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Al-Shareef AS, Babkair K, Baljoon JM, Alkhamisi TA, Altwairqi A, Bogari H, Altirkistani B, Alsukhayri N, Ramadan M. Propofol vs Midazolam As the Initial Sedation Strategy for Mechanically Ventilated Patients: A Single-Center Experience From Saudi Arabia. Cureus 2024; 16:e66090. [PMID: 39100810 PMCID: PMC11297677 DOI: 10.7759/cureus.66090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/02/2024] [Indexed: 08/06/2024] Open
Abstract
Background Propofol and midazolam are the most common sedative agents used in critical settings. Propofol and midazolam might have different mortality rates after sedation administration. Some studies mention that propofol is associated with a lower mortality rate than midazolam in mechanically ventilated patients, but other studies have contradicting results. This study aims to compare the 28-day mortality of propofol versus midazolam for patients undergoing mechanical ventilation in the National Guard Hospital Health Affairs (NGHA)-Western Region (WR). Methods A retrospective chart review was conducted at (NGHA-WR) from March 2016 to July 2022. The inclusion criteria were those mechanically ventilated patients aged 18 years or older who were admitted to ICU, where they were given either propofol or midazolam as the initial sedative agent. Those who signed DNR (Do Not Resuscitate) or were contraindicated to sedation, such as allergy, were excluded from the study. Data were retrospectively retrieved and obtained from the Hospital Information System (HIS-BestCare, Saudi-Korean Health Informatics Company, Riyadh, Saudi Arabia) and the Office of Data Intelligence. Results There is a significant difference between the type of sedation and the 28-day mortality rate. Midazolam was associated with higher rates of mortality - 104 (47.93%) when compared to propofol - three (14.29%). Also, patients who used midazolam had longer durations of ICU stay compared to propofol, with a mean number of 19.23 days vs 7.55 days, respectively. Conclusion There is a significant difference regarding the 28-day mortality between patients who were given propofol or midazolam as an initial sedative agent for mechanical ventilation ≥ 24 hours. Moreover, the use of propofol is associated with fewer days of being intubated or being in ICU when compared to midazolam.
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Affiliation(s)
- Ali S Al-Shareef
- Department of Emergency Medicine, Ministry of National Guard-Health Affairs, Jeddah, SAU
- Research Department, King Abdullah International Medical Research Center, Jeddah, SAU
| | - Kholoud Babkair
- Department of Emergency Medicine, Ministry of National Guard-Health Affairs, Jeddah, SAU
- Research Department, King Abdullah International Medical Research Center, Jeddah, SAU
| | - Jamil M Baljoon
- Department of Medicine, College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Jeddah, SAU
- Department of Research, King Abdullah International Medical Research Center, Jeddah, SAU
| | - Tiaf A Alkhamisi
- Department of Surgery, King Abdullah International Medical Research Center, Jeddah, SAU
- Department of Research, King Abdullah International Medical Research Center, Jeddah, SAU
| | - Areen Altwairqi
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Jeddah, SAU
- Department of Research, King Abdullah International Medical Research Center, Jeddah, SAU
| | - Hassan Bogari
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Jeddah, SAU
- Department of Research, King Abdullah International Medical Research Center, Jeddah, SAU
| | - Bsaim Altirkistani
- Department of Emergency Medicine, Ministry of National Guard-Health Affairs, Jeddah, SAU
- Department of Research, King Abdullah International Medical Research Center, Jeddah, SAU
| | - Najd Alsukhayri
- Department of Emergency Medicine, Ministry of National Guard-Health Affairs, Jeddah, SAU
| | - Majed Ramadan
- Department of Biomedical Research, King Abdullah International Medical Research Center, Jeddah, SAU
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Fuchs VF, Simon HV, Soldinger N, Volk T, Meiser A. Neuropsychological follow-up of isoflurane sedated intensive care patients: a substudy of a randomized trial. Minerva Anestesiol 2024; 90:377-385. [PMID: 38482637 DOI: 10.23736/s0375-9393.24.17834-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/22/2024]
Abstract
BACKGROUND Inhaled sedation of intensive care unit (ICU) patients ventilated >24 hours may have long term effects. We hypothesized that isoflurane has a better neuropsychological outcome in a one-year follow-up compared to propofol sedation. METHODS All 66 patients included by the coordinating center of the ISOCONDA study (EudraCT#: 2016-004551-67) took part in this substudy (DRKS00020240). A delirium test (CAM-ICU) was performed 24 hours after end of sedation. Sedation-, ventilator-, ICU- and delirium-free days within 30 days were calculated. Patients were sent five questionnaires one, three and twelve months after ICU discharge: ICU-Memory-tool (ICU-MT), Short-Form-36-Health-survey (SF-36), Posttraumatic-Stress-Scale-14 (PTSS-14), WHO-Five-Well-Being-Index (WHO-5) and Hospital-Anxiety-Depression-Scale (HADS). RESULTS CAM-ICU was positive in 17% of patients, however 68% showed signs of delirium during the ICU stay (no group differences). Mortality was lower after isoflurane (30-days: 1/33 versus 7/33, P=0.024; One-year: 9/33 versus 14/33, P=0.156). Isoflurane led to significantly more sedation- (median [IQR]: 28[25-29] versus 24[21-29], P=0.016), ventilator- (28[24-29] versus 22[4-28], P=0.011), ICU- (23[13-26] versus 11[0-25], P=0.044) and delirium-free days (25[21-29] versus 20[12-28], P=0.031). Return rate of questionnaires was high (87/128). In the ICU-MT, isoflurane patients recalled significantly more factual memories after one year. Generally, the psychological tests suggested a poor quality of life (SF-36), high rates of post-traumatic-stress-disorder (PTSS-14: 38%) and depression (WHO-5: 54%, HADS: 43%), without significant group differences. CONCLUSIONS Isoflurane sedation leads to more delirium free days during the ICU treatment and more factual memories of the ICU stay one year after the ICU stay. However long-term outcome of ventilated ICU patients is poor, and there were no differences between isoflurane and propofol sedation.
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Affiliation(s)
- Verena F Fuchs
- Department of Anesthesiology, Intensive Care and Pain Therapy, Faculty of Medicine, Saarland University Medical Center, Saarland University, Homburg, Germany
- Department of General Pediatrics and Neonatology, Faculty of Medicine, Saarland University Medical Center, Saarland University, Homburg, Germany
| | - Henrik V Simon
- Department of Anesthesiology, Intensive Care and Pain Therapy, Faculty of Medicine, Saarland University Medical Center, Saarland University, Homburg, Germany -
| | - Nina Soldinger
- Department of Anesthesiology, Intensive Care and Pain Therapy, Faculty of Medicine, Saarland University Medical Center, Saarland University, Homburg, Germany
| | - Thomas Volk
- Department of Anesthesiology, Intensive Care and Pain Therapy, Faculty of Medicine, Saarland University Medical Center, Saarland University, Homburg, Germany
| | - Andreas Meiser
- Department of Anesthesiology, Intensive Care and Pain Therapy, Faculty of Medicine, Saarland University Medical Center, Saarland University, Homburg, Germany
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De Bels D, Bousbiat I, Perriens E, Blackman S, Honoré PM. Sedation for adult ICU patients: A narrative review including a retrospective study of our own data. Saudi J Anaesth 2023; 17:223-235. [PMID: 37260674 PMCID: PMC10228859 DOI: 10.4103/sja.sja_905_22] [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: 12/29/2022] [Revised: 01/06/2023] [Accepted: 01/19/2023] [Indexed: 06/02/2023] Open
Abstract
The optimization of patients' treatment in the intensive care unit (ICU) needs a lot of information and literature analysis. Many changes have been made in the last years to help evaluate sedated patients by scores to help take care of them. Patients were completely sedated and had continuous intravenous analgesia and neuromuscular blockades. These three drug classes were the main drugs used for intubated patients in the ICU. During these last 20 years, ICU management went from fully sedated to awake, calm, and nonagitated patients, using less sedatives and choosing other drugs to decrease the risks of delirium during or after the ICU stay. Thus, the usefulness of these three drug classes has been challenged. The analgesic drugs used were primarily opioids but the use of other drugs instead is increasing to lessen or wean the use of opioids. In severe acute respiratory distress syndrome patients, neuromuscular blocking agents have been used frequently to block spontaneous respiration for 48 hours or more; however, this has recently been abolished. Optimizing a patient's comfort during hemodynamic or respiratory extracorporeal support is essential to reduce toxicity and secondary complications.
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Affiliation(s)
- David De Bels
- Intensive Care Unit, Brugmann University Hospital, Brussels, Belgium
| | - Ibrahim Bousbiat
- Intensive Care Unit, Brugmann University Hospital, Brussels, Belgium
| | - Emily Perriens
- Intensive Care Unit, Brugmann University Hospital, Brussels, Belgium
| | - Sydney Blackman
- Intensive Care Unit, Brugmann University Hospital, Brussels, Belgium
| | - Patrick M Honoré
- Department of Intensive Care, CHU UCL Godinne Namur, UCL Louvain Medical School, Yvoir, Belgium
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Prendergast NT, Onyemekwu CA, Potter KM, Tiberio PJ, Turnbull AE, Girard TD. Agitation is a Common Barrier to Recovery of ICU Patients. J Intensive Care Med 2023; 38:208-214. [PMID: 36300248 PMCID: PMC10443676 DOI: 10.1177/08850666221134262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Importance: Agitation is common in mechanically ventilated ICU patients, but little is known about physician attitudes regarding agitation in this setting. Objectives: To characterize physician attitudes regarding agitation in mechanically ventilated ICU patients. Design, Setting, and Participants: We surveyed critical care physicians within a multicenter health system in Western Pennsylvania, assessing attitudes regarding agitation during mechanical ventilation and use of and confidence in agitation management options. We used quantitative clinical vignettes to determine whether agitation influences confidence regarding readiness for extubation. We sent our survey to 332 critical care physicians, of whom 80 (24%) responded and 69 were eligible (had cared for a mechanically ventilated patient in the preceding three months). Main Outcomes and Measures: Respondent confidence in patient readiness for extubation (0-100%, continuous) and frequency of use and confidence in management options (1-5, Likert). Results: Of 69 eligible responders, 61 (88%) agreed agitation is common and 49 (71%) agreed agitation is a barrier to extubation, but only 27 (39%) agreed their approach to agitation is evidence-based. Attitudes regarding agitation did not differ much by practice setting or physician demographics, though respondents working in medical ICUs were more likely (P = .04) and respondents trained in surgery or emergency medicine were less likely (P = .03) than others to indicate that agitation is an extubation barrier. Fifty-three (77%) respondents reported they frequently use non-pharmacologic measures to treat agitation, and 42 (70%) of those who reported they used non-pharmacologic measures during the prior 3 months indicated confidence in their effectiveness. In responses to clinical vignettes, confidence in patient's readiness for extubation was significantly lower if the patient was agitated (P < .001) or tachypneic (P < .001), but the presence of both agitation and tachypnea did not reduce confidence compared with tachypnea alone (P = .24). Conclusions and Relevance: Most critical care physicians consider agitation during mechanical ventilation a common problem and agreed that agitation is a barrier to extubation. Treatment practice varies widely.
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Affiliation(s)
- Niall T Prendergast
- Division of Pulmonary, Allergy, and Critical Care Medicine in the Department of Medicine, 12317University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Chukwudi A Onyemekwu
- Division of Pulmonary, Allergy, and Critical Care Medicine in the Department of Medicine, 12317University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Kelly M Potter
- Clinical Research, Investigation, and Systems Modeling of Acute illness (CRISMA) Center in the Department of Critical Care Medicine, 12317University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Perry J Tiberio
- Division of Pulmonary, Allergy, and Critical Care Medicine in the Department of Medicine, 12317University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Alison E Turnbull
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Timothy D Girard
- Clinical Research, Investigation, and Systems Modeling of Acute illness (CRISMA) Center in the Department of Critical Care Medicine, 12317University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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Zhou Y, Yang J, Wang B, Wang P, Wang Z, Yang Y, Liang G, Jing X, Jin X, Zhang Z, Deng Y, Hu C, Liao X, Yin W, Tang Z, Tian Y, Tao L, Kang Y. Sequential use of midazolam and dexmedetomidine for long-term sedation may reduce weaning time in selected critically ill, mechanically ventilated patients: a randomized controlled study. Crit Care 2022; 26:122. [PMID: 35505432 PMCID: PMC9066885 DOI: 10.1186/s13054-022-03967-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Accepted: 03/28/2022] [Indexed: 02/08/2023] Open
Abstract
Background Current sedatives have different side effects in long-term sedation. The sequential use of midazolam and dexmedetomidine for prolonged sedation may have distinct advantages. We aimed to evaluate the efficacy and safety of the sequential use of midazolam and either dexmedetomidine or propofol, and the use of midazolam alone in selected critically ill, mechanically ventilated patients. Methods This single-center, randomized controlled study was conducted in medical and surgical ICUs in a tertiary, academic medical center. Patients enrolled in this study were critically ill, mechanically ventilated adult patients receiving midazolam, with anticipated mechanical ventilation for ≥ 72 h. They passed the spontaneous breathing trial (SBT) safety screen, underwent a 30-min-SBT without indication for extubation and continued to require sedation. Patients were randomized into group M-D (midazolam was switched to dexmedetomidine), group M-P (midazolam was switched to propofol), and group M (sedation with midazolam alone), and sedatives were titrated to achieve the targeted sedation range (RASS − 2 to 0). Results Total 252 patients were enrolled. Patients in group M-D had an earlier recovery, faster extubation, and more percentage of time at the target sedation level than those in group M-P and group M (all P < 0.001). They also experienced less weaning time (25.0 h vs. 49.0 h; HR1.47, 95% CI 1.05 to 2.06; P = 0.025), and a lower incidence of delirium (19.5% vs. 43.8%, P = 0.002) than patients in group M. Recovery (P < 0.001), extubation (P < 0.001), and weaning time (P = 0.048) in group M-P were shorter than in group M, while the acquisition cost of sedative drug was more expensive than other groups (both P < 0.001). There was no significant difference in adverse events among these groups (all P > 0.05). Conclusions The sequential use of midazolam and dexmedetomidine was an effective and safe sedation strategy for long-term sedation and could provide clinically relevant benefits for selected critically ill, mechanically ventilated patients. Trial registration NCT02528513. Registered August 19, 2015.
