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Gil Castillejos D, Rubio ML, Ferre C, de Gracia MDLÁ, Bodí M, Sandiumenge A. Impact of difficult sedation on the management and outcome of critically ill patients. Nurs Crit Care 2020; 27:528-536. [DOI: 10.1111/nicc.12558] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Revised: 09/08/2020] [Accepted: 09/10/2020] [Indexed: 12/22/2022]
Affiliation(s)
| | | | - Carmen Ferre
- Department of Nursing Rovira i Virgili University Tarragona Spain
| | | | - María Bodí
- University Hospital Joan XXIII/IISPV/URV Tarragona/CIBERES Tarragona Spain
| | - Alberto Sandiumenge
- Medical Trasplant Coordinator University Hospital Vall d'Hebron Barcelona Spain
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2
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Schneider R, Puetz A, Vassiliou T, Wiesmann T, Lewan U, Wulf H, Bartsch DK, Rolfes C. The Benefit of Benzodiazepine Reduction: Improving Sedation in Surgical Intensive Care. Indian J Crit Care Med 2017; 21:274-280. [PMID: 28584430 PMCID: PMC5455020 DOI: 10.4103/ijccm.ijccm_67_17] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Aims: Sedation, as it is often required in critical care, is associated with immobilization, prolonged ventilation, and increased morbidity. Most sedation protocols are based on benzodiazepines. The presented study analyzes the benefit of benzodiazepine-free sedation. Methods: In 2008, 134 patients were treated according to a protocol using benzodiazepine and propofol (Group 1). In 2009, we introduced a new sedation strategy based on sufentanil, nonsteroidal anti-inflammatory drugs, neuroleptics, and antidepressants, which was applied in 140 consecutive patients (Group 2). Depth of sedation, duration of mechanical ventilation, duration of Intensive Care Unit, and hospital stay were analyzed. Results: Group 1 had both a longer duration of deep sedation (18.7 ± 2.5 days vs. 12.6 ± 1.85 days, P = 0.031) and a longer duration of controlled ventilation (311, 35 ± 32.69 vs. 143, 96 ± 20.76 h, P < 0.0001) than Group 2. Ventilator days were more frequent in Group 1 (653, 66 ± 98.37 h vs. 478, 89 ± 68.92 h, P = 0.128). Conclusions: The benzodiazepine-free sedation protocol has been shown to significantly reduce depth of sedation and controlled ventilation. Additional evidence is needed to ascertain reduction of ventilator days which would not only be of benefit for the patient but also for the hospital Management.
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Affiliation(s)
- Ralph Schneider
- Department of Visceral, Thoracic and Vascular Surgery, Philipps University Marburg, Germany
| | - Andreas Puetz
- Department of Anaesthesiology and Intensive Care Therapy, Philipps University Marburg, Germany
| | - Timon Vassiliou
- Department of Anaesthesiology and Intensive Care Therapy, Philipps University Marburg, Germany
| | - Thomas Wiesmann
- Department of Anaesthesiology and Intensive Care Therapy, Philipps University Marburg, Germany
| | - Ulrike Lewan
- Department of Anaesthesiology and Intensive Care Therapy, Philipps University Marburg, Germany
| | - Hinnerk Wulf
- Department of Anaesthesiology and Intensive Care Therapy, Philipps University Marburg, Germany
| | - Detlef K Bartsch
- Department of Visceral, Thoracic and Vascular Surgery, Philipps University Marburg, Germany
| | - Caroline Rolfes
- Department of Anaesthesiology and Intensive Care Therapy, Philipps University Marburg, Germany.,Clinic of Anesthesiology and Intensive Care Medicine, University of Cologne, Germany
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3
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Validación transcultural y lingüística de la escala de sedación y agitación Richmond al español. ACTA ACUST UNITED AC 2016. [DOI: 10.1016/j.rca.2016.04.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Chlan LL. Engaging Critically Ill Patients in Symptom Management: Thinking Outside the Box! Am J Crit Care 2016; 25:293-300. [PMID: 27369026 DOI: 10.4037/ajcc2016932] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Caring for critically ill patients receiving mechanical ventilation in the intensive care unit (ICU) is an immense challenge for clinicians. Interventions to maintain physiological stability and life itself can cause a number of adverse effects that have a marked impact on patients beyond the period of critical illness or injury. These ICU-acquired conditions include but are not limited to weakness, depression, and post-intensive care syndrome, all of which markedly affect patients' quality of life after they leave the unit. How best to manage the many symptoms experienced by patients undergoing mechanical ventilation without contributing to adverse ICU-acquired sequelae remains a daunting charge for clinicians and requires innovative "out of the box" approaches to address these complex issues. Systematic, cutting-edge research is needed to challenge the "usual" way of managing ICU patients in order to provide the best available evidence for practice integration that minimizes adverse, ICU-acquired sequelae and improves outcomes for the most vulnerable patients. This article highlights a program of research focused on interventions for managing symptoms in critically ill patients receiving mechanical ventilatory support, including the appropriate empowerment of symptom self-management by patients undergoing mechanical ventilation. Development and testing of innovative, nontraditional interventions specifically tailored for ICU patients receiving mechanical ventilatory support are presented. Music listening is highlighted as a nonpharmacological, adjunctive intervention to reduce anxiety associated with mechanical ventilation. Patient-controlled sedation is discussed as an alternative method to meet patients' highly individual needs for sedative therapy to promote comfort.
