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Formenti P, Piuri G, Bisatti R, Pinciroli R, Umbrello M. Role of acupuncture in critically ill patients: A systematic review. J Tradit Complement Med 2022; 13:62-71. [PMID: 36685071 PMCID: PMC9845654 DOI: 10.1016/j.jtcme.2022.10.005] [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: 07/25/2022] [Revised: 10/26/2022] [Accepted: 10/27/2022] [Indexed: 11/07/2022] Open
Abstract
Acupuncture is part of a complex medical approach used in China for about 2000 years, known as Traditional Chinese Medicine, whose central assumption is that health occurs when the patterned energy flow throughout the body is balanced. Within this paradigm, acute illness occurs when a major state of imbalance or disruption arises, and the use of acupuncture may help in correcting these imbalances. While the Chinese hospital system often offers the integration of traditional and western medicine, in Europe and the United States this combined approach is infrequently practiced. However, several investigations have consistently shown the effectiveness of acupuncture for different aspects of critical illness. The aim of this systematic review is to increase the clinician's awareness of the current evidence regarding the use of acupuncture for the management of critically ill patients, both alone or as a complement to western medicine. The effects of acupuncture on critical illness, with a particular focus on respiratory function, pain and delirium treatment and prevention, circulatory function, nutritional support, and recovery after acute illness are explored and summarized, and evidence is provided that acupuncture is an acceptable and feasible option for the management of several aspects of critical illness. In addition, we suggest a practical selection of potentially useful acupuncture points in the critical care setting, with indications for simple localization and the correct puncture method.
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Affiliation(s)
- Paolo Formenti
- SC Anestesia e Rianimazione, Ospedale San Paolo – Polo Universitario, ASST Santi Paolo e Carlo, Milan, Italy
| | | | | | - Riccardo Pinciroli
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
| | - Michele Umbrello
- SC Anestesia e Rianimazione II, Ospedale San Carlo Borromeo, ASST Santi Paolo e Carlo – Polo Universitario, Milan, Italy,Corresponding author. SC Anestesia e Rianimazione II, Ospedale San Carlo Borromeo, ASST Santi Paolo e Carlo – Polo Universitario, 20151, Milano, Italy.
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Mattsson J, Meijers J, Björling G. Challenges in Nursing Care of Children With Substance Withdrawal Syndrome in the PICU. SAGE Open Nurs 2022; 8:23779608221117382. [PMID: 35959413 PMCID: PMC9358588 DOI: 10.1177/23779608221117382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 06/27/2022] [Accepted: 07/16/2022] [Indexed: 11/22/2022] Open
Abstract
Introduction Substance withdrawal is one of the most common advert events in the Pediatric Intensive Care Unit (PICU), as the administration of potent opiates and sedative drugs is frequently performed several times each day. Objectives The present study explored the challenges in nursing care of children with substance withdrawal syndrome in the PICU. Method The study has an explorative and descriptive semi-structured qualitative interview design, with a strategic selection of informants. It was conducted at one out of three pediatric intensive care units in Sweden. Results Three different main themes were identified describing the different challenges regarding withdrawal symptoms: monitor the child’s interest, work with structured support, and understand the observation. Conclusions There is a discrepancy between the medical perspective and the nursing care perspective regarding children in PICU suffering from withdrawal syndrome. The lack of joint guidelines, language, and nursing diagnoses may lead to subjective evaluations and increase suffering for these children.