Supplementary Information The online version contains supplementary material available at 10.1186/s13054-022-03967-5.
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Affiliation(s)
- Yongfang Zhou
- Department of Critical Care Medicine, West China Hospital of Sichuan University, Guoxue Alley 37#, Wuhou District, Chengdu, 610041, Sichuan, China
| | - Jie Yang
- Department of Critical Care Medicine, West China Hospital of Sichuan University, Guoxue Alley 37#, Wuhou District, Chengdu, 610041, Sichuan, China
| | - Bo Wang
- Department of Critical Care Medicine, West China Hospital of Sichuan University, Guoxue Alley 37#, Wuhou District, Chengdu, 610041, Sichuan, China
| | - Peng Wang
- Department of Critical Care Medicine, West China Hospital of Sichuan University, Guoxue Alley 37#, Wuhou District, Chengdu, 610041, Sichuan, China
| | - Zhen Wang
- Department of Respiratory and Critical Care Medicine, West China Hospital of Sichuan University, Chengdu, 610041, Sichuan, China
| | - Yunqin Yang
- Department of Critical Care Medicine, West China Hospital of Sichuan University, Guoxue Alley 37#, Wuhou District, Chengdu, 610041, Sichuan, China
| | - Guopeng Liang
- Department of Critical Care Medicine, West China Hospital of Sichuan University, Guoxue Alley 37#, Wuhou District, Chengdu, 610041, Sichuan, China
| | - Xiaorong Jing
- Department of Critical Care Medicine, West China Hospital of Sichuan University, Guoxue Alley 37#, Wuhou District, Chengdu, 610041, Sichuan, China
| | - Xiaodong Jin
- Department of Critical Care Medicine, West China Hospital of Sichuan University, Guoxue Alley 37#, Wuhou District, Chengdu, 610041, Sichuan, China
| | - Zhongwei Zhang
- Department of Critical Care Medicine, West China Hospital of Sichuan University, Guoxue Alley 37#, Wuhou District, Chengdu, 610041, Sichuan, China
| | - Yiyun Deng
- Department of Critical Care Medicine, West China Hospital of Sichuan University, Guoxue Alley 37#, Wuhou District, Chengdu, 610041, Sichuan, China
| | - Chenggong Hu
- Department of Critical Care Medicine, West China Hospital of Sichuan University, Guoxue Alley 37#, Wuhou District, Chengdu, 610041, Sichuan, China
| | - Xuelian Liao
- Department of Critical Care Medicine, West China Hospital of Sichuan University, Guoxue Alley 37#, Wuhou District, Chengdu, 610041, Sichuan, China
| | - Wanhong Yin
- Department of Critical Care Medicine, West China Hospital of Sichuan University, Guoxue Alley 37#, Wuhou District, Chengdu, 610041, Sichuan, China
| | - Zhihong Tang
- Department of Critical Care Medicine, West China Hospital of Sichuan University, Guoxue Alley 37#, Wuhou District, Chengdu, 610041, Sichuan, China
| | - Yongming Tian
- Department of Critical Care Medicine, West China Hospital of Sichuan University, Guoxue Alley 37#, Wuhou District, Chengdu, 610041, Sichuan, China
| | - Liyuan Tao
- Research Center of Clinical Epidemiology, Peking University Third Hospital, Beijing, 100191, China
| | - Yan Kang
- Department of Critical Care Medicine, West China Hospital of Sichuan University, Guoxue Alley 37#, Wuhou District, Chengdu, 610041, Sichuan, China.
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Ji K, Gong X, Luan T, Gao X, Zang B. Pain management of nalbuphine and sufentanil in patients admitted intensive care unit of different ages. BMC Emerg Med 2022; 22:50. [PMID: 35346051 PMCID: PMC8961885 DOI: 10.1186/s12873-022-00592-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2021] [Accepted: 02/22/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Pain relief for patients in the intensive care unit (ICU) can improve treatment outcomes and reduce the burden on doctors and nurses. This study aims to report the clinical analgesic and sedative effects of nalbuphine and sufentanil on ICU patients.
Methods
This study retrospectively analyzed the medical records of 87 critically ill patients who received nalbuphine or sufentanil infusion in the ICU, including demographic data, diagnosis, Acute Physiology and Chronic Health Evaluation (APACHE) II, Critical Care Pain Observation Tool (CPOT), Richmond Agitation-Sedation Scale (RASS), systolic and diastolic blood pressure, heart rate and blood oxygen saturation (SpO2). The primary outcomes of this study were CPOT and RASS scores. The secondary outcomes were hemodynamic changes, including systolic blood pressure, diastolic blood pressure, heart rate, and SpO2. The adverse events recorded during pain management, such as hypoxemia, respiration depression and bradycardia, were also collected and analyzed.
Results
None of the patients in both groups experienced episode of hypoxemia, respiration depression and bradycardia. However, age-stratified analyses showed that nalbuphine has a better analgesic effect than sufentanil for patients aged ≤ 60 (P < 0.05). In contrast, sufentanil showed a better analgesic effect than nalbuphine for patients aged > 60 ( P < 0.05). Furthermore, nalbuphine has a significantly better sedative effect than sufentanil for patients aged ≤ 60 (P < 0.05).
Conclusion
ICU patients of different age groups may be suitable for different analgesics. For patients under the age of 60, nalbuphine has better analgesia and sedation than sufentanil, and does not cause respiratory depression and drastic hemodynamic changes.
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Sebastiani A, Bender S, Schäfer MKE, Thal SC. Posttraumatic midazolam administration does not influence brain damage after experimental traumatic brain injury. BMC Anesthesiol 2022; 22:60. [PMID: 35246037 PMCID: PMC8896377 DOI: 10.1186/s12871-022-01592-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Accepted: 02/09/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The benzodiazepine midazolam is a γ-aminobutyric acid (GABA)-A receptor agonist frequently used for sedation or stress control in patients suffering from traumatic brain injury (TBI). However, experimental studies on benzodiazepines have reported divergent results, raising concerns about its widespread use in patients. Some studies indicate that benzodiazepine-mediated potentiation of GABAergic neurotransmission is detrimental in brain-injured animals. However, other experimental investigations demonstrate neuroprotective effects, especially in pretreatment paradigms. This study investigated whether single-bolus midazolam administration influences secondary brain damage post-TBI. METHODS Two different midazolam dosages (0.5 and 5 mg/kg BW), a combination of midazolam and its competitive antagonist flumazenil, or vehicle solution (NaCl 0.9%) was injected intravenously to mice 24 h after experimental TBI induced by controlled cortical impact. Mice were evaluated for neurological and motor deficits using a 15-point neuroscore and the rotarod test. Histopathological brain damage and mRNA expression of inflammatory marker genes were analyzed using quantitative polymerase chain reaction three days after insult. RESULTS Histological brain damage was not affected by posttraumatic midazolam administration. Midazolam impaired functional recovery, and this effect could not be counteracted by administering the midazolam antagonist flumazenil. An increase in IL-1β mRNA levels due to postinjury application of midazolam was reversible by flumazenil administration. However, other inflammatory parameters were not affected. CONCLUSIONS This study merely reports minor effects of a postinjury midazolam application. Further studies focusing on a time-dependent analysis of posttraumatic benzodiazepine administration are required.
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Affiliation(s)
- Anne Sebastiani
- Department of Anesthesiology, HELIOS University Hospital Wuppertal, University of Witten/Herdecke, Heusnerstrasse 40, 42283, Wuppertal, Germany.,Department of Anesthesiology, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Simone Bender
- Department of Anesthesiology, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Michael K E Schäfer
- Department of Anesthesiology, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Serge C Thal
- Department of Anesthesiology, HELIOS University Hospital Wuppertal, University of Witten/Herdecke, Heusnerstrasse 40, 42283, Wuppertal, Germany. .,Department of Anesthesiology, University Medical Center of the Johannes Gutenberg University, Mainz, Germany.
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Moran BL, Myburgh JA, Scott DA. The complications of opioid use during and post-intensive care admission: A narrative review. Anaesth Intensive Care 2022; 50:108-126. [PMID: 35172616 DOI: 10.1177/0310057x211070008] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Opioids are a commonly administered analgesic medication in the intensive care unit, primarily to facilitate invasive mechanical ventilation. Consensus guidelines advocate for an opioid-first strategy for the management of acute pain in ventilated patients. As a result, these patients are potentially exposed to high opioid doses for prolonged periods, increasing the risk of adverse effects. Adverse effects relevant to these critically ill patients include delirium, intensive care unit-acquired infections, acute opioid tolerance, iatrogenic withdrawal syndrome, opioid-induced hyperalgesia, persistent opioid use, and chronic post-intensive care unit pain. Consequently, there is a challenge of optimising analgesia while minimising these adverse effects. This narrative review will discuss the characteristics of opioid use in the intensive care unit, outline the potential short-term and long-term adverse effects of opioid therapy in critically ill patients, and outline a multifaceted strategy for opioid minimisation.
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Affiliation(s)
- Benjamin L Moran
- Critical Care Program, The George Institute of Global Health, Sydney, Australia.,Department of Intensive Care, 90112Gosford Hospital, Gosford Hospital, Gosford, Australia.,Department of Anaesthesia and Pain Medicine, Gosford Hospital, Gosford, Australia.,School of Medicine and Public Health, University of Newcastle, Callaghan, Australia
| | - John A Myburgh
- Critical Care Program, The George Institute of Global Health, Sydney, Australia.,Faculty of Medicine, 7800University of New South Wales, University of New South Wales, Kensington, Australia.,St George Hospital, Kogarah, Australia
| | - David A Scott
- Department of Anaesthesia and Acute Pain Medicine, St Vincent's Hospital, Fitzroy, Australia.,Department of Critical Care, University of Melbourne, Parkville, Australia
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Ghasemiyeh P, Mohammadi-Samani S, Firouzabadi N, Vazin A, Zand F. A brief ICU residents’ guide: Pharmacotherapy, pharmacokinetic aspects and dose adjustments in critically ill adult patients admitted to ICU. TRENDS IN ANAESTHESIA AND CRITICAL CARE 2021. [DOI: 10.1016/j.tacc.2021.05.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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10
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Addiction and the cerebellum with a focus on actions of opioid receptors. Neurosci Biobehav Rev 2021; 131:229-247. [PMID: 34555385 DOI: 10.1016/j.neubiorev.2021.09.021] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Revised: 08/12/2021] [Accepted: 09/12/2021] [Indexed: 01/19/2023]
Abstract
Increasing evidence suggests that the cerebellum could play a role in the higher cognitive processes involved in addiction as the cerebellum contains anatomical and functional pathways to circuitry controlling motivation and saliency. In addition, the cerebellum exhibits a widespread presence of receptors, including opioid receptors which are known to play a prominent role in synaptic and circuit mechanisms of plasticity associated with drug use and development of addiction to opioids and other drugs of abuse. Further, the presence of perineural nets (PNNs) in the cerebellum which contain proteins known to alter synaptic plasticity could contribute to addiction. The role the cerebellum plays in processes of addiction is likely complex, and could depend on the particular drug of abuse, the pattern of use, and the stage of the user within the addiction cycle. In this review, we discuss functional and structural modifications shown to be produced in the cerebellum by opioids that exhibit dependency-inducing properties which provide support for the conclusion that the cerebellum plays a role in addiction.
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Rahmawati IN. Implementing nursing round to deal with unresolved nursing problem on patient with acute pain: A case report. J Public Health Res 2021; 10. [PMID: 33855407 PMCID: PMC8129775 DOI: 10.4081/jphr.2021.2210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 03/22/2021] [Indexed: 12/04/2022] Open
Abstract
Background: The determining factors for improvement of health services quality includes nursing services. Furthermore, a method for providing this quality nursing services is professional nursing care model, and comprises nursing round. However, fewer hospitals implement this due to several barriers including lack of knowledge and practices. This study is, therefore, aimed at identifying improvements in quality of nursing care and solving of patient’s problem by frequent nursing rounds. Design and Method: This study employed a single case report design using exploratory and descriptive methods. A 27-year-old male underwent nephrectomy surgery to treat hydronephrosis. The person still revealed persistent pain in the surgery area even though it has been treated for 3 days. The staff nurses administered nursing round to discuss and solve this problem. The study participation was voluntary, while the involved patient gave the informed consent. The steps of nursing round procedure including preround, round, and post-round were used to solve the problem. Results: The results indicated that nurses discovered blood clots in the patient’s drain during nursing round. The cause of the persistent pain was revealed and used to determine the intervention modification needed. It was recommended to evacuate the blood clot and followed by appropriate pain management. Furthermore, the problem in the patient with acute pain was resolved. Results: The results indicated that nurses discovered blood clots in the patient’s drain during nursing round. The cause of the persistent pain was revealed and used to determine the intervention modification needed. It was recommended to evacuate the blood clot and followed by appropriate pain management. Furthermore, the problem in the patient with acute pain was resolved. Significance for public health The presence of nursing rounds positively impacted patient satisfaction, and has the potential to improve patient-nurse interactions and promote the quality of care. Furthermore, nursing round is a structured intervention providing nurses with the opportunity to identify and solve patient’s needs and problems respectively. The findings on specific related problems are useful to support the evidence provided with regards to the possible benefits. This facilitates improved nurses decision-making abilities based on clinical observations and patient-centered care.