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Affiliation(s)
- Linda L. Chlan
- Linda L. Chlan is associate dean for nursing research, Mayo Clinic, Rochester, Minnesota
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Rojas-Gambasica JA, Valencia-Moreno A, Nieto-Estrada VH, Méndez-Osorio P, Molano-Franco D, Jiménez-Quimbaya ÁT, Escobar-Modesto R, Cortés-Rodríguez N, Correa LP. Transcultural and linguistic adaptation of the Richmond Agitation-Sedation Scale to Spanish. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2016. [DOI: 10.1016/j.rcae.2016.04.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Transcultural and linguistic adaptation of the Richmond Agitation-Sedation Scale to Spanish☆. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2016. [DOI: 10.1097/01819236-201644030-00006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Xia ZQ, Chen SQ, Yao X, Xie CB, Wen SH, Liu KX. Clinical benefits of dexmedetomidine versus propofol in adult intensive care unit patients: a meta-analysis of randomized clinical trials. J Surg Res 2013; 185:833-43. [DOI: 10.1016/j.jss.2013.06.062] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2013] [Revised: 06/24/2013] [Accepted: 06/26/2013] [Indexed: 10/26/2022]
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8
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Clinical practice guidelines for evidence-based management of sedoanalgesia in critically ill adult patients. ACTA ACUST UNITED AC 2013. [DOI: 10.1016/j.medine.2013.04.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
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Celis-Rodríguez E, Birchenall C, de la Cal M, Castorena Arellano G, Hernández A, Ceraso D, Díaz Cortés J, Dueñas Castell C, Jimenez E, Meza J, Muñoz Martínez T, Sosa García J, Pacheco Tovar C, Pálizas F, Pardo Oviedo J, Pinilla DI, Raffán-Sanabria F, Raimondi N, Righy Shinotsuka C, Suárez M, Ugarte S, Rubiano S. Guía de práctica clínica basada en la evidencia para el manejo de la sedoanalgesia en el paciente adulto críticamente enfermo. Med Intensiva 2013; 37:519-74. [DOI: 10.1016/j.medin.2013.04.001] [Citation(s) in RCA: 73] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2013] [Accepted: 04/16/2013] [Indexed: 01/18/2023]
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Randomized controlled trial of interrupted versus continuous sedative infusions in ventilated children. Pediatr Crit Care Med 2012; 13:131-5. [PMID: 21283046 DOI: 10.1097/pcc.0b013e31820aba48] [Citation(s) in RCA: 66] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVE To compare daily interruption vs. continuous sedative infusions in mechanically ventilated children with respect to lengths of mechanical ventilation and intensive care unit stay. DESIGN Prospective randomized controlled trial. SETTING Pediatric intensive care unit of a tertiary care teaching and referral hospital. PATIENTS One hundred two patients mechanically ventilated for >48 hrs. INTERVENTIONS Patients were randomized to receive either continuous (group 1) or interrupted (group 2) sedative infusion (midazolam bolus of 0.1 mg/kg, followed by infusion, to achieve a Ramsay score of 3-4). Each patient in group 2 had daily interruption of infusion at 8:00 AM till he/she became fully awake (response to verbal commands) or so agitated/uncomfortable that he/she needed restarting of infusion (whichever was earlier) at a dose 50% less than the previous dose. Primary outcome variables were the lengths of mechanical ventilation and intensive care unit stay, while the number and percentage of days awake on sedative infusions, frequency of adverse events, and total dose of sedatives required were the secondary outcome variables. MEASUREMENTS AND MAIN RESULTS Of the 102 patients included in the study, 56 were randomized into the continuous sedation protocol and 46 into the interrupted sedation protocol. Both were statistically similar with respect to demography, primary diagnosis, severity of illness score (Pediatric Risk