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Affiliation(s)
- Janet Mattsson
- Department of Learning, Informatics, Management and Ethics, LIME, Karolinska Institutet, Stockholm, Sweden
- Children’s Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
| | - Johannes Meijers
- Children’s Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
| | - Gunilla Björling
- Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden
- Faculty of Nursing, Kilimanjaro Christian Medical University College, Moshi, Tanzania
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Temesgen N, Chekol B, Tamirie T, Eshetie D, Simeneh N, Feleke A. Adult sedation and analgesia in a resource limited intensive care unit - A Systematic Review and evidence based guideline. Ann Med Surg (Lond) 2021; 66:102356. [PMID: 34035907 PMCID: PMC8138481 DOI: 10.1016/j.amsu.2021.102356] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 04/15/2021] [Accepted: 04/25/2021] [Indexed: 12/04/2022] Open
Abstract
Background Sedation and analgesia are essential in the intensive care unit in order to promote control of pain, anxiety, prevent loss of materials, accidental extubation and improve the synchrony of patients with ventilator. However, excess of these medications leads to an increased morbidity and mortality, and thus demands protocol. Methods Preferred Reporting Items for Systematic Reviews and the Meta-Analysis Protocol have been used to undertake this review. Pub Med, Cochrane Library, and Google Scholar search engines were used to find up-to-date evidence that helps to draw recommendations and conclusions. Results In this Guideline and Systematic Review, we have used 16 Systemic Review and Meta-Analysis, 3 Evidence-Based Guidelines and 10 RCT Meta-Analysis, 6 Systemic Reviews of Non-randomized Studies, 8 Randomized Clinical Trials, 11 Cohort Studies, 5 Cross-Sectional Studies and 1 Case Report with their respective study descriptions. Discussion Analgesia, which as a sedation basement can reduce sedative use, is key aspect of treatment in ICU patients, and we can also conclude that an analgesic sedation regimen can reduce the occurrence of delirium by reducing sedatives. The aim of this guideline and the systematic review is to write up and formulate analgesia-based sedation for limited resource settings. Conclusions Analgesia and sedation are effective in critically ill patients; however, too much sedation is associated with longer periods of mechanical ventilation and longer duration of ICU stay. Poorly managed ICU patients have a delirium rate of up to 80%, increased mortality, longer hospital stays, higher hospital costs and bad long-term outcomes. Critically ill patients shall be awake, alert without pain, anxiety and delirium. Analgesia and sedation in the ICU shall be given as per needed after determined they are in need of. Sedation breaks are paramount important as equal as spontaneous breathing trials. Unnecessary deep sedations will increase hospital and personnel costs by increasing length of ICU stay.
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Affiliation(s)
- Netsanet Temesgen
- Debre Tabor University, College of Health Sciences, School of Medicine, Department of Anesthesia, Ethiopia
| | - Bsazinew Chekol
- Debre Tabor University, College of Health Sciences, School of Medicine, Department of Anesthesia, Ethiopia
| | - Tadesse Tamirie
- Debre Tabor University, College of Health Sciences, School of Medicine, Department of Anesthesia, Ethiopia
| | - Denberu Eshetie
- Debre Tabor University, College of Health Sciences, School of Medicine, Department of Anesthesia, Ethiopia
| | - Nigussie Simeneh
- University of Gondar, College of Medicine and Health Sciences, Department of Anesthesia and Critical Care, Ethiopia
| | - Abatneh Feleke
- University of Gondar, College of Medicine and Health Sciences, Department of Anesthesia and Critical Care, Ethiopia
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Smit L, Dijkstra-Kersten SMA, Zaal IJ, van der Jagt M, Slooter AJC. Haloperidol, clonidine and resolution of delirium in critically ill patients: a prospective cohort study. Intensive Care Med 2021; 47:316-324. [PMID: 33591422 PMCID: PMC7952362 DOI: 10.1007/s00134-021-06355-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2020] [Accepted: 01/15/2021] [Indexed: 01/06/2023]
Abstract
Purpose Haloperidol and clonidine are commonly used to treat agitation in delirious intensive care unit (ICU) patients, but it is unclear whether these agents may shorten the duration of delirium. The objective of this study was to determine whether haloperidol, clonidine, or their combined administration to delirious ICU patients results in delirium resolution. Methods This was a cohort study on a mixed ICU, excluding patients with a primary neurological disorder. The main outcome was the probability of delirium resolution, using propensity score matching and Markov multinomial logistic regression models for daily transitions. Secondary outcomes were delirium duration, number of delirium days, ventilation days, length of stay in the ICU and hospital, and ICU mortality. Results A total of 3614 patients were included (1165 delirious [32%]; 2449 non-delirious [68%]). Delirium occurred on 4708 (18.9%) of 24,906 days. The probability of delirium resolution was lower in delirious patients who received haloperidol (OR 0.47, 95% CI 0.39–0.57), clonidine (OR 0.78, 95% CI 0.63–0.97), or both (OR 0.45, 95% CI 0.36–0.56) compared to untreated delirious patients. Delirious patients who received haloperidol, clonidine, or both had generally longer delirium duration, more delirium and ventilation days, and spent more time in the ICU and in hospital than untreated delirious patients. These agents had no effect on ICU mortality. Conclusion Haloperidol and clonidine use in delirious ICU patients may be associated with reduced probability of delirium resolution. This finding, however, merits further investigation given inherent limitations of this observational analysis. Supplementary Information The online version contains supplementary material available at 10.1007/s00134-021-06355-9.