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Rouhi AJ, Zeraatchi A, Rahmani F, Rouhi AJ, Motamed N, Rastin A, Karami A, Nejabatian A. Effect of Oral Midazolam in Pain Relief of Patients Need Nasogastric Tube Insertion: A Clinical Trial Study. J Res Pharm Pract 2020; 9:112-117. [PMID: 33102386 PMCID: PMC7547745 DOI: 10.4103/jrpp.jrpp_19_80] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2019] [Accepted: 12/30/2019] [Indexed: 11/25/2022] Open
Abstract
Objective: Due to the presence of pain during nasogastric tube (NGT) insertion and related complications and lack of positive clinical response of nasopharyngeal anesthesia with lidocaine and the related side effects and limitations in ketamine and intravenous midazolam, this study aims to determine the efficacy of oral midazolam in relieving pain in the patients requiring NGT insertion. Methods: A randomized, triple-blind clinical trial was performed on the patients in the Emergency Department of Zanjan Valiasr and Mousavi Hospitals in Iran, who were nominated for NGT. In each group, 100 patients were examined. Two milligram syrups of midazolam and placebo were administered 20 min before the procedure. In two groups, the pain based on the Visual Analog Scale and satisfaction rate of patients during the NGT insertion were compared. The data were analyzed through the SPSS software version 16.0. Findings: There was no statistically significant difference in the demographic characteristics of two groups. Despite the effects of potential confounding variables, the cause of the referral and indication of NGT, as well as the use of midazolam syrup, had a significant relationship with the outcome, so that midazolam group experienced less pain. The mean and standard deviation of the examined outcomes (feeling of pain and satisfaction with NGT insertion) was statistically significantly different in the midazolam group as compared to the placebo group (P = 0.001). Conclusion: Midazolam was effective in decreasing pain and increasing the satisfaction of patients after NGT insertion. This manuscript is registered in Irct. com with code IRCT20110629006922N4.
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Affiliation(s)
- Asghar Jafari Rouhi
- Department of Emergency Medicine, Moosavi Hospital, Zanjan University of Medical Science, Zanjan, Iran
| | - Alireza Zeraatchi
- Department of Emergency Medicine, Moosavi Hospital, Zanjan University of Medical Science, Zanjan, Iran
| | - Farzad Rahmani
- Department of Emergency Medicine, Sina Hospital, Tabriz University of Medical science, Tabriz, Iran
| | - Asghar Jafari Rouhi
- Department of Clinical Pharmacy (Pharmacotherapy), Drug Applied Research Center, Sina Hospital, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Nima Motamed
- Department of Social Medicine, Zanjan University of Medical Sciences, Zanjan, Iran
| | - Ala Rastin
- Department of Emergency Medicine, Moosavi Hospital, Zanjan University of Medical Science, Zanjan, Iran
| | - Afsaneh Karami
- Department of Infectious Disease, Valiasr Hospital, Zanjan University of Medical Science, Zanjan, Iran
| | - Arezoo Nejabatian
- Department of Emergency Medicine, Moosavi Hospital, Zanjan University of Medical Science, Zanjan, Iran
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Amini-Parikhani M, Ghaffarazad A, Soleimanpour H, Ebrahimi-Bakhtavar H, Rahmani F. Efficacy of adding midazolam to paracetamol in pain control of patients with a primary headache: A randomized, clinical trial study. Turk J Emerg Med 2020; 20:63-68. [PMID: 32587924 PMCID: PMC7305668 DOI: 10.4103/2452-2473.285011] [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: 01/20/2020] [Revised: 02/19/2020] [Accepted: 04/04/2020] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVES: This study aimed to determine the effect of adding intravenous midazolam to paracetamol in the treatment of patients with primary headache referring to the emergency department. METHODS: In a randomized clinical trial, 120 patients (18–65 years old) with primary headache referring to the emergency department were enrolled. Patients were divided into two groups (case: paracetamol + midazolam and control: paracetamol + placebo), and the treatment was administered based on the treatment group. The severity of pain (according to the initial Visual Analog Scale) and at different times after the treatment onset (15, 30, and 60 min) and the degree of satisfaction with the treatment were compared in two groups of patients. RESULTS: There were no statistically difference between the two groups about the median of pain severity at the time of 0 min (case: 8 vs. control: 8), 15 min (case: 6 vs. control: 6), and 30 min (case: 4 vs. control: 4) with P > 0.05. Headache severity at 60 min after the treatment onset in the case group (median: 1) was less than that of the control group (median: 3). There was also a statistically significant difference in the median of patient satisfaction in the case group (case: 9 and control: 7 with P < 0.001) and satisfaction in the case group was higher. CONCLUSIONS: Based on our primary and secondary outcomes and the results of the study, we conclude that adding intravenous midazolam to paracetamol do not improve the therapeutic response ratio over time, but the effect of this intervention appeared after 1 h.
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Affiliation(s)
- Mahin Amini-Parikhani
- Student Research Committee, Tabriz University of Medical Sciences, East Azerbaijan, I. R, Tabriz, Iran
| | - Amir Ghaffarazad
- Emergency Medicine Research Team, Tabriz University of Medical Sciences Tabriz, East Azerbaijan, I. R, Tabriz, Iran
| | - Hassan Soleimanpour
- Cardiovascular Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Haniyeh Ebrahimi-Bakhtavar
- Emergency Medicine Research Team, Tabriz University of Medical Sciences Tabriz, East Azerbaijan, I. R, Tabriz, Iran
| | - Farzad Rahmani
- Emergency Medicine Department, Tabriz University of Medical Sciences, Tabriz, Iran
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Devabhakthuni S, Kapoor K, Verceles AC, Netzer G, Ludmir J, Ramani G, Chaudhry A, Bolgiano M, Pollock JS, Mccurdy MT. Financial impact of an analgosedation protocol for mechanically ventilated patients in a cardiovascular intensive care unit. Am J Health Syst Pharm 2020; 77:14-21. [PMID: 31800956 DOI: 10.1093/ajhp/zxz265] [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] [Indexed: 11/14/2022] Open
Abstract
PURPOSE The primary objective was to evaluate the impact of an analgosedation protocol in a cardiac intensive care unit (CICU) on daily doses and costs of analgesic, sedative, and antipsychotic medications. METHODS We conducted a single-center quasi-experimental study in 363 mechanically ventilated patients admitted to our CICU from March 1, 2011, to April 13, 2013. On March 1, 2012, an analgosedation protocol was implemented. Patients in the pre-implementation group were managed at the cardiologist's discretion, which consisted of a continuous sedative-hypnotic approach and opioids as needed. Patients in the implementation group were managed using this protocol. RESULTS The mean ± S.D. per-patient doses (mg/day) of propofol, lorazepam, and clonazepam decreased with the use of an analgosedation protocol (propofol 132,265.7 ± 12,951 versus 87,980.5 ± 10,564 [p = 0.03]; lorazepam 10.5 ± 7.3 versus 3.3 ± 4.0 [p < 0.001]; clonazepam 9.9 ± 8.3 versus 1.1 ± 0.5 [p = 0.03]). The mean daily cost of propofol and lorazepam also significantly decreased (33.5% reduction in propofol cost [p = 0.03]; 69.0% reduction in lorazepam cost [p < 0.001]). The per-patient dose and cost of fentanyl (mcg/day) declined with analgosedation protocol use (fentanyl 2,274.2 ± 2317.4 versus 1,026.7 ± 981.4 [p < 0.001]; 54.8% decrease in fentanyl cost [p < 0.001]). CONCLUSION The implementation of an analgosedation protocol significantly decreased both the use and cost of propofol, lorazepam, and fentanyl. Further investigation of the clinical impact and cost-effectiveness of a critical care consultation service with implementation of an analgosedation protocol is warranted in the CICU.
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Affiliation(s)
- Sandeep Devabhakthuni
- Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, MD
| | - Karan Kapoor
- Division of Cardiology, Johns Hopkins Medicine, Baltimore, MD
| | - Avelino C Verceles
- Division of Pulmonary and Critical Care, University of Maryland School of Medicine, Baltimore, MD
| | - Giora Netzer
- Division of Pulmonary and Critical Care Medicine, Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD
| | - Jonathan Ludmir
- Cardiology Division, Massachusetts General Hospital, Boston, MA
| | - Gautam Ramani
- Division of Cardiology, University of Maryland School of Medicine, Baltimore, MD
| | - Amal Chaudhry
- Department of Medicine, Inova Fairfax Hospital, Falls Church, VA
| | - Mary Bolgiano
- Department of Emergency Medicine, Baylor College of Medicine, Houston, TX
| | - Jeremy S Pollock
- St. Joseph Cardiovascular Associates, University of Maryland St. Joseph Medical Group, Baltimore, MD
| | - Michael T Mccurdy
- Division of Pulmonary and Critical Care Medicine, Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD
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ADA M, YILMAZ E. Mekanik Ventilatör Desteğindeki Hastaların İntravasküler Girişimler Sırasındaki Ağrı Davranışları. KOCAELI ÜNIVERSITESI SAĞLIK BILIMLERI DERGISI 2020. [DOI: 10.30934/kusbed.617091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Chiu JA, Shergill M, Dhingra V, Ronco JJ, LeBlanc A, Pamplin C, McKeown S, Dodek PM. Variation in the Management of Pain, Agitation, and Delirium in Intensive Care Units in British Columbia. Am J Crit Care 2020; 29:122-129. [PMID: 32114614 DOI: 10.4037/ajcc2020396] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND Pain, agitation, and delirium are associated with negative outcomes in critically ill patients. Reducing variation in pain, agitation, and delirium management among institutions could improve care. OBJECTIVES To define opportunities to improve pain, agitation, and delirium management in intensive care units in British Columbia, Canada. METHODS A 13-item survey was developed to determine practices for assessing and managing pain, agitation, and delirium. Target participants were persons designated as the most informed about pain, agitation, and delirium management at each of the 30 intensive care units in British Columbia. Main measures were protocol use, assessment tool(s) used and frequency, and management approaches. RESULTS All 30 units responded; half of them had a unit-specific pain algorithm. The Behavioral Pain Scale and the numerical rating scale were the most common tools used to assess pain. Sites reported 15 different approaches to pain management: two-thirds used a sedation assessment tool, but some relied on physician diagnoses to identify sedation. Sites reported 18 different approaches to sedation management: most included an algorithm or order set for sedation management, but the most commonly used approach was individualized management by a clinician (17% for sedation and 30% for agitation). Sites reported 22 different approaches for delirium management: more than two-thirds used a delirium measurement instrument, but some relied on physician diagnoses to identify delirium. CONCLUSION Variation in assessment and management of pain, agitation, and delirium in British Columbia intensive care units highlights opportunities to improve care.
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Affiliation(s)
- Judy A. Chiu
- Judy A. Chiu is a project manager at the Centre for Health Evaluation & Outcome Sciences, Vancouver, British Columbia, Canada
| | - Meher Shergill
- Meher Shergill was a consultant at the BC Patient Safety and Quality Council, Vancouver
| | - Vinay Dhingra
- Vinay Dhingra was a physician consultant at the BC Patient Safety and Quality Council and are physicians at the Division of Critical Care Medicine, University of British Columbia, Vancouver
| | - Juan J. Ronco
- Juan J. Ronco was a physician consultant at the BC Patient Safety and Quality Council and are physicians at the Division of Critical Care Medicine, University of British Columbia, Vancouver
| | - Allana LeBlanc
- Allana LeBlanc is a nurse educator at the Vancouver Coastal Health Authority, Vancouver
| | - Chantale Pamplin
- Chantale Pamplin was a consultant at the BC Patient Safety and Quality Council
| | - Shari McKeown
- Shari McKeown was a leader at the BC Patient Safety and Quality Council and a faculty member at Thompson Rivers University, Kamloops, British Columbia
| | - Peter M. Dodek
- Peter M. Dodek is a scientist at the Centre for Health Evaluation and Outcome Sciences and a physician at the Division of Critical Care Medicine, University of British Columbia
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Talsi O, Kiiski Berggren R, Johansson G, Winsö O. A national survey on routines regarding sedation in Swedish intensive care units. Ups J Med Sci 2019; 124:199-202. [PMID: 31119971 PMCID: PMC6758647 DOI: 10.1080/03009734.2019.1616339] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Background: Previous studies concerning sedation in Swedish intensive care units (ICU) have shown variability in drug choices and strategies. Currently, there are no national guidelines on this topic. As an update to a Nordic survey from 2004, and as a follow-up to a recently introduced quality indicator from the Swedish Intensive Care Registry, we performed a national survey. Methods: A digital survey was sent to the ICUs in Sweden, asking for sedation routines regarding hypnosedatives, analgosedatives, protocols, sedation scales, etc. Results: Fifty out of 80 ICUs responded to the survey. All units used sedation scales, and 88% used the RASS scale; 80% used written guidelines for sedation. Propofol and dexmedetomidine were the preferred short-term hypnosedatives. Propofol, dexmedetomidine, and midazolam were preferred for long-term hypnosedation. Remifentanil, morphine, and fentanyl were the most frequently used agents for analgosedation. Conclusions: All ICUs used a sedation scale, an increase compared with previous studies. Concerning the choice of hypno- and analgosedatives, the use of dexmedetomidine, clonidine, and remifentanil has increased, and the use of benzodiazepines has decreased since the Nordic survey in 2004.