of Mortality I and III), indication for mechanical ventilation, and initial ventilatory variables except that the patients under the interrupted arm had lower peak inspiratory pressure and positive end-expiratory pressure requirements at the start of ventilation (p = .002 and p = .028, respectively). The mean (SD) length of mechanical ventilation in the interrupted sedation protocol was significantly less than that in the continuous sedation protocol (7.0 ± 4.8 days vs. 10.3 ± 8.4 days; p = .021). Similarly, the difference in the median duration of pediatric intensive care unit stay was significantly less in the interrupted sedation as compared to the continuous sedation protocol (10.7 days vs. 14.0 days; p = .048). The mean total dose of midazolam and the total calculated cost of midazolam in the former were significantly less compared to those of the latter (7.1 ± 4.7 mL vs. 10.9 ± 6.9 mL, p = .002; 4827 ± 5445 rupees vs. 13,865 ± 25,338 rupees, p = .020). The frequencies of adverse events in both the groups were however similar. CONCLUSION The length of mechanical ventilation, duration of intensive care unit stay, total dose of midazolam, and average calculated cost of the therapy were significantly reduced in the interrupted as compared to the continuous group of sedation.
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Han L, Li JP, Sit JWH, Chung L, Jiao ZY, Ma WG. Effects of music intervention on physiological stress response and anxiety level of mechanically ventilated patients in China: a randomised controlled trial. J Clin Nurs 2010; 19:978-87. [PMID: 20492042 DOI: 10.1111/j.1365-2702.2009.02845.x] [Citation(s) in RCA: 82] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
AIM To examine the effects of music intervention on the physiological stress response and the anxiety level among mechanically ventilated patients in intensive care unit. BACKGROUND Despite the fact that previous studies have found music interventions to be effective in stress and anxiety reduction, effects of music on the Chinese population are inconclusive and warranted systematic study to evaluate its effect fully for a different Asian culture. DESIGN A randomised placebo-controlled trial. METHODS A total of 137 patients receiving mechanical ventilation were randomly assigned to either music listening group, headphone group or control group. Outcome measures included the Chinese version of Spielberger State-Trait Anxiety Scale and physiological parameters (heart rate, respiratory rate, saturation of oxygen and blood pressure). RESULTS Comparison of mean differences (pretest score-posttest score) showed significant differences in heart rate, respiratory rate, systolic blood pressure and diastolic blood pressure as well as the Chinese version of Spielberger State-Trait Anxiety Scale, but not in SaO(2) among the three groups (ranging from p < 0.001 to p = 0.007), of which greater mean differences were found in music listening group. A significant reduction in physiological stress response (heart rate and respiratory rate) over time was found in music listening group (p < 0.001 for both variables) and a significant increase in heart rate and respiratory rate over time in control group (p < 0.001 and p = 0.032), with no significant change over time in headphone group. Within group pretest-posttest comparison of the Chinese version of Spielberger State-Trait Anxiety Scale demonstrated a significant reduction in anxiety for the music listening group (p < 0.001) and headphone group (p < 0.001) but not the control group. CONCLUSIONS Our findings confirm that short-term therapeutic effects of music listening results in substantial reduction in physiological stress responses arising from anxiety in mechanically ventilated patients. RELEVANCE TO CLINICAL PRACTICE Music as a non-pharmacological nursing intervention can be used as complementary adjunct in the care of patients with low-energy states who tire easily, such as those requiring mechanical ventilator support.