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Affiliation(s)
- Lisa Smit
- Department of Intensive Care Adults, Erasmus MC, University Medical Center, Rotterdam, The Netherlands.
| | - Sandra M A Dijkstra-Kersten
- Department of Intensive Care Medicine, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Irene J Zaal
- Department of Intensive Care Medicine, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Mathieu van der Jagt
- Department of Intensive Care Adults, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Arjen J C Slooter
- Department of Intensive Care Medicine, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
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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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Wang CT, Mao Y, Zhao L, Ma B. The impact of analgosedation on mortality and delirium in critically ill patients: A systematic review and meta-analysis. Intensive Crit Care Nurs 2019; 54:7-14. [DOI: 10.1016/j.iccn.2019.06.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2018] [Revised: 06/06/2019] [Accepted: 06/20/2019] [Indexed: 11/15/2022]
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Weatherburn C, Endacott R, Tynan P, Bailey M. The Impact of Bispectral Index Monitoring on Sedation Administration in Mechanically Ventilated Patients. Anaesth Intensive Care 2019; 35:204-8. [PMID: 17444309 DOI: 10.1177/0310057x0703500208] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The aim of this prospective randomised controlled trial was to assess the effectiveness of the Bispectral Index (BIS) monitor in supporting clinical sedation management decisions in mechanically ventilated intensive care unit patients. Fifty adult mechanically ventilated surgical and general intensive care unit patients receiving sedative infusions of morphine and midazolam were randomly allocated to receive BIS monitoring (n=25) or standard sedation management (n=25). In the BIS group, sedation was titrated to maintain a BIS value of greater than 70. In the standard management group, sedative needs were titrated based on subjective assessment and clinical signs. There was no statistically significant difference in the amount of sedation administered (morphine P =0.67 and midazolam P =0.85). However, there was a statistically significant difference in sedation administration over time. Patients in the BIS group received increasing amounts of sedation over time whilst those in the control group received decreasing amounts of sedation over time. The same inverse relationship existed for both sedative agents (morphine P=0.005, midazolam P=0.03). Duration of mechanical ventilation was comparable in the two groups. We conclude that the use of BIS monitoring did not reduce the amount of sedation used, the length of mechanical ventilation time or the length of ICU stay.
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Affiliation(s)
- C Weatherburn
- Intensive Care Unit, The Alfred Hospital, Melbourne, Victoria, Australia
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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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Abstract
INTRODUCTION To study stimulation-related facial electromyographic (FEMG) activity in intensive care unit (ICU) patients, develop an algorithm for quantifying the FEMG activity, and to optimize the algorithm for monitoring the sedation state of ICU patients. METHODS First, the characteristics of FEMG response patterns related to vocal stimulation of 17 ICU patients were studied. Second, we collected continuous FEMG data from 30 ICU patients. Based on these data, we developed the Responsiveness Index (RI) algorithm that quantifies FEMG responses. Third, we compared the RI values with clinical sedation level assessments and adjusted algorithm parameters for best performance. RESULTS In patients who produced a clinically observed response to the vocal stimulus, the poststimulus FEMG power was 0.33 µV higher than the prestimulus power. In nonresponding patients, there was no difference. The sensitivity and specificity of the developed RI for detecting deep sedation in the subgroup with low probability of encephalopathy were 0.90 and 0.79, respectively. CONCLUSION Consistent FEMG patterns were found related to standard stimulation of ICU patients. A simple and robust algorithm was developed and good correlation with clinical sedation scores achieved in the development data.