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Affiliation(s)
- Oskar Talsi
- Department of Surgical and Perioperative Sciences, Anaesthesiology and Intensive Care Medicine, Umeå University, Umeå, Sweden
| | - Ritva Kiiski Berggren
- Department of Surgical and Perioperative Sciences, Anaesthesiology and Intensive Care Medicine, Umeå University, Umeå, Sweden
- Swedish National Quality Registry for Intensive Care (SIR), Karlstad, Sweden
| | - Göran Johansson
- Department of Surgical and Perioperative Sciences, Anaesthesiology and Intensive Care Medicine, Umeå University, Umeå, Sweden
| | - Ola Winsö
- Department of Surgical and Perioperative Sciences, Anaesthesiology and Intensive Care Medicine, Umeå University, Umeå, Sweden
- CONTACT Ola Winsö Department of Surgical and Perioperative Sciences, Anesthesiology and Intensive Care Medicine, Umeå University, Umeå, Sweden
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Arias-Rivera S, López-López C, Frade-Mera MJ, Via-Clavero G, Rodríguez-Mondéjar JJ, Sánchez-Sánchez MM, Acevedo-Nuevo M, Gil-Castillejos D, Robleda G, Cachón-Pérez M, Latorre-Marco I. Assessment of analgesia, sedation, physical restraint and delirium in patients admitted to Spanish intensive care units. Proyecto ASCyD. ENFERMERIA INTENSIVA 2019; 31:3-18. [PMID: 31003871 DOI: 10.1016/j.enfi.2018.11.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2018] [Revised: 11/15/2018] [Accepted: 11/23/2018] [Indexed: 01/25/2023]
Abstract
AIMS Main aim: To determine the Spanish intensive care units (ICU) that assess and record pain levels, sedation/agitation, delirium and the use of physical restraint (PR) as standard practice. Secondary aims: To determine the use of validated assessment tools and to explore patients' levels of pain and sedation/agitation, the prevalence of delirium, and the use of PR. METHOD An observational, descriptive, cross-sectional, prospective and multicentre study using an ad hoc survey with online access that consisted of 2 blocks. Block I: with questions on the unit's characteristics and routine practice; Block II: aspects of direct care and direct assessments of patients admitted to participating units. RESULTS One hundred and fifty-eight units and 1574 patients participated. The pain of communicative patients (CP) was assessed and recorded as standard in 109 units (69%), the pain of non-communicative patients (NCP) in 84 (53%), sedation/agitation in 111 (70%), and delirium in 39 units (25%). There was recorded use of PR in 39 units (25%). Validated scales were used to assess the pain of CP in 139 units (88%), of NCP in 102 (65%), sedation/agitation in 145 (92%), delirium in 53 units (34%). In 33 units (21%) pain, sedation/agitation and delirium of PC and NPC was assessed, and in 8 of these units there was a specific PR protocol and register. Among the patients who could be assessed, an absence of pain was reported in 57%, moderate pain in 27%; 48% were calm and collaborative, and 10% agitated; 21% had PR, and 12.6% of the patients had delirium. CONCLUSIONS The assessment of pain, sedation and delirium is demonstrated, and low percentages of agitation and delirium achieved. We observed a high percentage of patients with pain, and moderate use of PC. We should generalise the use of protocols to assess, prevent and treat pain and delirium by appropriately managing analgesia, sedation, and individual and well-considered use of PC. (ClinicalTrials.gov Identifier: NCT03773874).
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Affiliation(s)
- S Arias-Rivera
- Hospital Universitario de Getafe, Getafe, Madrid, España; CIBER Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, España; Grupo de Trabajo de Analgesia, Sedación, Contenciones y Delirio de la Sociedad Española de Enfermería Intensiva y Unidades Coronarias (GT-ASCyD-SEEIUC), España.
| | - C López-López
- Grupo de Trabajo de Analgesia, Sedación, Contenciones y Delirio de la Sociedad Española de Enfermería Intensiva y Unidades Coronarias (GT-ASCyD-SEEIUC), España; Hospital Universitario 12 de Octubre, Madrid, España; Instituto de Investigación Sanitaria Hospital 12 de Octubre (Imas12), Madrid, España; Facultad de Enfermería, Fisioterapia y Podología, Universidad Complutense, Madrid, España
| | - M J Frade-Mera
- Grupo de Trabajo de Analgesia, Sedación, Contenciones y Delirio de la Sociedad Española de Enfermería Intensiva y Unidades Coronarias (GT-ASCyD-SEEIUC), España; Hospital Universitario 12 de Octubre, Madrid, España; Facultad de Enfermería, Fisioterapia y Podología, Universidad Complutense, Madrid, España
| | - G Via-Clavero
- Grupo de Trabajo de Analgesia, Sedación, Contenciones y Delirio de la Sociedad Española de Enfermería Intensiva y Unidades Coronarias (GT-ASCyD-SEEIUC), España; Hospital Universitari de Bellvitge (GRIN-IDIBELL), Hospitalet de Llobregat, Barcelona, España
| | - J J Rodríguez-Mondéjar
- Grupo de Trabajo de Analgesia, Sedación, Contenciones y Delirio de la Sociedad Española de Enfermería Intensiva y Unidades Coronarias (GT-ASCyD-SEEIUC), España; Gerencia de Urgencias y Emergencias 061, Servicio Murciano de Salud, Murcia, España; Universidad de Murcia, Instituto Murciano de Investigación Biomédica del HCU Virgen de la Arrixaca (IMIB-Arrixaca), Murcia, España
| | - M M Sánchez-Sánchez
- Hospital Universitario de Getafe, Getafe, Madrid, España; Grupo de Trabajo de Analgesia, Sedación, Contenciones y Delirio de la Sociedad Española de Enfermería Intensiva y Unidades Coronarias (GT-ASCyD-SEEIUC), España
| | - M Acevedo-Nuevo
- Grupo de Trabajo de Analgesia, Sedación, Contenciones y Delirio de la Sociedad Española de Enfermería Intensiva y Unidades Coronarias (GT-ASCyD-SEEIUC), España; Hospital Universitario Puerta de Hierro Majadahonda, Majadahonda, Madrid, España; Instituto de Investigación Sanitaria Puerta de Hierro-Segovia de Arana (IDIPHISA), Majadahonda, Madrid, España; Facultad de Ciencias de la Salud, Universidad Autónoma de Madrid, Madrid, España
| | - D Gil-Castillejos
- Grupo de Trabajo de Analgesia, Sedación, Contenciones y Delirio de la Sociedad Española de Enfermería Intensiva y Unidades Coronarias (GT-ASCyD-SEEIUC), España; Hospital Universitario Juan XXIII, Tarragona, España
| | - G Robleda
- Grupo de Trabajo de Analgesia, Sedación, Contenciones y Delirio de la Sociedad Española de Enfermería Intensiva y Unidades Coronarias (GT-ASCyD-SEEIUC), España; Escuela Superior de Enfermería Mar (ESIMar), Universidad Pompeu Fabra, Barcelona, España; Centro Cochrane Iberoamericano, Hospital de la Santa Creu i Sant Pau, Barcelona, España
| | - M Cachón-Pérez
- Grupo de Trabajo de Analgesia, Sedación, Contenciones y Delirio de la Sociedad Española de Enfermería Intensiva y Unidades Coronarias (GT-ASCyD-SEEIUC), España; Facultad de Ciencias Biomédicas y de la Salud, Universidad Europea de Madrid, Villaviciosa de Odón, Madrid, España
| | - I Latorre-Marco
- Grupo de Trabajo de Analgesia, Sedación, Contenciones y Delirio de la Sociedad Española de Enfermería Intensiva y Unidades Coronarias (GT-ASCyD-SEEIUC), España; Hospital Universitario Puerta de Hierro Majadahonda, Majadahonda, Madrid, España; Instituto de Investigación Sanitaria Puerta de Hierro-Segovia de Arana (IDIPHISA), Majadahonda, Madrid, España
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Panahi Y, Dehcheshmeh HS, Mojtahedzadeh M, Joneidi-Jafari N, Johnston TP, Sahebkar A. Analgesic and sedative agents used in the intensive care unit: A review. J Cell Biochem 2018; 119:8684-8693. [PMID: 30076655 DOI: 10.1002/jcb.27141] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Accepted: 05/18/2018] [Indexed: 11/10/2022]
Abstract
Pain is a common experience for most patients in the intensive care unit (ICU). In the current study, the advantages and disadvantages of analgesic and sedative drugs used in the ICU are reviewed. An ideal sedative and analgesic agent should have features such as rapid onset of action, rapid recovery after discontinuation, predictability, minimal accumulation of the agent and metabolites in the body, and lack of toxicity. None of the sedative and analgesic agents have all of these desired characteristics; nevertheless, clinicians must be familiar with these classes of drugs to optimize pharmacotherapy and ensure as few side-effects as possible for ICU patients.
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Affiliation(s)
- Yunes Panahi
- Pharmacotherapy Department, School of Pharmacy, Baqiyatallah University of Medical Sciences, Tehran, Iran
| | | | - Mojtaba Mojtahedzadeh
- Clinical Pharmacy Department, Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran.,Research Center for Rational Use of Drugs, Tehran University of Medical Sciences, Tehran, Iran
| | | | - Thomas P Johnston
- Division of Pharmaceutical Sciences, School of Pharmacy, University of Missouri-Kansas City, Kansas City, Missouri
| | - Amirhossein Sahebkar
- Neurogenic Inflammation Research Center, Mashhad University of Medical Sciences, Mashhad, Iran.,Biotechnology Research Center, Pharmaceutical Technology Institute, Mashhad University of Medical Sciences, Mashhad, Iran.,School of Pharmacy, Mashhad University of Medical Sciences, Mashhad, Iran
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Wang J, Peng ZY, Zhou WH, Hu B, Rao X, Li JG. A National Multicenter Survey on Management of Pain, Agitation, and Delirium in Intensive Care Units in China. Chin Med J (Engl) 2018; 130:1182-1188. [PMID: 28485318 PMCID: PMC5443024 DOI: 10.4103/0366-6999.205852] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
Background: The management of pain, agitation, and delirium (PAD) in Intensive Care Unit (ICU) is beneficial for patients and makes it widely applied in clinical practice. Previous studies showed that the clinical practice of PAD in ICU was improving; yet relatively little information is available in China. This study aimed to investigate the practice of PAD in ICUs in China. Methods: A multicenter, nationwide survey was conducted using a clinician-directed questionnaire from September 19 to December 18, 2016. The questionnaire focused on the assessment and management of PAD by the clinicians in ICUs. The practice of PAD was compared among the four regions of China (North, Southeast, Northwest, and Southwest). The data were expressed as percentage and frequency. The Chi-square test, Fisher's exact test, and line-row Chi-square test were used. Results: Of the 1011 valid questionnaire forms, the response rate was 80.37%. The clinicians came from 704 hospitals across 158 cities of China. The rate of PAD assessment was 75.77%, 90.21%, and 66.77%, respectively. The rates of PAD scores were 45.8%, 68.94%, and 34.03%, respectively. The visual analog scale, Richmond agitation-sedation scale, and confusion assessment method for the ICU were the first choices of scales for PAD assessment. Fentanyl, midazolam, and dexmedetomidine were the first choices of agents for analgesic, sedation, and delirium treatment. While choosing analgesics and sedatives, the clinicians put the pharmacological characteristics of drugs in the first place (66.07% and 76.36%). Daily interruption for sedation was carried out by 67.26% clinicians. Most of the clinicians (87.24%) used analgesics while using sedatives. Of the 738 (73%) clinicians titrating the sedatives on the basis of the proposed target sedation level, 268 (26.61%) clinicians just depended on their clinical experience. Totally, 519 (51.34%) clinicians never used other nondrug strategies for PAD. The working time of clinicians was an important factor in the management of analgesia and sedation rather than their titles and educational background. The ratios of pain score and sedation score in the Southwest China were the highest and the North China were the lowest. The ratios of delirium assessment and score were the same in the four regions of China. Moreover, the first choices of scales for PAD in the four regions were the same. However, the top three choices of agents in PAD treatment in the four regions were not the same. Conclusions: The practice of PAD in China follows the international guidelines; however, the pain assessment should be improved. The PAD practice is a little different across the four regions of China; however, the trend is consistent. Trial Registration: The study is registered at http://www.clinicaltrials.gov (No. ChiCTR-OOC-16009014, www.chictr.org.cn/index.aspx.).