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Affiliation(s)
- Lin Han
- School of Nursing, The West China Medical College, Sichuan University, Chengdu, China
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12
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Abstract
The potential clinical applications of active control for pharmacology in general, and anesthesia and critical care unit medicine in particular, are clearly apparent. Specifically, monitoring and controlling the depth of anesthesia in surgery and the intensive care unit is of particular importance. Nonnegative and compartmental models provide a broad framework for biological and physiological systems, including clinical pharmacology, and are well suited for developing models for closed-loop control for drug administration. These models are derived from mass and energy balance considerations that involve dynamic states whose values are nonnegative and are characterized by conservation laws (e.g., mass, energy, fluid, etc.) capturing the exchange of material between kinetically homogenous entities called compartments. Compartmental models have been particularly important for understanding pharmacokinetics and pharmacodynamics. One of the basic motivations for pharmacokinetic/pharmacodynamic research is to improve drug delivery. In critical care medicine it is current clinical practice to administer potent drugs that profoundly influence levels of consciousness, respiratory, and cardiovascular function by manual control based on the clinician's experience and intuition. Open-loop control (manual control) by clinical personnel can be tedious, imprecise, time-consuming, and sometimes of poor quality, depending on the skills and judgement of the clinician. Closed-loop control based on appropriate dynamical systems models merits investigation as a means of improving drug delivery in the intensive care unit. In this article, we discuss the challenges and opportunities of feedback control using nonnegative and compartmental system theory for the specific problem of closed-loop control of intensive care unit sedation. Several closed-loop control paradigms are investigated including adaptive control, neural network adaptive control, optimal control, and hybrid adaptive control algorithms for intensive care unit sedation.
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13
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Chlan L. A review of the evidence for music intervention to manage anxiety in critically ill patients receiving mechanical ventilatory support. Arch Psychiatr Nurs 2009; 23:177-9. [PMID: 19327560 DOI: 10.1016/j.apnu.2008.12.005] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2008] [Accepted: 12/12/2008] [Indexed: 11/30/2022]
Abstract
Critically ill patients receiving mechanical ventilatory support experience profound anxiety with this common treatment modality. Music intervention is one adjunctive therapy that can be implemented to allay anxiety. This article reviews the evidence support music as an adjunctive intervention with mechanically ventilated patients.
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Affiliation(s)
- Linda Chlan
- University of Minnesota, School of Nursing, 5-160 Weaver-Densford Hall, 308 Harvard St. SE, Minneapolis, MN 55455, USA.
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Belda JF, Soro M, Badenes R, Meiser A, García ML, Aguilar G, Martí FJ. The predictive performance of a pharmacokinetic model for manually adjusted infusion of liquid sevofluorane for use with the Anesthetic-Conserving Device (AnaConDa): a clinical study. Anesth Analg 2008; 106:1207-14, table of contents. [PMID: 18349194 DOI: 10.1213/ane.0b013e31816782ff] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND The Anesthetic-Conserving Device (AnaConDa) can be used to administer inhaled anesthetics using an intensive care unit (ICU) ventilator. We evaluated the predictive performance of a simple manually adjusted pump infusion scheme, for infusion of liquid sevoflurane to the AnaConDa. METHODS We studied 50 ICU patients who received sevoflurane via the AnaConDa. They were randomly divided into three groups. A 6-h infusion of liquid anesthetic was adjusted according to the infusion scheme to a target end-tidal sevoflurane concentration of 1% (Group 1%, n = 15) and 1.5% (Group 1.5%, n = 15). The initial rate was adjusted to reach the target concentration in 10 min and then the infusion was reduced to the first hour maintenance rate and readjusted once each hour afterwards. The actual concentrations were measured in the breathing circuit and compared with the target values. In the third group (n = 20) we used the model to increase and decrease the target concentration (+/-0.3%) for 3 h and evaluated the actual change in concentration achieved. The ability of the infusion scheme to provide the target concentration was quantified by calculating the performance error (PE). Infusion scheme performance was evaluated in terms of accuracy (median absolute PE, MDAPE) and bias (median PE, MDPE). RESULTS Performance parameters (mean +/- SD, %) were for 1%, 1.5%, increase of concentration by 0.3% and decrease of concentration by 0.3% groups, respectively: MDAPE 5.3 +/- 5.5, 2.6 +/- 4.0, 5.0 +/- 5.6, 5.5 +/- 5.4; MDPE -5.3 +/- 5.5, -2.3 +/- 4.1, -0.1 +/- 7.1, 0.2 +/- 5.4. No significant differences were found between means of all performance parameters when the 1% and 1.5% groups were compared. CONCLUSIONS There is an excellent 6-h predictive performance of a simplified pharmacokinetic model for manually adjusted infusion of liquid sevoflurane when using the AnaConDa to deliver sevoflurane to ICU patients.
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Affiliation(s)
- Javier F Belda
- Anesthesiology and Intensive Care Department, Hospital Clínico Universitario de Valencia, Avenida Blasco Ibáñez, 17. 46010 Valencia, Spain.