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Wolf A, McKay A, Spowart C, Granville H, Boland A, Petrou S, Sutherland A, Gamble C. Prospective multicentre randomised, double-blind, equivalence study comparing clonidine and midazolam as intravenous sedative agents in critically ill children: the SLEEPS (Safety profiLe, Efficacy and Equivalence in Paediatric intensive care Sedation) study. Health Technol Assess 2016; 18:1-212. [PMID: 26099138 DOI: 10.3310/hta18710] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Children in paediatric intensive care units (PICUs) require analgesia and sedation but both undersedation and oversedation can be harmful. OBJECTIVE Evaluation of intravenous (i.v.) clonidine as an alternative to i.v. midazolam. DESIGN Multicentre, double-blind, randomised equivalence trial. SETTING Ten UK PICUs. PARTICIPANTS Children (30 days to 15 years inclusive) weighing ≤ 50 kg, expected to require ventilation on PICU for > 12 hours. INTERVENTIONS Clonidine (3 µg/kg loading then 0-3 µg/kg/hour) versus midazolam (200 µg/kg loading then 0-200 µg/kg/hour). Maintenance infusion rates adjusted according to behavioural assessment (COMFORT score). Both groups also received morphine. MAIN OUTCOME MEASURES Primary end point Adequate sedation defined by COMFORT score of 17-26 for ≥ 80% of the time with a ± 0.15 margin of equivalence. Secondary end points Percentage of time spent adequately sedated, increase in sedation/analgesia, recovery after sedation, side effects and safety data. RESULTS The study planned to recruit 1000 children. In total, 129 children were randomised, of whom 120 (93%) contributed data for the primary outcome. The proportion of children who were adequately sedated for ≥ 80% of the time was 21 of 61 (34.4%) - clonidine, and 18 of 59 (30.5%) - midazolam. The difference in proportions for clonidine-midazolam was 0.04 [95% confidence interval (CI) -0.13 to 0.21], and, with the 95% CI including values outside the range of equivalence (-0.15 to 0.15), equivalence was not demonstrated; however, the study was underpowered. Non-inferiority of clonidine to midazolam was established, with the only values outside the equivalence range favouring clonidine. Times to reach maximum sedation and analgesia were comparable hazard ratios: 0.99 (95% CI 0.53 to 1.82) and 1.18 (95% CI 0.49 to 2.86), respectively. Percentage time spent adequately sedated was similar [medians clonidine 73.8% vs. midazolam 72.8%: difference in medians 0.66 (95% CI -5.25 to 7.24)]. Treatment failure was 12 of 64 (18.8%) on clonidine and 7 of 61 (11.5%) on midazolam [risk ratio (RR) 1.63, 95% CI 0.69 to 3.88]. Proportions with withdrawal symptoms [28/60 (46.7%) vs. 30/58 (52.6%)] were similar (RR 0.89, 95% CI 0.62 to 1.28), but a greater proportion required clinical intervention in those receiving midazolam [11/60 (18.3%) vs. 16/58 (27.6%) (RR 0.66, 95% CI 0.34 to 1.31)]. Post treatment, one child on clonidine experienced mild rebound hypertension, not requiring intervention. A higher incidence of inotropic support during the first 12 hours was required for those on clonidine [clonidine 5/45 (11.1%) vs. midazolam 3/52 (5.8%)] (RR 1.93 95% CI 0.49 to 7.61). CONCLUSIONS Clonidine is an alternative to midazolam. Our trial-based economic evaluation suggests that clonidine is likely to be a cost-effective sedative agent in the PICU in comparison with midazolam (probability of cost-effectiveness exceeds 50%). Rebound hypertension did not appear to be a significant problem with clonidine but, owing to its effects on heart rate, specific cardiovascular attention needs to be taken during the loading and early infusion phase. Neither drug in combination with morphine provided ideal sedation, suggesting that in unparalysed patients a third background agent is necessary. The disappointing recruitment rates reflect a reluctance of parents to provide consent when established on a sedation regimen, and reluctance of clinicians to allow sedation to be studied in unstable critically ill children. Future studies will require less exacting protocols allowing enhanced recruitment. TRIAL REGISTRATION Current Controlled Trials ISRCTN02639863. FUNDING This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 18, No. 71. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Andrew Wolf