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Affiliation(s)
- Jing Wang
- Department of Intensive Care Unit, Zhongnan Hospital of Wuhan University, Wuhan, Hubei 430071, China
| | - Zhi-Yong Peng
- Department of Intensive Care Unit, Zhongnan Hospital of Wuhan University, Wuhan, Hubei 430071, China
| | - Wen-Hai Zhou
- Department of Clinical Medicine, City College, Wuhan university of Science and Technology, Wuhan, Hubei 430083, China
| | - Bo Hu
- Department of Intensive Care Unit, Zhongnan Hospital of Wuhan University, Wuhan, Hubei 430071, China
| | - Xin Rao
- Department of Intensive Care Unit, Zhongnan Hospital of Wuhan University, Wuhan, Hubei 430071, China
| | - Jian-Guo Li
- Department of Intensive Care Unit, Zhongnan Hospital of Wuhan University, Wuhan, Hubei 430071, China
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Shetty RM, Bellini A, Wijayatilake DS, Hamilton MA, Jain R, Karanth S, Namachivayam A. BIS monitoring versus clinical assessment for sedation in mechanically ventilated adults in the intensive care unit and its impact on clinical outcomes and resource utilization. Cochrane Database Syst Rev 2018; 2:CD011240. [PMID: 29464690 PMCID: PMC6353112 DOI: 10.1002/14651858.cd011240.pub2] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Patients admitted to intensive care and on mechanical ventilation, are administered sedative and analgesic drugs to improve both their comfort and interaction with the ventilator. Optimizing sedation practice may reduce mortality, improve patient comfort and reduce cost. Current practice is to use scales or scores to assess depth of sedation based on clinical criteria such as consciousness, understanding and response to commands. However these are perceived as subjective assessment tools. Bispectral index (BIS) monitors, which are based on the processing of electroencephalographic signals, may overcome the restraints of the sedation scales and provide a more reliable and consistent guidance for the titration of sedation depth.The benefits of BIS monitoring of patients under general anaesthesia for surgical procedures have already been confirmed by another Cochrane review. By undertaking a well-conducted systematic review our aim was to find out if BIS monitoring improves outcomes in mechanically ventilated adult intensive care unit (ICU) patients. OBJECTIVES To assess the effects of BIS monitoring compared with clinical sedation assessment on ICU length of stay (LOS), duration of mechanical ventilation, any cause mortality, risk of ventilator-associated pneumonia (VAP), risk of adverse events (e.g. self-extubation, unplanned disconnection of indwelling catheters), hospital LOS, amount of sedative agents used, cost, longer-term functional outcomes and quality of life as reported by authors for mechanically ventilated adults in the ICU. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, CINAHL, ProQuest, OpenGrey and SciSearch up to May 2017 and checked references citation searching and contacted study authors to identify additional studies. We searched trial registries, which included clinicaltrials.gov and controlled-trials.com. SELECTION CRITERIA We included all randomized controlled trials comparing BIS versus clinical assessment (CA) for the management of sedation in mechanically ventilated critically ill adults. DATA COLLECTION AND ANALYSIS We used Cochrane's standard methodological procedures. We undertook analysis using Revman 5.3 software. MAIN RESULTS We identified 4245 possible studies from the initial search. Of those studies, four studies (256 participants) met the inclusion criteria. One more study is awaiting classification. Studies were, conducted in single-centre surgical and mixed medical-surgical ICUs. BIS monitor was used to assess the level of sedation in the intervention arm in all the studies. In the control arm, the sedation assessment tools for CA included the Sedation-Agitation Scale (SAS), Ramsay Sedation Scale (RSS) or subjective CA utilizing traditional clinical signs (heart rate, blood pressure, conscious level and pupillary size). Only one study was classified as low risk of bias, the other three studies were classified as high risk.There was no evidence of a difference in one study (N = 50) that measured ICU LOS (Median (Interquartile Range IQR) 8 (4 to 14) in the CA group; 12 (6 to 18) in the BIS group; low-quality evidence).There was little or no effect on the duration of mechanical ventilation (MD -0.02 days (95% CI -0.13 to 0.09; 2 studies; N = 155; I2 = 0%; low-quality evidence)). Adverse events were reported in one study (N = 105) and the effects on restlessness after suction, endotracheal tube resistance, pain tolerance during sedation or delirium after extubation were uncertain due to very low-quality evidence. Clinically relevant adverse events such as self-extubation were not reported in any study. Three studies reported the amount of sedative agents used. We could not measure combined difference in the amount of sedative agents used because of different sedation protocols and sedative agents used in the studies. GRADE quality of evidence was very low. No study reported other secondary outcomes of interest for the review. AUTHORS' CONCLUSIONS We found insufficient evidence about the effects of BIS monitoring for sedation in critically ill mechanically ventilated adults on clinical outcomes or resource utilization. The findings are uncertain due to the low- and very low-quality evidence derived from a limited number of studies.
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Affiliation(s)
- Rajesh M Shetty
- Manipal Hospital WhitefieldDepartment of Critical Care MedicineITPL RoadWhitefieldBangaloreKarnatakaIndia560048
| | - Antonio Bellini
- Barking Havering and Redbridge University Hospitals NHS TrustIntensive Care UnitRom Valley WayRomfordUKRM7 0AG
| | - Dhuleep S Wijayatilake
- Barking Havering and Redbridge University Hospitals NHS TrustAnaesthesia and Neurocritical careRom Valley WayRomfordUKRM7 0AG
| | - Mark A Hamilton
- St. George's HospitalGeneral Intensive Care Unit1st Floor St. James wingBlackshaw RoadLondonUKSW17 0QT
| | - Rajesh Jain
- Barking Havering and Redbridge University Hospitals NHS TrustAnaesthesia and Neurocritical careRom Valley WayRomfordUKRM7 0AG
| | - Sunil Karanth
- Manipal HospitalMultidisciplinary Critical Care Unit98, Old Airport RoadRustombaghBangaloreKarnatakaIndia560017
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Kayir S, Ulusoy H, Dogan G. The Effect of Daily Sedation-Weaning Application on Morbidity and Mortality in Intensive Care Unit Patients. Cureus 2018; 10:e2062. [PMID: 29545985 PMCID: PMC5849345 DOI: 10.7759/cureus.2062] [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] [Indexed: 11/30/2022] Open
Abstract
Background/aims Sedation is one of the most important components of intensive care unit (ICU) in patients who are mechanically ventilated at intensive care conditions. As a result of sedation and analgesia in the intensive care unit, the patient is to be awakened a comfortable and easy process. The aim of the study is to demonstrate the effects of day-time sedation interruptions in intensive care patients. Material and methods We made a retrospective review of 100 patients who were monitored, mechanically ventilated and treated at our intensive care unit between January 2008 and January 2013. Patients were divided into two groups, including Group P (continuous infusion of sedative agent) and Group D (daily sedation interruptions - daily recovery). Demographics, mechanical ventilation time, stay at intensive care unit, hospitalization period, time of first weaning, success of weaning, ventilator-related pneumonia (VRP), total doses of drugs, re-intubation frequency, Acute Physiology and Chronic Health Evaluation II (APACHE II), Sequential Organ Failure Assessment (SOFA) scores and mortality rates of patients were compared. Ramsay Sedation Score (RSS) was used to evaluate the level of sedation. Considering that ideal sedation level is "3" with RSS, RSS < 3 is considered as mild sedation, while RSS > 3 is considered as deep sedation. Results There was no difference between demographics of patients. Mechanical ventilation period was significantly longer in Group P than Group D (p < 0.001). When stay at ICU unit was considered, ICU stay was significantly longer in Group P than Group D (p < 0.001). No statistically significant difference was found between two groups with respect to hospitalization period. In inter-group comparison, time to start first weaning was significantly late in Group P than Group D (p < 0.05). There was no difference between groups in terms of frequency of success of weaning and mortality rate (p > 0.05). In inter-group comparison the frequency of reintubation viewed in Group D was significantly less than in Group P (p < 0.05). Considering development of VRP, it was significantly more common in Group P in comparison with Group D (p < 0.05). No statistically significant difference was found between groups in terms of doses of sedative agents (p > 0.05). Considering doses of opioid analgesics, the total dose of fentanyl was significantly higher in Group P than Group D (p = 0.04), while no difference was found for doses of morphine (p > 0.05). Again, no statistical difference was found in doses of muscle relaxant agents (p > 0.05). Conclusion It was observed that the sedation technique with daily interruption is superior to continuous infusion of sedatives. Accordingly, we believe that daily weaning will make positive contributions to patients who are mechanically ventilated at intensive care unit.
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Affiliation(s)
- Selcuk Kayir
- Anesthesiology and Reanimation, Hitit University Erol Olcok Training and Research Hospital
| | - Hulya Ulusoy
- Anesthesiology and Reanimation, Karadeniz Technical University
| | - Guvenc Dogan
- Anesthesiology and Reanimation, Hitit University Erol Olcok Training and Research Hospital
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Kotfis K, Zegan-Barańska M, Żukowski M, Kusza K, Kaczmarczyk M, Ely EW. Multicenter assessment of sedation and delirium practices in the intensive care units in Poland - is this common practice in Eastern Europe? BMC Anesthesiol 2017; 17:120. [PMID: 28865447 PMCID: PMC5581441 DOI: 10.1186/s12871-017-0415-2] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2017] [Accepted: 08/25/2017] [Indexed: 11/25/2022] Open
Abstract
Background The majority of critically ill patients experience distress during their stay in the Intensive Care Unit (ICU), resulting from systemic illness, multiple interventions and environmental factors. Providing humane care should address concomitant treatment of pain, agitation and delirium. The use of sedation and approaches to ICU delirium should be monitored according to structured guidelines. However, it is unknown to what extent these concepts are followed in Eastern European countries like Poland. The aim of this study was to evaluate sedation and delirium practices in ICUs in Poland, as a representative of the Eastern European block, particularly the implementation of sedation and ICU delirium screening tools, availability of written sedation guidelines, choice of sedation and delirium treatment agents. Methods A national postal survey was conducted in all Polish ICUs in early 2016. Results A total of 165 responses out of 436 addressed units were received (37.8%). Out of responding ICUs delirium is monitored in only 11.9% of the units in Poland. Sedation monitoring tool is used in only 46.1% of units. Only 19.4% of ICUs have written protocols for sedation and 32.1% do not practice daily sedation interruption. The most frequently used agents for short-term sedation (<24 h) were propofol and fentanyl infusions and benzodiazepines (midazolam) and morphine for longer sedation (>24 h). The preferred agents for delirium treatment were haloperidol (77.6%), dexmedetomidine (43.6%) and quetiapine (19.4%). Close to one-third (32.7%) of respondents chose a benzodiazepine (diazepam) for ICU delirium treatment. Non-pharmacological treatment for ICU delirium was reported by only 45% of the respondents. Conclusions A majority of Polish ICUs do not adhere to international guidelines regarding sedation and delirium practices. There continues to be inadequate use of sedation and delirium monitoring tools. High usage of benzodiazepines for sedation and ICU delirium treatment reveals persistence of non-evidence-based practice. This study should prompt further assessment of other Eastern Europe countries and help generate a collective response to update these aspects of patient safety and comfort.
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Affiliation(s)
- Katarzyna Kotfis
- Department of Anaesthesiology, Intensive Therapy and Acute Intoxications, Pomeranian Medical University, Szczecin, Poland.
| | - Małgorzata Zegan-Barańska
- Department of Anaesthesiology, Intensive Therapy and Acute Intoxications, Pomeranian Medical University, Szczecin, Poland
| | - Maciej Żukowski
- Department of Anaesthesiology, Intensive Therapy and Acute Intoxications, Pomeranian Medical University, Szczecin, Poland
| | - Krzysztof Kusza
- Department of Anesthesiology and Intensive Therapy, Poznan University of Medical Sciences University, Poznań, Poland
| | - Mariusz Kaczmarczyk
- Department of Clinical and Molecular Biochemistry, Pomeranian Medical University, Szczecin, Poland
| | - E Wesley Ely
- Department of Medicine/Allergy, Pulmonary and Critical Care, Vanderbilt University School ofMedicine, Vetaran's Affairs Geriatric Research Education Clinical Center (GRECC) for Tennessee Valley, Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, TN, USA
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Zhu Y, Wang Y, Du B, Xi X. Could remifentanil reduce duration of mechanical ventilation in comparison with other opioids for mechanically ventilated patients? A systematic review and meta-analysis. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2017; 21:206. [PMID: 28774327 PMCID: PMC5543734 DOI: 10.1186/s13054-017-1789-8] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/04/2017] [Accepted: 07/05/2017] [Indexed: 02/02/2023]
Abstract
Background Sedation and analgesia are commonly required to relieve anxiety and pain in mechanically ventilated patients. Fentanyl and morphine are the most frequently used opioids. Remifentanil is a selective μ-opioid receptor that is metabolized by unspecific esterases and eliminated independently of liver or renal function. Remifentanil has a rapid onset and offset and a short context-sensitive half-life regardless of the duration of infusion, which may lead to reductions in weaning and extubation. We aimed to compare the efficacy and safety of remifentanil to that of other opioids in mechanically ventilated patients. Methods We conducted a search to identify relevant randomized controlled studies (RCTs) in the PubMed, Embase, Cochrane Library and SinoMed databases that had been published up to 31 December 2016. The results were analysed using weighted mean differences (WMDs) and 95% confidence intervals (CIs). Results Twenty-three RCTs with 1905 patients were included. Remifentanil was associated with reductions in the duration of mechanical ventilation (mean difference -1.46; 95% CI -2.44 to -0.49), time to extubation after sedation cessation (mean difference -1.02; 95% CI -1.59 to -0.46), and ICU-LOS (mean difference -0.10; 95% CI -0.16 to -0.03). No significant differences were identified in hospital-LOS (mean difference -0.05; 95% CI -0.25 to 0.15), costs (mean difference -709.71; 95% CI -1590.98 to 171.55; I2 88%), mortality (mean difference -0.64; 95% CI -1.33 to 0.06; I2 87%) or agitation (mean difference -0.71; 95% CI -1.80 to 0.37; I2 93%). Conclusions Remifentanil seems to be associated with reductions in the duration of mechanical ventilation, time to extubation after cessation of sedation, and ICU-LOS. No significant differences were identified between remifentanil and other opioids in terms of hospital-LOS, costs, mortality or agitation. Electronic supplementary material The online version of this article (doi:10.1186/s13054-017-1789-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Yibing Zhu
- Department of Critical Care Medicine, Fuxing Hospital, Capital Medical University, 20A FuXing Men Wai Da Jie, Xicheng District, Beijing, 100038, China
| | - Yinhua Wang
- Department of Critical Care Medicine, Fuxing Hospital, Capital Medical University, 20A FuXing Men Wai Da Jie, Xicheng District, Beijing, 100038, China.,Department of Critical Care Medicine, North China University of Science and Technology Affiliated Hospital, 73 Jianshe Road, Tangshan, 063000, China
| | - Bin Du
- Medical ICU, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, 1 Shuai Fu Yuan, Beijing, 100730, China.
| | - Xiuming Xi
- Department of Critical Care Medicine, Fuxing Hospital, Capital Medical University, 20A FuXing Men Wai Da Jie, Xicheng District, Beijing, 100038, China.