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Rose RL, Bucknall T. Staff perceptions on the use of a sedation protocol in the intensive care setting. Aust Crit Care 2008; 17:151-9. [PMID: 18038524 DOI: 10.1016/s1036-7314(04)80020-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
Sedation protocols are increasingly being investigated as a method of achieving improved patient outcomes whilst guiding the decision making of both nursing and medical practitioners. However, only a limited number of studies have investigated the perceptions of staff towards a sedation protocol during its implementation. This study was designed to survey the perceptions of staff regarding the implementation of a sedation protocol in an Australian intensive care unit (ICU). Questionnaires were distributed to all multidisciplinary team members who had used the sedation protocol. The response rate was 50% (n=70). The questionnaire combined the use of visual analogue scales plus a comments section to obtain qualitative data. The results revealed that staff perceived sedation management to be enhanced with the use of a protocol and therefore should be incorporated into routine clinical practice. Staff perceived that providing clear guidelines that facilitated decision making and assisted beginner practitioners enhanced sedation management. In addition, there was a perceived improvement in the patient outcomes, including a decrease in the frequency of over-sedation resulting in a reduced ICU stay. Positive perceptions may assist in the introduction of other interventional protocols. Other protocols may target areas where variability in clinical decision making exists, despite research evidence that supports specific therapeutic interventions. Further studies addressing protocol implementation for clinical interventions are warranted in other ICU settings.
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Affiliation(s)
- R Louise Rose
- Division of Nursing, RMIT University, Bundoora West Campus, Melbourne VIC
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Celis-Rodríguez E, Besso J, Birchenall C, de la Cal M, Carrillo R, Castorena G, Ceraso D, Dueñas C, Gil F, Jiménez E, Meza J, Muñoz M, Pacheco C, Pálizas F, Pinilla D, Raffán F, Raimondi N, Rubiano S, Suárez M, Ugarte S. Guía de práctica clínica basada en la evidencia para el manejo de la sedo-analgesia en el paciente adulto críticamente enfermo. Med Intensiva 2007; 31:428-71. [DOI: 10.1016/s0210-5691(07)74853-2] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Tonner PH, Weiler N, Paris A, Scholz J. Sedation and analgesia in the intensive care unit. Curr Opin Anaesthesiol 2007; 16:113-21. [PMID: 17021449 DOI: 10.1097/00001503-200304000-00003] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Sedation and analgesia are important means of providing care for the critically ill patient. RECENT FINDINGS It is now clear that posttraumatic stress disorders resulting from an intensive care unit stay may be prevented by the right level of sedation. New drug developments but also recent findings in new ventilation strategies allow for a sedation management that is better tailored to an individual's need. Most importantly, regular definition of the appropriate level of sedation and analgesia as well as monitoring of the desired level will help to avoid over- and undersedation and may ultimately improve the outcome of the patient and reduce costs. SUMMARY Sedation and analgesia are now regarded as an integral part of treatment on the intensive care unit instead of being an unpleasant but necessary and minor issue. The importance of monitoring the level of sedation and analgesia has only recently been realized. It remains to be shown that new management strategies including an evaluation of the patient, planned interventions and the choice of drugs will further improve the care for the critically ill.
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Affiliation(s)
- Peter H Tonner
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Kiel, Kiel, Germany.
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Szumita PM, Baroletti SA, Anger KE, Wechsler ME. Sedation and analgesia in the intensive care unit: evaluating the role of dexmedetomidine. Am J Health Syst Pharm 2007; 64:37-44. [PMID: 17189578 DOI: 10.2146/ajhp050508] [Citation(s) in RCA: 74] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
PURPOSE A review highlighting the application of sedatives and analgesics in the intensive care unit (ICU) setting, with a focus on the use of dexmedetomidine, is presented. SUMMARY Relevant and applicable clinical trials that resulted from a search of the literature from 1966 to July 2006 using key search terms such as dexmedetomidine, intensive care unit, sedation, delirium, and analgesia were evaluated. Many agents have been evaluated in the search of the optimal regimen for sedation and analgesia in the ICU, including opioids, benzodiazepines, propofol, and antipsychotic agents. Dexmedetomidine has demonstrated efficacy as a sedative analgesic on the basis of its ability to lower opioid, benzodiazepine, and propofol requirements in clinical trials. The role of dexmedetomidine in ICU clinical practice is limited because of a lack of mortality and other morbidity endpoints, such as ICU length of stay, hospital length of stay, time to extubation, long-term complications after discharge from the ICU, and delirium. The most commonly reported adverse effects of dexmedetomidine are secondary to its effects as an alpha(2)-receptor agonist and are cardiac in nature. A detailed cost analysis may be warranted to justify the relatively high acquisition cost of dexmedetomidine. CONCLUSION Dexmedetomidine may be an effective agent for ICU sedation and analgesia. However, the lack of clinically relevant endpoints in trials, the concern about adverse cardiovascular effects, and the relatively high acquisition cost of this drug limit its use to a select number of patients who may benefit from its distinguished mechanism of action.