- Bristol Royal Children's Hospital, Bristol, UK
| | - Andrew McKay
- Clinical Trials Research Centre, University of Liverpool, Liverpool, UK
| | - Catherine Spowart
- Clinical Trials Research Centre, University of Liverpool, Liverpool, UK
| | - Heather Granville
- Clinical Trials Research Centre, University of Liverpool, Liverpool, UK
| | - Angela Boland
- Liverpool Reviews and Implementation Group, University of Liverpool, Liverpool, UK
| | | | - Adam Sutherland
- Central Manchester University Hospitals NHS Trust, Manchester, UK
| | - Carrol Gamble
- Clinical Trials Research Centre, University of Liverpool, Liverpool, UK
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Porhomayon J, Joude P, Adlparvar G, El-Solh AA, Nader ND. The Impact of High Versus Low Sedation Dosing Strategy on Cognitive Dysfunction in Survivors of Intensive Care Units: A Systematic Review and Meta-Analysis. J Cardiovasc Thorac Res 2015; 7:43-8. [PMID: 26191390 PMCID: PMC4492176 DOI: 10.15171/jcvtr.2015.10] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2015] [Accepted: 05/11/2015] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND The practice of low vs. high sedation dosing strategy may impact the cognitive and mental health function in the intensive care unit (ICU). We aim to demonstrate that high sedation strategy will result in change of mental health function in ICU patients. METHODS We performed a systemic search and meta-analysis of medical databases in MEDLINE (from 1966 to March 2013) and EMBASE (from 1980 to March 2013), as well as the Cochrane Library using the MESH terms "Intensive Care Unit," and "Mental Health, for assessing the impact of sedation on posttraumatic stress disorder (PTSD) or anxiety/depression and delirium in the mix ICU setting including cardiac surgery patients. A total of 1216 patients were included in the final analysis. RESULTS We included 11 studies in the final analysis and concluded that high dose sedation strategy resulted in higher incidence of cognitive dysfunction with P value of 0.009. The result for subgroup of delirium showed P = 0.11 and PTSD/depression or anxiety of P = 0.001, Heterogeneity I2 was 64%. Overall analysis was statistically significant with a P value of 0.002. CONCLUSION High sedation dosing strategy will negatively affect cognitive function in critically ill patients. Large randomized trials are needed to address cognitive dysfunction in subgroup of patients with delirium.
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Affiliation(s)
- Jahan Porhomayon
- VA Western New York Healthcare System, Division of Critical Care Medicine, Department of Anesthesiology, State University of New York at Buffalo School of Medicine and Biomedical Sciences, Buffalo, New York, USA
| | - Philippe Joude
- VA Western New York Healthcare System, Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, State University of New York at Buffalo School of Medicine and Biomedical Sciences, Buffalo, New York, USA
| | - Ghazaleh Adlparvar
- Monroe College, State University of New York at Buffalo School of Medicine and Biomedical Sciences, Rochester, New York, USA
| | - Ali A El-Solh
- VA Western New York Healthcare System, Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, State University of New York at Buffalo School of Medicine and Biomedical Sciences, Buffalo, New York, USA
| | - Nader D Nader
- VA Western New York Healthcare System, Division of Cardiothoracic Anesthesia and Pain Medicine, Department of Anesthesiology, State University of New York at Buffalo School of Medicine and Biomedical Sciences, Buffalo, New York, USA