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Djafarzadeh S, Vuda M, Jeger V, Takala J, Jakob SM. The Effects of Fentanyl on Hepatic Mitochondrial Function. Anesth Analg 2017; 123:311-25. [PMID: 27089001 DOI: 10.1213/ane.0000000000001280] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Remifentanil interferes with hepatic mitochondrial function. The aim of the present study was to evaluate whether hepatic mitochondrial function is affected by fentanyl, a more widely used opioid than remifentanil. METHODS Human hepatoma HepG2 cells were exposed to fentanyl or pretreated with naloxone (an opioid receptor antagonist) or 5-hydroxydecanoate (5-HD, an inhibitor of mitochondrial adenosine triphosphate (ATP)-sensitive potassium [mitoKATP] channels), followed by incubation with fentanyl. Mitochondrial function and metabolism were then analyzed. RESULTS Fentanyl marginally reduced maximal mitochondrial complex-specific respiration rates using exogenous substrates (decrease in medians: 11%-18%; P = 0.003-0.001) but did not affect basal cellular respiration rates (P = 0.834). The effect on stimulated respiration was prevented by preincubation with naloxone or 5-HD. Fentanyl reduced cellular ATP content in a dose-dependent manner (P < 0.001), an effect that was not significantly prevented by 5-HD and not explained by increased total ATPase concentration. However, in vitro ATPase activity of recombinant human permeability glycoprotein (an ATP-dependent drug efflux transporter) was significantly stimulated by fentanyl (P = 0.004). CONCLUSIONS Our data suggest that fentanyl reduces stimulated mitochondrial respiration of cultured human hepatocytes by a mechanism that is blocked by a mitoKATP channel antagonist. Increased energy requirements for fentanyl efflux transport may offer an explanation for the substantial decrease in cellular ATP concentration.
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Affiliation(s)
- Siamak Djafarzadeh
- From the *Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Switzerland; and †Department of Clinical Research, Graduate School for Cellular and Biomedical Sciences, University of Bern, Bern, Switzerland
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Zakaria S, Kwong HJ, Sevransky JE, Williams MS, Chandra-Strobos N. Editor's Choice-The cardiovascular implications of sedatives in the cardiac intensive care unit. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2017; 7:671-683. [PMID: 29064259 DOI: 10.1177/2048872617695231] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Patients admitted to the cardiac intensive care unit frequently develop multi-organ system dysfunction associated with their cardiac disease. In many cases, invasive mechanical ventilation is required, which often necessitates sedation for patient-ventilator synchrony, reduction of work of breathing, and patient comfort. In this paper, we describe the use of common sedatives available in the endotracheally intubated critically ill patient and emphasize the clinical and cardiovascular effects. We review γ-aminobutyric acid agonists such as etomidate, benzodiazepines, and propofol, the centrally acting α2-agonist dexmedetomidine, and the N-methyl-D-aspartate receptor antagonist ketamine. Additionally, we outline the use of opioids and their role in potentiating other sedatives. We note that some sedatives are associated with increased delirium rates, and emphasize that judicious strategies minimizing sedative use are associated with decreases in morbidity and mortality. We also discuss standardized sedation assessment scales and highlight the importance of sedation weaning. Finally, we offer recommendations for sedation use during therapeutic hypothermia, and discuss the use of adjuvant neuromuscular blocking agents.
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Affiliation(s)
- Sammy Zakaria
- 1 Department of Medicine, Johns Hopkins University School of Medicine, USA
| | - Helaine J Kwong
- 1 Department of Medicine, Johns Hopkins University School of Medicine, USA
| | | | - Marlene S Williams
- 1 Department of Medicine, Johns Hopkins University School of Medicine, USA
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27
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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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Taets GGDC, Figueiredo NMAD. A quasi-experimental nursing study on pain in comatose patients. Rev Bras Enferm 2016; 69:927-932. [PMID: 27783736 DOI: 10.1590/0034-7167-2015-0121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2015] [Accepted: 06/25/2016] [Indexed: 11/21/2022] Open
Abstract
Objective: to verify whether comatose patients feel pain during the bed bath nursing procedure. Method: nineteen patients aged 61 ± 17.39 years participated in the study. A quantitative analysis was conducted on the P substance (PS) in the saliva collected before and during a bed bath, using the ELISA method. Program Graph Pad Prisma 6 was used to analyze the data. The verification of normality was made through the Shapiro Wilk test, which determined the choice for the Wilcoxon nonparametric test. Results: the study showed a statistically significant increase (∆= 5.62%, p<0.001) in the PS level of the patients studied during the nursing procedure. Conclusion: when caring for comatose patients during a bed bath, professionals cause or add painful stimuli; therefore, they feel pain.
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Affiliation(s)
| | - Nébia Maria Almeida de Figueiredo
- Universidade Federal do Estado do Rio de Janeiro, Centro de Ciências Biológicas e da Saúde, Escola de Enfermagem Alfredo Pinto. Rio de Janeiro-RJ, Brasil
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Richards-Belle A, Canter RR, Power GS, Robinson EJ, Reschreiter H, Wunsch H, Harvey SE. National survey and point prevalence study of sedation practice in UK critical care. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2016; 20:355. [PMID: 27788680 PMCID: PMC5084331 DOI: 10.1186/s13054-016-1532-x] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/08/2016] [Accepted: 10/14/2016] [Indexed: 12/11/2022]
Abstract
Background The present study was designed to (1) establish current sedation practice in UK critical care to inform evidence synthesis and potential future primary research and (2) to compare practice reported via a survey with actual practice assessed in a point prevalence study (PPS). Methods UK adult general critical care units were invited to participate in a survey of current sedation practice, and a representative sample of units was invited to participate in a PPS of sedation practice at the patient level. Survey responses were compared with PPS data where both were available. Results Survey responses were received from 214 (91 %) of 235 eligible critical care units. Of these respondents, 57 % reported having a written sedation protocol, 94 % having a policy of daily sedation holds and 94 % using a sedation scale to assess depth of sedation. In the PPS, across units reporting a policy of daily sedation holds, a median of 50 % (IQR 33–75 %) of sedated patients were considered for a sedation hold. A median of 88 % (IQR 63–100 %) of patients were assessed using the same sedation scale as reported in the survey. Both the survey and the PPS indicated propofol as the preferred sedative and alfentanil, fentanyl and morphine as the preferred analgesics. In most of the PPS units, all patients had received the unit’s reported first-choice sedative (median across units 100 %, IQR 64–100 %), and a median of 80 % (IQR 67–100 %) of patients had received the unit’s reported first-choice analgesic. Most units (83 %) reported in the survey that sedatives are usually administered in combination with analgesics. Across units that participated in the PPS, 69 % of patients had received a combination of agents – most frequently propofol combined with either alfentanil or fentanyl. Conclusions Clinical practice reported in the national survey did not accurately reflect actual clinical practice at the patient level observed in the PPS. Employing a mixed methods approach provided a more complete picture of sedation practice in terms of breadth and depth of information. Electronic supplementary material The online version of this article (doi:10.1186/s13054-016-1532-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Alvin Richards-Belle
- Intensive Care National Audit & Research Centre (ICNARC), Napier House, 24 High Holborn, London, WC1V 6AZ, UK
| | - Ruth R Canter
- Intensive Care National Audit & Research Centre (ICNARC), Napier House, 24 High Holborn, London, WC1V 6AZ, UK
| | - G Sarah Power
- Intensive Care National Audit & Research Centre (ICNARC), Napier House, 24 High Holborn, London, WC1V 6AZ, UK
| | - Emily J Robinson
- Intensive Care National Audit & Research Centre (ICNARC), Napier House, 24 High Holborn, London, WC1V 6AZ, UK
| | - Henrik Reschreiter
- Poole Hospital NHS Foundation Trust, Longfleet Road, Poole, BH15 2JB, UK
| | - Hannah Wunsch
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Toronto, ON, Canada
| | - Sheila E Harvey
- Intensive Care National Audit & Research Centre (ICNARC), Napier House, 24 High Holborn, London, WC1V 6AZ, UK.
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Abstract
This chapter reviews the neurologic complications of medications administered in the hospital setting, by class, introducing both common and less common side effects. Detail is devoted to the interaction between pain, analgesia, sedation, and their residual consequences. Antimicrobials are given in nearly every hospital setting, and we review their capacity to produce neurologic sequelae with special devotion to cefepime and the antiviral treatment of human immunodeficiency virus. The management of hemorrhagic stroke has become more complex with the introduction of novel oral anticoagulants, and we provide an update on what is known about reversal of the new oral anticoagulants. Both central and peripheral nervous system complications of immunosuppressants and chemotherapies are reviewed. Because diagnosis is generally based on clinical acumen, alone, neurotoxic syndromes resulting from psychotropic medications may be easily overlooked until severe dysautonomia develops. We include a practical approach to the diagnosis of serotonin syndrome and neuroleptic malignant syndrome.
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Affiliation(s)
- Elliot T Dawson
- Department of Neurology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
| | - Sara E Hocker
- Department of Neurology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
- Department of Neurology, Division of Critical Care Neurology, Mayo Clinic, Rochester, MN, USA.
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Reupke V, Walliser K, Perl T, Kimmina S, Schraepler A, Quintel M, Kunze-Szikszay N. Total intravenous anaesthesia using propofol and sufentanil allows controlled long-term ventilation in rabbits without neuromuscular blocking agents. Lab Anim 2016; 51:284-291. [PMID: 27413175 DOI: 10.1177/0023677216660337] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The aim of this study was to evaluate a total intravenous anaesthesia (TIVA) protocol using propofol and sufentanil without neuromuscular blocking agents (NBAs) for a non-recovery lung pathology study in rabbits including 10 h of pressure-controlled ventilation. TIVA was started with 20 mg/kg/h propofol and 0.5 µg/kg/h sufentanil. The depth of anaesthesia was assessed by reflex testing and monitoring of spontaneous movements or respiratory efforts. Vital parameters were monitored to assess the effects of the TIVA protocol. The infusion rates were increased whenever reflex testing indicated inadequate depth of anaesthesia, and were reduced when vital parameters indicated unnecessarily deep levels. Median infusion rates of 35 mg/kg/h propofol and 2.0 µg/kg/h sufentanil were needed to ensure an adequate depth of anaesthesia. This protocol suppressed spontaneous movements, breathing and palpebral reflexes, but was unable to suppress corneal and pedal withdrawal reflexes. Since significant drops in arterial blood pressure (ABP) were observed and the animals were not exposed to painful procedures, positive corneal and pedal withdrawal reflexes were tolerated. In conclusion, propofol and sufentanil is a suitable combination for long-term anaesthesia in non-recovery lung pathology models in rabbits without painful procedures. ABP must be monitored carefully because of the circulatory side-effects, but it is an inappropriate surrogate marker for depth of anaesthesia. Due to the lack of neuromuscular blockade this TIVA protocol allows the adjustment of infusion rates based on reflex testing. The resulting decreased risk of unnoticed awareness is a decisive refinement in anaesthesia for similar studies including long-term mechanical ventilation in rabbits.
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Affiliation(s)
- Verena Reupke
- 1 Central Animal Facility, University Medical Centre Göttingen, Göttingen, Germany
| | - Karoline Walliser
- 2 Department of Anaesthesiology, University Medical Centre Göttingen, Göttingen, Germany
| | - Thorsten Perl
- 2 Department of Anaesthesiology, University Medical Centre Göttingen, Göttingen, Germany
| | - Sarah Kimmina
- 3 Max Planck Institute for Biophysical Chemistry, Göttingen, Germany
| | - Anke Schraepler
- 1 Central Animal Facility, University Medical Centre Göttingen, Göttingen, Germany
| | - Michael Quintel
- 2 Department of Anaesthesiology, University Medical Centre Göttingen, Göttingen, Germany
| | - Nils Kunze-Szikszay
- 2 Department of Anaesthesiology, University Medical Centre Göttingen, Göttingen, Germany
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33
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Olsen BF, Rustøen T, Sandvik L, Miaskowski C, Jacobsen M, Valeberg BT. Development of a pain management algorithm for intensive care units. Heart Lung 2016; 44:521-7. [PMID: 26572773 DOI: 10.1016/j.hrtlng.2015.09.001] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2015] [Revised: 09/02/2015] [Accepted: 09/02/2015] [Indexed: 10/22/2022]
Abstract
OBJECTIVES To develop a pain management algorithm for intensive care unit (ICU) patients and to evaluate the psychometric properties of the translated tools used in the algorithm. BACKGROUND Many ICU patients experience pain. However, an evidence-based algorithm for pain management does not exist. METHODS Literature review, expert panel, and pilot testing were used to develop the algorithm. The tools were evaluated for inter-rater reliability between two nurses. Discriminant validity was evaluated by comparing pain during turning and rest. RESULTS An algorithm was developed. The Behavioral Pain Scale (BPS) and the Behavioral Pain Scale-Non Intubated (BPS-NI) discriminated between pain scores during turning and rest. Inter-rater reliability for the BPS varied from moderate (0.46) to very good (1.00). Inter-rater reliability for the BPS-NI varied from fair (0.21) to good (0.63). CONCLUSIONS The content of the pain management algorithm is consistent with the latest clinical practice guideline recommendations. It may be a useful tool to improve pain assessment and management in adult ICU patients.