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Affiliation(s)
- Paul M Szumita
- Department of Pharmacy, Brigham and Women's Hospital (BWH), Boston, MA 02115-6110, USA.
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Martin J, Franck M, Fischer M, Spies C. Sedation and analgesia in German intensive care units: how is it done in reality? Results of a patient-based survey of analgesia and sedation. Intensive Care Med 2006; 32:1137-42. [PMID: 16741692 DOI: 10.1007/s00134-006-0214-6] [Citation(s) in RCA: 70] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2005] [Accepted: 05/02/2006] [Indexed: 11/29/2022]
Abstract
OBJECTIVE This study carried out the first patient-oriented survey on the practice of analgesia and sedation in German intensive care units, examining whether the goals of early spontaneous breathing and awake, cooperative patients are achieved. DESIGN A postal survey was sent to 261 hospitals in Germany. Each hospital received three patient-oriented forms with questions regarding current agents and techniques for analgesia and sedation of a specific patient. Responses were obtained from 220 (84%) hospitals which returned 305 questionnaires. RESULTS Patients' Ramsay sedation scale was significantly higher in all phases of analgesia and sedation, indicating that the patients were more deeply sedated than currently intended by the therapist. Propofol was used for most of the patients during short-term sedation (57%) and during weaning (48%). The preferred agent for sedation longer than 72[Symbol: see text]h was midazolam (66%). CONCLUSION The choice of agents and techniques for analgesia and sedation in the intensive care unit thus follows the German guidelines. The fact that the patients were more deeply sedated than intended by the therapist in all phases of sedation may be due to the low use of sedation scales and clinical practice guidelines or to the lack of training in using these techniques.
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Affiliation(s)
- Jörg Martin
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, Hospital am Eichert, Eichertstrasse 3, 73035 Göppingen, Germany.
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Chlan L, Savik K, Weinert C. Development of a shortened state anxiety scale from the Spielberger State-Trait Anxiety Inventory (STAI) for patients receiving mechanical ventilatory support. J Nurs Meas 2005; 11:283-93. [PMID: 15633782 DOI: 10.1891/jnum.11.3.283.61269] [Citation(s) in RCA: 66] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Anxiety is a common experience for mechanically ventilated patients. There are a number of established instruments available to measure anxiety. However, there are significant limitations with these instruments, particularly the length of many scales when using them with ill persons. An instrument development study was conducted to develop a shortened scale from the 20-item Spielberger State Anxiety Inventory. Two-hundred ventilated patients were recruited from nine ICUs in the urban Midwest. Exploratory factor analysis techniques were used to create a shortened, 6-item scale, which accounted for 66.6 percent of the variance. A Cronbach's alpha of 0.78 with a correlation of 0.92 to the 20-item version resulted based on a 6-item scale, and the shortened scale retained many of the desirable properties of the full-length version. The shortened version of the Spielberger State Anxiety Inventory generally had good psychometric properties. However, additional research is needed to further validate this shortened scale.
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Affiliation(s)
- Linda Chlan
- University of Minnesota School of Nursing, Minneapolis 55455, USA.
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Chlan LL. Description of anxiety levels by individual differences and clinical factors in patients receiving mechanical ventilatory support. Heart Lung 2003; 32:275-82. [PMID: 12891169 DOI: 10.1016/s0147-9563(03)00096-7] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
BACKGROUND Though anxiety is a common experience for patients receiving mechanical ventilatory support, little is known about how it may vary among patients on the basis of individual or clinical factors. There is an absence of data objectively describing anxiety levels in ventilated patients on the basis of salient factors that could be useful in designing and tailoring interventions. PURPOSE The purpose of this study was to describe anxiety levels in a sample of mechanically ventilated patients by individual differences (eg, gender or ethnicity) and clinical factors (eg, medical indication for and length of mechanical ventilation). SAMPLE Two hundred alert, mechanically ventilated adult patients were recruited from 9 intensive care units in the urban Midwest. METHODS This study was a secondary analysis of existing data that used a descriptive design. Anxiety was assessed via the 20-item Spielberger State Anxiety Inventory. RESULTS Whereas state anxiety varied widely, participants receiving mechanical ventilatory support reported moderate anxiety (mean = 49.2) with comparable levels by gender and ethnicity. Patients receiving ventilatory support for greater than 22 days tended to report slightly higher state anxiety (mean = 54.2) compared with those chronically ventilator dependent (mean = 45.8). Those participants with primarily respiratory diagnoses reported the highest levels (50.5) among the diagnostic groups. Findings from this study document the individual, variable nature of state anxiety. Additional research is needed to further elucidate whether these and other important clinical factors, such as illness severity or dyspnea, affect state anxiety ratings in ventilated patients to guide the researcher and clinician in appropriately testing and tailoring interventions.
