-21; quiz 22. [PMID: 25086090 DOI: 10.4037/ccn2014243] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Malnutrition is common in critically ill patients and is associated with poor outcomes for patients and increased health care spending. Enteral nutrition is the method of choice for nutrition delivery. Enteral nutrition delivery practices vary widely, and underfeeding is widespread in critical care. Interruptions in enteral nutrition due to performance of procedures, positioning, technical issues with feeding accesses, and gastrointestinal intolerance contribute to underfeeding. Strategies such as head-of-bed positioning, use of prokinetic agents, tolerance of higher gastric residual volumes, consideration of postpyloric feeding access, and use of a nutrition support protocol may decrease time spent without nutrition.
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Affiliation(s)
- Melissa L Stewart
- Melissa Stewart is a staff nurse in the medical intensive care unit at the University of Kentucky Chandler Medical Center in Lexington.
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12
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Porhomayon J, Joude P, Adlparvar G, El-Solh AA, Nader ND. The Impact of High Versus Low Sedation Dosing Strategy on Cognitive Dysfunction in Survivors of Intensive Care Units: A Systematic Review and Meta-Analysis. J Cardiovasc Thorac Res 2015; 7:43-8. [PMID: 26191390 PMCID: PMC4492176 DOI: 10.15171/jcvtr.2015.10] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2015] [Accepted: 05/11/2015] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND The practice of low vs. high sedation dosing strategy may impact the cognitive and mental health function in the intensive care unit (ICU). We aim to demonstrate that high sedation strategy will result in change of mental health function in ICU patients. METHODS We performed a systemic search and meta-analysis of medical databases in MEDLINE (from 1966 to March 2013) and EMBASE (from 1980 to March 2013), as well as the Cochrane Library using the MESH terms "Intensive Care Unit," and "Mental Health, for assessing the impact of sedation on posttraumatic stress disorder (PTSD) or anxiety/depression and delirium in the mix ICU setting including cardiac surgery patients. A total of 1216 patients were included in the final analysis. RESULTS We included 11 studies in the final analysis and concluded that high dose sedation strategy resulted in higher incidence of cognitive dysfunction with P value of 0.009. The result for subgroup of delirium showed P = 0.11 and PTSD/depression or anxiety of P = 0.001, Heterogeneity I2 was 64%. Overall analysis was statistically significant with a P value of 0.002. CONCLUSION High sedation dosing strategy will negatively affect cognitive function in critically ill patients. Large randomized trials are needed to address cognitive dysfunction in subgroup of patients with delirium.
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Affiliation(s)
- Jahan Porhomayon
- VA Western New York Healthcare System, Division of Critical Care Medicine, Department of Anesthesiology, State University of New York at Buffalo School of Medicine and Biomedical Sciences, Buffalo, New York, USA
| | - Philippe Joude
- VA Western New York Healthcare System, Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, State University of New York at Buffalo School of Medicine and Biomedical Sciences, Buffalo, New York, USA
| | - Ghazaleh Adlparvar
- Monroe College, State University of New York at Buffalo School of Medicine and Biomedical Sciences, Rochester, New York, USA
| | - Ali A El-Solh
- VA Western New York Healthcare System, Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, State University of New York at Buffalo School of Medicine and Biomedical Sciences, Buffalo, New York, USA
| | - Nader D Nader
- VA Western New York Healthcare System, Division of Cardiothoracic Anesthesia and Pain Medicine, Department of Anesthesiology, State University of New York at Buffalo School of Medicine and Biomedical Sciences, Buffalo, New York, USA
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Balzer F, Weiß B, Kumpf O, Treskatsch S, Spies C, Wernecke KD, Krannich A, Kastrup M. Early deep sedation is associated with decreased in-hospital and two-year follow-up survival. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2015; 19:197. [PMID: 25928417 PMCID: PMC4435917 DOI: 10.1186/s13054-015-0929-2] [Citation(s) in RCA: 92] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/23/2015] [Accepted: 04/15/2015] [Indexed: 12/11/2022]
Abstract
Introduction There is increasing evidence that deep sedation is detrimental to critically ill patients. The aim of this study was to examine effects of deep sedation during the early period after ICU admission on short- and long-term survival. Methods In this observational, matched-pair analysis, patients receiving mechanical ventilation that were admitted to ICUs of a tertiary university hospital in six consecutive years were grouped as either lightly or deeply sedated within the first 48 hours after ICU admission. The Richmond Agitation-Sedation Score (RASS) was used to assess sedation depth (light sedation: −2 to 0; deep: −3 or below). Multivariate Cox regression was conducted to investigate the impact of early deep sedation within the first 48 hours of admission on in-hospital and two-year follow-up survival. Results In total, 1,884 patients met inclusion criteria out of which 27.2% (n = 513) were deeply sedated. Deeply sedated patients had longer ventilation times, increased length of stay and higher rates of mortality. Early deep sedation was associated with a hazard ratio of 1.661 (95% CI: 1.074 to 2.567; P = 0.022) for in-hospital survival and 1.866 (95% CI: 1.351 to 2.576; P <0.001) for two-year follow-up survival. Conclusions Early deep sedation during the first 48 hours of intensive care treatment was associated with decreased in-hospital and two-year follow-up survival. Since early deep sedation is a modifiable risk factor, this data shows an urgent need for prospective clinical trials focusing on light sedation in the early phase of ICU treatment. Electronic supplementary material The online version of this article (doi:10.1186/s13054-015-0929-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Felix Balzer
- Department of Anaesthesiology and Intensive Care Medicine, Charité - Universitätsmedizin Berlin, Charitéplatz 1, Berlin, 10117, Germany.