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Affiliation(s)
- Brita F Olsen
- Østfold Hospital Trust, Fredrikstad, Norway; Oslo University Hospital, Division of Emergencies and Critical Care, Oslo, Norway.
| | - Tone Rustøen
- Oslo University Hospital, Division of Emergencies and Critical Care, Oslo, Norway; Faculty of Medicine, University of Oslo, Norway
| | - Leiv Sandvik
- Oslo Center for Biostatistics and Epidemiology, Oslo University Hospital, Oslo, Norway
| | | | - Morten Jacobsen
- Østfold Hospital Trust, Fredrikstad, Norway; Faculty of Medicine, University of Oslo, Norway; Norwegian University of Life Sciences, Aas, Norway
| | - Berit T Valeberg
- Oslo and Akershus University College of Applied Sciences, Oslo, Norway
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Rosenberger DS, Falangola MF, Ledreux A, Nie X, Suhre WM, Boger HA, Granholm AC. Memory and hippocampal architecture following short-term midazolam in western diet-treated rats. Neurosci Lett 2016; 621:68-74. [PMID: 27080429 PMCID: PMC4853265 DOI: 10.1016/j.neulet.2016.04.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2015] [Revised: 03/15/2016] [Accepted: 04/09/2016] [Indexed: 01/01/2023]
Abstract
The impact of short-term benzodiazepine exposure on cognition in middle-aged or older patients is a highly debated topic among anesthesiologists, critical care physicians and public media. "Western diet" (WD) consumption is linked to impaired cognition as well. The combination of benzodiazepines with substantial exposure to WD might set the stage for increased hippocampal vulnerability for benzodiazepines leading to exaggerated cognitive impairment in the postoperative period. In this study, Fischer 344 rats were fed either WD or standard rodent diet from 5 to 10.5 months of age. Rats were exposed to midazolam or placebo two days prior to an MRI scan using Diffusional Kurtosis Imaging (DKI) to assess brain microstructural integrity, followed by behavioral testing using a water radial arm maze. Hippocampal tissue was collected to assess alterations in protein biochemistry in brain regions associated with learning and memory. Our results showed that rats exposed to the combination of midazolam and WD had significantly delayed time of learning and exhibited spatial memory impairment. Further, we observed an overall increase of kurtosis metrics in the hippocampus and increased expression of the mitochondrial protein VDAC2 in midazolam-treated rats. Our data suggest that both the short-acting benzodiazepine midazolam and WD contribute to negatively affect the brain in middle-aged rats. This study is the first application of DKI on the effects of midazolam and WD exposure, and the findings demonstrate that diffusion metrics are sensitive indicators of changes in the complexity of neurite architecture.
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Affiliation(s)
- Dorothea S Rosenberger
- Department of Anesthesiology, University of Utah School of Medicine, Salt Lake City, UT 84132, United States.
| | - Maria F Falangola
- Department of Radiology and Radiological Science, Medical University of South Carolina, Charleston, SC 29425, United States; Center for Biomedical Imaging, Medical University of South Carolina, Charleston, SC 29425, United States; Department of Neuroscience and the Center on Aging, Medical University of South Carolina, Charleston, SC 29425, United States
| | - Aurélie Ledreux
- Department of Neuroscience and the Center on Aging, Medical University of South Carolina, Charleston, SC 29425, United States
| | - Xingju Nie
- Department of Radiology and Radiological Science, Medical University of South Carolina, Charleston, SC 29425, United States; Center for Biomedical Imaging, Medical University of South Carolina, Charleston, SC 29425, United States
| | - Wendy M Suhre
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, 98195, United States
| | - Heather A Boger
- Department of Neuroscience and the Center on Aging, Medical University of South Carolina, Charleston, SC 29425, United States
| | - Ann-Charlotte Granholm
- Department of Neuroscience and the Center on Aging, Medical University of South Carolina, Charleston, SC 29425, United States; Knoebel Institute for Healthy Aging, University of Denver, Denver, CO, United States
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35
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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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Mavri M, Rellos K, Pantazopoulos I, Kampolis C, Floros I, Iacovidou N, Xanthos T, Pantazopoulos C. Comparison between dexmetomidine and midazolam on early extubation and hemodynamic profile. a randomized double-blind study. Intensive Care Med Exp 2015. [PMCID: PMC4798284 DOI: 10.1186/2197-425x-3-s1-a327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Mahmood S, Al-Thani H, El-Menyar A, Alani M, Al-Hassani A, Mathrdikkal S, Peralta R, Latifi R. Tramadol in traumatic brain injury: Should we continue to use it? J Anaesthesiol Clin Pharmacol 2015; 31:344-8. [PMID: 26330713 PMCID: PMC4541181 DOI: 10.4103/0970-9185.161670] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background and Aims: Tramadol is commonly used to treat moderate to moderately-severe pain in adults. We aimed to analyze the clinical relevance of tramadol use during weaning and extubation in patients with traumatic brain injury (TBI). Material and Methods: A retrospective observational study was conducted and included all the intubated TBI patients at the level I trauma center between 2011 and 2012. Data included patient's demographics, mechanism of injury (MOI), Glasgow Coma Scale (GCS), injury severity score, length of Intensive Care Unit (ICU) stay length of stay (LOS), agitation scale, analgesics, failure of extubation and tracheostomy. Patients were divided into two groups based on whether they received tramadol (Group 1) or not (Group 2) during ventilatory weaning. Chi-square and Student's t-tests were used for categorical and continuous variables; respectively. Logistic regression analysis was performed for predictors of agitation in ICU. Results: The study included 393 TBI patients; the majority (96%) was males with a mean age of 33.6 ± 14 years. The most common MOI were motor vehicle crash (39%), fall (29%) and pedestrian (17%). The associated injuries were mainly chest (35%) and abdominal (16%) trauma. Tramadol was administered in 51.4% of TBI patients. Tracheostomy was performed in 12.4% cases. Agitation was observed in 34.2% cases. Group 1 patients had significantly lower age (31.6 ± 12.4 vs. 35.7 ± 15.6; P = 0.005) and head AIS (3.5 ± 0.8 vs. 3.9 ± 0.9; P = 0.001) compared to Group 2. The incidence of agitation, ICU and hospital LOS were higher in Group 1. Failure of extubation and tracheostomy were reported more frequently in Group 1 (P = 0.001). On multivariate analysis, tramadol use was an independent predictor for agitation (adjusted odds ratio 21; P = 0.001), followed by low GCS. Conclusion: Patients with TBI who received tramadol are more likely to develop agitation, undergo tracheostomy and to have longer hospital LOS. Therefore, an extensive risk-benefit assessment would help to attain maximum efficacy of the drug in TBI patients.
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Affiliation(s)
- Saeed Mahmood
- Department of Surgery, Section of Trauma Surgery, Hamad General Hospital (HGH), Doha, Qatar
| | - Hassan Al-Thani
- Department of Surgery, Section of Trauma Surgery, Hamad General Hospital (HGH), Doha, Qatar
| | - Ayman El-Menyar
- Department of Surgery, Clinical Research, Section of Trauma Surgery, HGH, Doha, Qatar ; Clinical Medicine, Weill Cornell Medical School, Doha, Qatar
| | - Mushrek Alani
- Department of Surgery, Section of Trauma Surgery, Hamad General Hospital (HGH), Doha, Qatar
| | - Ammar Al-Hassani
- Department of Surgery, Section of Trauma Surgery, Hamad General Hospital (HGH), Doha, Qatar
| | - Saji Mathrdikkal
- Department of Surgery, Section of Trauma Surgery, Hamad General Hospital (HGH), Doha, Qatar
| | - Ruben Peralta
- Department of Surgery, Section of Trauma Surgery, Hamad General Hospital (HGH), Doha, Qatar
| | - Rifat Latifi
- Department of Surgery, Section of Trauma Surgery, Hamad General Hospital (HGH), Doha, Qatar ; Department of Surgery, University of Arizona, Tucson, AZ, USA
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Shinotsuka CR, Salluh JIF. Perceptions and practices regarding delirium, sedation and analgesia in critically ill patients: a narrative review. Rev Bras Ter Intensiva 2015; 25:155-61. [PMID: 23917981 PMCID: PMC4031827 DOI: 10.5935/0103-507x.20130027] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2013] [Accepted: 06/13/2013] [Indexed: 11/20/2022] Open
Abstract
A significant number of landmark studies have been published in the last decade that
increase the current knowledge on sedation for critically ill patients. Therefore,
many practices that were considered standard of care are now outdated. Oversedation
has been shown to be hazardous, and light sedation and no-sedation protocols are
associated with better patient outcomes. Delirium is increasingly recognized as a
major form of acute brain dysfunction that is associated with higher mortality,
longer duration of mechanical ventilation and longer lengths of stay in the intensive
care unit and hospital. Despite all the available evidence, translating research into
bedside care is a daunting task. International surveys have shown that practices such
as sedation interruption and titration are performed only in the minority of cases.
Implementing best practices is a major challenge that must also be addressed in the
new guidelines. In this review, we summarize the findings of sedation and delirium
research over the last years. We also discuss the gap between evidence and clinical
practice and highlight ways to implement best practices at the bedside.
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Gupta S, Singh D, Sood D, Kathuria S. Role of dexmedetomidine in early extubation of the intensive care unit patients. J Anaesthesiol Clin Pharmacol 2015; 31:92-8. [PMID: 25788780 PMCID: PMC4353161 DOI: 10.4103/0970-9185.150554] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background and Aims: Patients on ventilatory support in intensive care unit (ICU) require sedation and analgesia to facilitate mechanical ventilation and endotracheal tube tolerance. The selection of the agent should be such that it does not interfere with the early extubation of the patients. We compared the efficacy of dexmedetomidine with midazolam to facilitate extubation of patients from mechanical ventilation in terms of the sedative properties, cardiovascular responses, ventilation, and extubation characteristics and safety profile. Materials and Methods: A total of 40 adult, mechanically ventilated patients of either sex, aged 18-60 years, meeting the standard criteria for weaning, randomized into 2 groups of 20 patients each, received intravenous infusion of dexmedetomidine (0.2-0.7 mcg/kg/h) or midazolam (0.04-0.2 mg/kg/h) as needed for Ramsay sedation scale 2-4. Extubation following standard extubation protocol was done. Time for extubation and vital parameters were regularly recorded. Results: The time to extubation in the dexmedetomidine group was significantly lower than in the midazolam group. Heart rate and blood pressure was significantly lower in dexmedetomidine group than the midazolam group at most of the times. Conclusions: Dexmedetomidine has clinically relevant benefits compared with midazolam in facilitating extubation due to its shorter time to extubation, more hemodynamic stability, easy arousability, and lack of respiratory depression.
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Affiliation(s)
- Shikha Gupta
- Department of Anaesthesiology, Dayanand Medical College and Hospital, Ludhiana, Punjab, India
| | - Dupinder Singh
- Department of Anaesthesiology, Dayanand Medical College and Hospital, Ludhiana, Punjab, India
| | - Dinesh Sood
- Department of Anaesthesiology, Dayanand Medical College and Hospital, Ludhiana, Punjab, India
| | - Suneet Kathuria
- Department of Anaesthesiology, Dayanand Medical College and Hospital, Ludhiana, Punjab, India
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40
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Why do some of us still hyper-sedate mechanically ventilated patients? Ann Am Thorac Soc 2015; 11:851-2. [PMID: 24936700 DOI: 10.1513/annalsats.201312-463le] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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41
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Esfahani MA, Beiki A, Asgarian S. Case report on the administration of an eighty milligram diazepam injection without respiratory depression. Adv Biomed Res 2015; 3:255. [PMID: 25590033 PMCID: PMC4283244 DOI: 10.4103/2277-9175.146925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2013] [Accepted: 05/18/2014] [Indexed: 11/04/2022] Open
Abstract
Nowadays one of the most challenging problems in Medicine is addiction - addiction to sedative drugs such as benzodiazepines. In this article, we are going to describe a case of diazepam addiction that has tolerated a high dose of intravenous diazepam.
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Affiliation(s)
| | - Arash Beiki
- Department of Internal Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Sedigheh Asgarian
- Department of Cardiology, Isfahan University of Medical Sciences, Isfahan, Iran
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Baumgarten M, Poulsen I. Patients' experiences of being mechanically ventilated in an ICU: a qualitative metasynthesis. Scand J Caring Sci 2014; 29:205-14. [DOI: 10.1111/scs.12177] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2014] [Accepted: 07/23/2014] [Indexed: 01/01/2023]
Affiliation(s)
- Mette Baumgarten
- Department of Anaesthesiology; Intensive Care Unit; Copenhagen University Hospital; Hvidovre Denmark
| | - Ingrid Poulsen
- Department of Neurorehabilitation; TBI Unit; Copenhagen University Hospital; Glostrup (Satellite Department on Hvidovre Hospital); Hvidovre Denmark
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Chawla R, Myatra SN, Ramakrishnan N, Todi S, Kansal S, Dash SK. Current practices of mobilization, analgesia, relaxants and sedation in Indian ICUs: A survey conducted by the Indian Society of Critical Care Medicine. Indian J Crit Care Med 2014; 18:575-84. [PMID: 25249742 PMCID: PMC4166873 DOI: 10.4103/0972-5229.140146] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Background and Aim: Use of sedation, analgesia and neuromuscular blocking agents is widely practiced in Intensive Care Units (ICUs). Our aim is to study the current practice patterns related to mobilization, analgesia, relaxants and sedation (MARS) to help in standardizing best practices in these areas in the ICU. Materials and Methods: A web-based nationwide survey involving physicians of the Indian Society of Critical Care Medicine (ISCCM) and the Indian Society of Anesthesiologists (ISA) was carried out. A questionnaire included questions on demographics, assessment scales for delirium, sedation and pain, as also the pharmacological agents and the practice methods. Results: Most ICUs function in a semi-closed model. Midazolam (94.99%) and Fentanyl (47.04%) were the most common sedative and analgesic agents used, respectively. Vecuronium was the preferred neuromuscular agent. Monitoring of sedation, analgesia and delirium in the ICU. Ramsay's Sedation Scale (56.1%) and Visual Analogue Scale (48.07%) were the preferred sedation and pain scales, respectively. CAM (Confusion Assessment Method)-ICU was the most preferred method of delirium assessment. Haloperidol was the most commonly used agent for delirium. Majority of the respondents were aware of the benefit of early mobilization, but lack of support staff and safety concerns were the main obstacles to its implementation. Conclusion: The results of the survey suggest that compliance with existing guidelines is low. Benzodiazepines still remain the predominant ICU sedative. The recommended practice of giving analgesia before sedation is almost non-existent. Delirium remains an underrecognized entity. Monitoring of sedation levels, analgesia and delirium is low and validated and recommended scales for the same are rarely used. Although awareness of the benefits of early mobilization are high, the implementation is low.