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Affiliation(s)
- Linda L Chlan
- University of Minnesota School of Nursing, Minneapolis, Minnesota 55455, USA
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Dial S, Silver P, Bock K, Sagy M. Pediatric sedation for procedures titrated to a desired degree of immobility results in unpredictable depth of sedation. Pediatr Emerg Care 2001; 17:414-20. [PMID: 11753184 DOI: 10.1097/00006565-200112000-00004] [Citation(s) in RCA: 61] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To test the hypothesis that the need to attain immobility during pediatric sedation for procedures determines the depth of sedation, which cannot always be predicted. DESIGN A retrospective review of sedation documents of 301 consecutive sedations of pediatric patients undergoing various procedures SETTING Division of Critical Care sedation service within a children's hospital. MEASUREMENTS AND MAIN RESULTS The medical records and sedation forms of our most recent 301 consecutive sedations were retrospectively reviewed. Based on the data gathered, the patients were categorized according to their achieved level of immobility, their level of consciousness according to the definitions of the American Academy of Pediatrics, the procedures for which sedation was administered, and the sedatives used. A total of 125 males and 89 females received 301 sedations. Their ages ranged from 22 days to 29 years (mean 7 y + 6 y). We recognized four categories of immobility for procedures. In category 1, some motion was allowed during painless and noninvasive procedures to the extent that it did not risk the patient nor hinder the successful performance of the procedures. In category 2, the patients were kept motionless during painless and noninvasive procedures. In category 3, the patients were kept motionless during painful and invasive procedures with the addition of local anesthetic. In category 4, the patients remained motionless throughout their painful or invasive procedure without the use of local anesthetics. There were 32, 10, 156 and 103 sedations in each category, respectively. Conscious sedation (CS) was observed in six sedations (19%) in category 1 of immobility; it was observed in none (0%) in category 2, in 4 sedations (2.6%) in category 3, and in 1 sedation (1%) in category 4. Deep sedation (DS) was noted in 26 category 1 sedations (81%), in 10 category 2 sedations (100%), in 136 category 3 sedations (87%), and in 63 category 4 sedations (61%). General anesthesia (GA) was only observed in categories 3 and 4 in 16 sedations (10%) and 39 sedations (38%), respectively. Intravenous (IV) ketamine, as a single agent or in combination with other agents, was the most frequently used sedative (88%) followed by IV benzodiazepines (64%), propofol (39%), opiates (15%), and barbiturates (5%). A total of 59 (19%) adverse events were encountered during the 301 sedations. In categories 1 and 2, no adverse event (0%) was encountered. In category 3, 19 adverse events took place (32%), and 40 adverse events (68%) (P< 0.05) occurred in category 4. CONCLUSIONS Pediatric sedation results in 4 categories of immobility. Complete immobility during painful and invasive procedures is associated with a higher incidence of adverse events. The depth of sedation (ie, CS, DS, or GA) required to achieve each category of immobility is unpredictable and varies from patient to patient. Thus, granting a limited sedation authority (conscious sedation only) to physicians may be of limited practical value.
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Affiliation(s)
- S Dial
- Division of Pediatric Critical Care Medicine, Schneider Children's Hospital, North Shore - Long Island Jewish Health System, New Hyde Park, New York, USA.