| | - Björn Weiß
- Department of Anaesthesiology and Intensive Care Medicine, Charité - Universitätsmedizin Berlin, Charitéplatz 1, Berlin, 10117, Germany.
| | - Oliver Kumpf
- Department of Anaesthesiology and Intensive Care Medicine, Charité - Universitätsmedizin Berlin, Charitéplatz 1, Berlin, 10117, Germany.
| | - Sascha Treskatsch
- Department of Anaesthesiology and Intensive Care Medicine, Charité - Universitätsmedizin Berlin, Charitéplatz 1, Berlin, 10117, Germany.
| | - Claudia Spies
- Department of Anaesthesiology and Intensive Care Medicine, Charité - Universitätsmedizin Berlin, Charitéplatz 1, Berlin, 10117, Germany.
| | - Klaus-Dieter Wernecke
- Charité - Universitätsmedizin Berlin and SOSTANA GmbH, Wildensteiner Straße 27, Berlin, 10318, Germany.
| | - Alexander Krannich
- Coordination Centre for Clinical Trials, Department of Biostatistics, Charité -Universitätsmedizin Berlin, Charitéplatz 1, Berlin, 10117, Germany.
| | - Marc Kastrup
- Department of Anaesthesiology and Intensive Care Medicine, Charité - Universitätsmedizin Berlin, Charitéplatz 1, Berlin, 10117, Germany.
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Ramoo V, Abdullah KL, Tan PS, Wong LP, Chua PY. Intervention to improve intensive care nurses' knowledge of sedation assessment and management. Nurs Crit Care 2014; 21:287-94. [PMID: 25271143 DOI: 10.1111/nicc.12105] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2014] [Revised: 03/25/2014] [Accepted: 04/30/2014] [Indexed: 01/25/2023]
Abstract
BACKGROUND Sedation management is an integral component of critical care practice. It requires the greatest attention of critical care practitioners because it carries significant risks to patients. Therefore, it is imperative that nurses are aware of potential adverse consequences of sedation therapy and current sedation practice recommendations. AIMS AND OBJECTIVES To evaluate the impact of an educational intervention on nurses' knowledge of sedation assessment and management. DESIGNS AND METHODS A quasi-experimental design with a pre- and post-test method was used. The educational intervention included theoretical sessions on assessing and managing sedation and hands-on sedation assessment practice using the Richmond Agitation Sedation Scale. Its effect was measured using self-administered questionnaire, completed at the baseline level and 3 months following the intervention. RESULTS Participants were 68 registered nurses from an intensive care unit of a teaching hospital in Malaysia. Significant increases in overall mean knowledge scores were observed from pre- to post-intervention phases (mean of 79·00 versus 102·00, p < 0·001). Nurses with fewer than 5 years of work experience, less than 26 years old, and with a only basic nursing education had significantly greater level of knowledge improvement at the post-intervention phase compared to other colleagues, with mean differences of 24·64 (p = 0·001), 23·81 (p = 0·027) and 27·25 (p = 0·0001), respectively. A repeated-measures analysis of variance revealed a statistically significant effect of educational intervention on knowledge score after controlling for age, years of work and level of nursing education (p = 0·0001, ηp (2) = 0·431). CONCLUSION An educational intervention consisting of theoretical sessions and hands-on sedation assessment practice was found effective in improving nurses' knowledge and understanding of sedation management. RELEVANCE TO CLINICAL PRACTICE This study highlighted the importance of continuing education to increase nurses' understanding of intensive care practices, which is vital for improving the quality of patient care.
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Affiliation(s)
- Vimala Ramoo
- Department of Nursing Science, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Khatijah L Abdullah
- Department of Nursing Science, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Patrick Sk Tan
- Department of Anaesthesiology, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Li P Wong
- Department of Social and Preventive Medicine, Faculty of Medicine, University of Malaya and Julius Centre University of Malaya (JCUM), Kuala Lumpur, Malaysia
| | - Piaw Y Chua
- Institute of Educational Leadership & Unit for the Enhancement of Academic Performance (ULPA), University of Malaya, Kuala Lumpur, Malaysia
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Porhomayon J, Kolesnikov S, Nader ND. The Impact of Stress Hormones on Post-traumatic Stress Disorders Symptoms and Memory in Cardiac Surgery Patients. J Cardiovasc Thorac Res 2014; 6:79-84. [PMID: 25031821 PMCID: PMC4097856 DOI: 10.5681/jcvtr.2014.018] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2014] [Accepted: 06/02/2014] [Indexed: 11/24/2022] Open
Abstract
The relationship and interactions between stress hormones and post-traumatic stress disorder (PTSD) are well established from both animal and human research studies. This interaction is especially important in the post-operative phase of cardiac surgery where the development of PTSD symptoms will result in increased morbidity and mortality and prolong length of stay for critically ill cardiac surgery patients. Cardiopulmonary bypass itself will independently result in massive inflammation response and release of stress hormones in the perioperative period. Glucocorticoid may reduce this response and result in reduction of PTSD symptom clusters and therefore improve health outcome. In this review, we plan to conduct a systemic review and analysis of the literatures on this topic.
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