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Affiliation(s)
- Rajesh Chawla
- Department of Critical Care Medicine, Indraprastha Apollo Hospital, New Delhi, India
| | - Sheila Nainan Myatra
- Department of Anaesthesia, Critical Care and Pain, Tata Memorial Hospital, Mumbai, India
| | | | - Subhash Todi
- Department of Critical Care Medicine, Vision Care Hospital, Mukundpur, Kolkata, India
| | - Sudha Kansal
- Department of Critical Care Medicine, Indraprastha Apollo Hospital, New Delhi, India
| | - Sananta Kumar Dash
- Department of Anaesthesia and Critical Care Medicine, Citizens Hospitals and American Oncology Hospitals, Hyderabad, India
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Shetty RM, Bellini A, Wijayatilake DS, Hamilton MA, Jain R, De La Cerda G, Stowell S, Karanth S. BIS monitoring versus clinical assessment for sedation in mechanically ventilated adult patients in the intensive care unit and its impact on clinical outcomes and resource utilization. Hippokratia 2014. [DOI: 10.1002/14651858.cd011240] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Rajesh M Shetty
- Manipal Hospital; Multidisciplinary Intensive Care Unit; 98, Old Airport Road Bangalore Karnataka India 560017
| | - Antonio Bellini
- Barking Havering and Redbridge University Hospitals NHS Trust; Intensive Care Unit; Rom Valley Way Romford UK RM7 0AG
| | - Dhuleep S Wijayatilake
- Barking Havering and Redbridge University Hospitals NHS Trust; Anaesthesia and Neurocritical care; Rom Valley Way Romford UK RM7 0AG
| | - Mark A Hamilton
- St. George's Hospital; General Intensive Care Unit; 1st Floor St. James wing Blackshaw Road London UK SW17 0QT
| | - Rajesh Jain
- Barking Havering and Redbridge University Hospitals NHS Trust; Anaesthesia and Neurocritical care; Rom Valley Way Romford UK RM7 0AG
| | - Gonzalo De La Cerda
- Barking Havering and Redbridge University Hospitals NHS Trust; Intensive Care Unit; Rom Valley Way Romford UK RM7 0AG
| | - Sarah Stowell
- StatAssured; 82 Piggotts Way Bishop's Stortford UK CM23 3QU
| | - Sunil Karanth
- Manipal Hospital; Multidisciplinary Critical Care Unit; 98, Old Airport Road Rustombagh Bangalore Karnataka India 560017
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Varndell W, Elliott D, Fry M. The validity, reliability, responsiveness and applicability of observation sedation-scoring instruments for use with adult patients in the emergency department: a systematic literature review. ACTA ACUST UNITED AC 2014; 18:1-23. [PMID: 25103566 DOI: 10.1016/j.aenj.2014.07.001] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2014] [Revised: 07/11/2014] [Accepted: 07/15/2014] [Indexed: 12/14/2022]
Abstract
AIM This paper reports a systematic literature review examining the range of published observational sedation-scoring instruments available in the assessment, monitoring and titration of continuous intravenous sedation to critically ill adult patients in the Emergency Department, and the extent to which validity, reliability, responsiveness and applicability of the instruments has been addressed. BACKGROUND Emergency nurses are increasingly responsible for the ongoing assessment, monitoring and titration of continuous intravenous sedation, in addition to analgesia for the critically ill adult patient. One method to optimise patient sedation is to use a validated observational sedation-scoring tool. It is not clear however what the optimal instrument available is for use in this clinical context. METHODS A systematic literature review methodology was employed. A range of electronic databases were searched for the period 1946-2013. Search terms incorporated "sedation scale", "sedation scoring system", "measuring sedation", and "sedation tool" and were used to retrieve relevant literature. In addition, manual searches were conducted and articles retrieved from those listed in key papers. Articles were assessed using the Critical Appraisal Skills Program (CASP) making sense of evidence tools. RESULTS A total of 27 observational sedation-scoring instruments were identified. Sedation-scoring instruments can be categorised as linear or composite, the former being the most common. A wide variety of patient behaviours are used within the instruments to measure depth and quality of patient sedation. Typically sedation-scoring instruments incorporated three patient behaviours, which were then rated to generate a numerical score. The majority of the instruments have been subjected to validity and reliability testing, however few have been examined for responsiveness or applicability. CONCLUSIONS None of the 27 observational sedation-scoring instruments were designed or trialled within ED. The Richmond Agitation and Assessment Scale was identified as most suitable to be trialled prospectively within an Australian ED.
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Affiliation(s)
- Wayne Varndell
- Prince of Wales Hospital Emergency Department, Australia; Faculty of Health, University of Technology, Sydney, Australia.
| | - Doug Elliott
- Faculty of Health, University of Technology, Sydney, Australia
| | - Margaret Fry
- Faculty of Health, University of Technology, Sydney, Australia; School of Nursing, University of Sydney, Australia
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Zhou Y, Jin X, Kang Y, Liang G, Liu T, Deng N. Midazolam and propofol used alone or sequentially for long-term sedation in critically ill, mechanically ventilated patients: a prospective, randomized study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2014; 18:R122. [PMID: 24935517 PMCID: PMC4095601 DOI: 10.1186/cc13922] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/26/2013] [Accepted: 05/22/2014] [Indexed: 11/19/2022]
Abstract
Introduction Midazolam and propofol used alone for long-term sedation are associated with adverse effects. Sequential use may reduce the adverse effects, and lead to faster recovery, earlier extubation and lower costs. This study evaluates the effects, safety, and cost of midazolam, propofol, and their sequential use for long-term sedation in critically ill mechanically ventilated patients. Methods A total of 135 patients who required mechanical ventilation for >3 days were randomly assigned to receive midazolam (group M), propofol (group P), or sequential use of both (group M-P). In group M-P, midazolam was switched to propofol until the patients passed the spontaneous breathing trial (SBT) safety screen. The primary endpoints included recovery time, extubation time and mechanical ventilation time. The secondary endpoints were pharmaceutical cost, total cost of ICU stay, and recollection to mechanical ventilation-related events. Results The incidence of agitation following cessation of sedation in group M-P was lower than group M (19.4% versus 48.7%, P = 0.01). The mean percentage of adequate sedation and duration of sedation were similar in the three groups. The recovery time, extubation time and mechanical ventilation time of group M were 58.0 (interquartile range (IQR), 39.0) hours, 45.0 (IQR, 24.5) hours, and 192.0 (IQR, 124.0) hours, respectively; these were significantly longer than the other groups, while they were similar between the other two groups. In the treatment-received analysis, ICU duration was longer in group M than group M-P (P = 0.016). Using an intention-to-treat analysis and a treatment-received analysis, respectively, the pharmaceutical cost of group M-P was lower than group P (P <0.01) and its ICU cost was lower than group M (P <0.01; P = 0.015). The proportion of group M-P with unbearable memory of the uncomfortable events was lower than in group M (11.7% versus 25.0%, P <0.01), while the proportion with no memory was similar (P >0.05). The incidence of hypotension in group M-P was lower than group (P = 0.01). Conclusion Sequential use of midazolam and propofol was a safe and effective sedation protocol, with higher clinical effectiveness and better cost-benefit ratio than midazolam or propofol used alone, for long-term sedation of critically ill mechanically ventilated patients. Trial registration Current Controlled Trials ISRCTN01173443. Registered 25 February 2014.
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Song L, Wang S, Zuo Y, Chen L, Martyn JA, Mao J. Midazolam exacerbates morphine tolerance and morphine-induced hyperactive behaviors in young rats with burn injury. Brain Res 2014; 1564:52-61. [PMID: 24713351 DOI: 10.1016/j.brainres.2014.03.047] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2014] [Revised: 03/28/2014] [Accepted: 03/29/2014] [Indexed: 02/05/2023]
Abstract
Midazolam and morphine are often used in pediatric intensive care unit (ICU) for analgesia and sedation. However, how these two drugs interact behaviorally remains unclear. Here, we examined whether (1) co-administration of midazolam with morphine would exacerbate morphine tolerance and morphine-induced hyperactive behaviors, and (2) protein kinase C (PKC) would contribute to these behavioral changes. Male rats of 3-4 weeks old were exposed to a hindpaw burn injury. In Experiment 1, burn-injured young rats received once daily saline or morphine (10mg/kg, subcutaneous, s.c.), followed 30min later by either saline or midazolam (2mg/kg, intraperitoneal, i.p.), for 14 days beginning 3 days after burn injury. In Experiment 2, young rats with burn injury were administered with morphine (10mg/kg, s.c.), midazolam (2mg/kg, i.p.), and chelerythrine chloride (a non-specific PKC inhibitor, 10nmol, intrathecal) for 14 days. For both experiments, cumulative morphine anti-nociceptive dose-response (ED50) was tested and hyperactive behaviors such as jumping and scratching were recorded. Following 2 weeks of each treatment, ED50 dose was significantly increased in rats receiving morphine alone as compared with rats receiving saline or midazolam alone. The ED50 dose was further increased in rats receiving both morphine and midazolam. Co-administration of morphine and midazolam also exacerbated morphine-induced hyperactive behaviors. Expression of the NR1 subunit of the N-methyl-d-aspartate (NMDA) receptor and PKCγ in the spinal cord dorsal horn (immunohistochemistry; Western blot) was upregulated in burn-injured young rats receiving morphine alone or in combination with midazolam, and chelerythrine prevented the development of morphine tolerance. These results indicate that midazolam exacerbated morphine tolerance through a spinal NMDA/PKC-mediated mechanism.
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Affiliation(s)
- Li Song
- MGH Center for Translational Pain Research, Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; Department of Anesthesia, West China Hospital, Sichuan University, Chengdu, China
| | - Shuxing Wang
- MGH Center for Translational Pain Research, Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Yunxia Zuo
- Department of Anesthesia, West China Hospital, Sichuan University, Chengdu, China
| | - Lucy Chen
- MGH Center for Translational Pain Research, Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Jeevendra A Martyn
- MGH Center for Translational Pain Research, Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Jianren Mao
- MGH Center for Translational Pain Research, Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
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Aghdaii N, Yazdanian F, Faritus SZ. Sedative efficacy of propofol in patients intubated/ventilated after coronary artery bypass graft surgery. Anesth Pain Med 2014; 4:e17109. [PMID: 24660162 PMCID: PMC3961039 DOI: 10.5812/aapm.17109] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2013] [Revised: 01/05/2014] [Accepted: 01/11/2014] [Indexed: 12/30/2022] Open
Abstract
Background: Sedation after open heart surgery is important in preventing stress on the heart. The unique sedative features of propofol prompted us to evaluate its potential clinical role in the sedation of post-CABG patients. Objectives: To compare propofol-based sedation to midazolam-based sedation after coronary artery bypass graft (CABG) surgery in the intensive care unit (ICU). Patients and Methods: Fifty patients who were admitted to the ICU after CABG surgery was randomized into two groups to receive sedation with either midazolam or propofol infusions; and additional analgesia was administered if required. Inclusion criteria were as follows: patients 40-60 years old, hemodynamic stability, ejection fraction (EF) more than 40%; exclusion criteria included patients who required intra-aortic balloon pump or inotropic drugs post-bypass. The same protocol of anesthetic medications was used in both groups. Depth of sedation was monitored using the Ramsay sedation score (RSS). Invasive mean arterial pressure (MAP) and heart rate (HR), arterial blood gas (ABG) and ventilatory parameters were monitored continuously after the start of study drug and until the patients were extubated. Results: The depth of sedation was almost the same in the two groups (RSS=4.5 in midazolam group vs 4.7 in propofol group; P = 0.259) but the total dose of fentanyl in the midazolam group was significantly more than the propofol group (12.5 mg/hr vs 4 mg/hr) (P = 0.0039). No significant differences were found in MAP (P = 0.51) and HR (P = 0.41) between the groups. The mean extubation time in patients sedated with propofol was shorter than those sedated with midazolam (102 ± 27 min vs 245 ± 42 min, respectively; P < 0.05) but the ICU discharge time was not shorter (47.5 hr vs 36.3 hr, respectively; P = 0.24). Conclusions: Propofol provided a safe and acceptable sedation for post-CABG surgical patients, significantly reduced the requirement for analgesics, and allowed for more rapid tracheal extubation than midazolam but did not result in earlier ICU discharge.
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Affiliation(s)
- Nahid Aghdaii
- Rajaei Cardiovascular, Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
- Corresponding author: Nahid Aghdaii, Rajaei Cardiovascular, Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran. Tel. +98-2123922148, Fax +98-2122663293, E-mail:
| | - Frouzan Yazdanian
- Rajaei Cardiovascular, Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Seyedeh Zahra Faritus
- Rajaei Cardiovascular, Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
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Affiliation(s)
- Michael C Reade
- From the Burns, Trauma and Critical Care Research Centre, University of Queensland, and Joint Health Command, Australian Defence Force, Brisbane (M.C.R.); and the George Institute for Global Health, and Royal North Shore Hospital, University of Sydney, Sydney (S.F.) - all in Australia
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