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Soliman HM, Mélot C, Vincent JL. Sedative and analgesic practice in the intensive care unit: the results of a European survey. Br J Anaesth 2001; 87:186-92. [PMID: 11493487 DOI: 10.1093/bja/87.2.186] [Citation(s) in RCA: 204] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Sedation and analgesia are important aspects of patient care on the intensive care unit (ICU), yet relatively little information is available on common sedative and analgesic practice. We sought to assess international differences in the prescription of sedative and analgesic drugs in western European ICUs by means of a short, self-administered questionnaire. Six hundred and forty-seven intensive care physicians from 16 western European countries replied to the questionnaire. Midazolam was used as a sedative often or always by 63% of respondents and propofol by 35%. There were considerable international variations, with midazolam being preferred over propofol in France, Germany, the Netherlands, Norway and Austria. For analgesia, the drugs most commonly used were morphine (33%), fentanyl (33%) and sufentanil (24%). Morphine was preferred over fentanyl and sufentanil in Norway, UK and Ireland, Sweden, Switzerland, the Netherlands, and Spain and Portugal. Fentanyl was preferred in France, Germany and Italy. Sufentanil was preferred in Belgium and Luxemburg and in Austria. Multivariate analysis showed that the combination of midazolam with fentanyl was most often used in France; propofol with morphine in Sweden, the UK and Ireland, and Switzerland; midazolam with morphine in Norway; and propofol with sufentanil in Belgium and Luxemburg, Germany and Italy. The use of a sedation scale varied from 72% in the UK and Ireland to 18% in Austria. When used, the most common sedation scale was the Ramsay scale. This study demonstrates substantial international differences in sedative and analgesic practices in western European ICUs.
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Affiliation(s)
- H M Soliman
- Department of Intensive Care, Erasme University Hospital, Free University of Brussels, Route de Lennik 808, B-1070 Brussels, Belgium
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Arbour R, Esparis B. Osmolar gap metabolic acidosis in a 60-year-old man treated for hypoxemic respiratory failure. Chest 2000; 118:545-6. [PMID: 10936154 DOI: 10.1378/chest.118.2.545] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Affiliation(s)
- R Arbour
- Medical Intensive Care Unit, Albert Einstein Medical Center, Philadelphia, PA, USA.
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Aranda M, Hanson CW. Anesthetics, sedatives, and paralytics. Understanding their use in the intensive care unit. Surg Clin North Am 2000; 80:933-47, x-xi. [PMID: 10897271 DOI: 10.1016/s0039-6109(05)70106-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
This article reviews the use of inhalational, intravenous, and epidural agents used in the operating room and ICU. An emphasis is placed on the rationale for their selection. Additionally, the side effects and expected complications are discussed. By developing expertise with one's own repertoire of sedatives, narcotics, and neuromuscular blocking agents, one may decrease postoperative complications and lengths of stay.
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Affiliation(s)
- M Aranda
- Department of Anesthesia, University of Pennsylvania School of Medicine, Philadelphia, USA.
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Chlan LL. Music therapy as a nursing intervention for patients supported by mechanical ventilation. AACN CLINICAL ISSUES 2000; 11:128-38. [PMID: 11040559 DOI: 10.1097/00044067-200002000-00014] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Music therapy is a nonpharmacologic nursing intervention that can be used as a complementary adjunct in the care of patients supported by mechanical ventilation. This article details the theoretical basis of music therapy for relaxation and anxiety reduction, highlights the research testing the intervention in such patients, and discusses areas of needed research to extend further the implementation of music therapy in critical care nursing practice in an effort to promote a healing environment for patients.
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Affiliation(s)
- L L Chlan
- University of Minnesota School of Nursing, Minneapolis 55455, USA
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Chlan L. Effectiveness of a music therapy intervention on relaxation and anxiety for patients receiving ventilatory assistance. Heart Lung 1998; 27:169-76. [PMID: 9622403 DOI: 10.1016/s0147-9563(98)90004-8] [Citation(s) in RCA: 170] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To test the effects of music therapy on relaxation and anxiety reduction for patients receiving ventilatory assistance. DESIGN Two-group, pretest-posttest experimental design with repeated measures. Subjects randomized to either a 30-minute music condition or a rest period. SETTING Four urban midwestern intensive care units. SUBJECTS Fifty-four alert, nonsedated patients receiving mechanical ventilation. OUTCOME MEASURES State anxiety (pretest and posttest), heart rate, and respiratory rate obtained every 5 minutes for 30 minutes. RESULTS Subjects who received music therapy reported significantly less anxiety posttest (10.1) than those subjects in the control group (16.2). Heart rate and respiratory rate decreased over time for those subjects in the music group as compared with the control group subjects. CONCLUSIONS A single music therapy session was found to be effective for decreasing anxiety and promoting relaxation, as indicated by decreases in heart rate and respiratory rate over the intervention period with this sample of patients receiving ventilatory assistance.
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Affiliation(s)
- L Chlan
- University of Iowa, College of Nursing, Iowa City 52242, USA
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