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Tedders KM, McNorton KN, Edwin SB. Efficacy and safety of analgosedation with fentanyl compared with traditional sedation with propofol. Pharmacotherapy 2014; 34:643-7. [PMID: 24753262 DOI: 10.1002/phar.1429] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVES To compare the efficacy and safety of analgosedation with fentanyl versus traditional sedation with propofol in critically ill patients receiving mechanical ventilation. METHODS Retrospective, observational study evaluating adult critically ill patients on mechanical ventilation at a community teaching hospital who received continuous infusion fentanyl (n=50) or propofol (n=50) from September 2011-March 2013. RESULTS Median duration of mechanical ventilation was similar between patients receiving propofol and fentanyl infusions (46.7 hr vs 46.0 hr, p=0.19). No difference was noted in median intensive care unit length of stay between groups (p=0.42). A larger percentage of patients receiving propofol required rescue opioids compared with patients receiving fentanyl (56% vs 34%, p=0.04). Furthermore, patients receiving propofol required significantly more rescue opioid therapy during the course of mechanical ventilation as calculated by fentanyl equivalents (150 μg vs 100 μg, p=0.03). No difference in the rate of intensive care unit delirium was noted between groups (fentanyl 23% vs propofol 27%, p=0.80). CONCLUSION Analgosedation with fentanyl appears to be a safe and effective strategy to facilitate mechanical ventilation. This regimen does not appear to affect duration of mechanical ventilation when compared with propofol, but may allow for more optimal pain management in critically ill patients.
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Affiliation(s)
- Kristen M Tedders
- Department of Pharmacy, St. John Macomb-Oakland Hospital, Warren, Michigan
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Automated sedation outperforms manual administration of propofol and remifentanil in critically ill patients with deep sedation: a randomized phase II trial. Intensive Care Med 2012; 39:454-62. [PMID: 23223772 DOI: 10.1007/s00134-012-2762-2] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2012] [Accepted: 11/05/2012] [Indexed: 01/14/2023]
Abstract
PURPOSE To compare automated administration of propofol and remifentanil guided by the Bispectral index (BIS) versus manual administration of short-acting drugs in critical care patients requiring deep sedation. The primary outcome was the percentage of BIS values between 40 and 60 (BIS(40-60)). METHODS This randomized controlled phase II trial in the intensive care unit (ICU) was conducted in adults with multiorgan failure. Thirty-one patients were assigned to receive sedation with propofol or remifentanil either by an automated or a manual system, both targeting BIS(40-60). Performance and feasibility of an automated administration were assessed. RESULTS The study groups were well balanced in terms of demographic characteristics. Study duration averaged 18 [8-24] h in the automated group and 14 [9-21] h in the manual group (p = 0.81). Adequate sedation (BIS(40-60)) was significantly more frequent in the automated group 77 [59-82] % than in the manual group 36 [22-56] %, with p = 0.001. Propofol consumption was reduced by a factor of 2 in the automated group with a median change of infusion rates of 39 ± 9 times per hour. In contrast, there were only 2 ± 1 propofol and 1 ± 1 remifentanil dose changes per hour in the manual group compared to 40 ± 9 for remifentanil in the automated group (p < 0.001). Vasopressors were more often discontinued or reduced in the automated group than in the manual control group (36 [6-40] vs. 12 [4-20] modifications, p = 0.03). CONCLUSIONS Continuous titration of propofol and remifentanil sedation with an automatic controller maintains deep sedation better than manual control in severely ill patients. It is associated with reduced sedative and vasopressor use.
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Pichot C, Longrois D, Ghignone M, Quintin L. [Dexmedetomidine and clonidine: a review of their pharmacodynamy to define their role for sedation in intensive care patients]. ACTA ACUST UNITED AC 2012; 31:876-96. [PMID: 23089375 DOI: 10.1016/j.annfar.2012.07.018] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2012] [Accepted: 07/12/2012] [Indexed: 11/29/2022]
Abstract
Alpha-2 adrenergic agonists ("alpha-2 agonists") present multiple pharmacodynamic effects: rousable sedation, decreased incidence of delirium in the setting of critical care, preservation of respiratory drive, decreased whole body oxygen consumption, decreased systemic and pulmonary arterial impedance, improved left ventricular systolic and diastolic function, preserved vascular reactivity to exogenous catecholamines, preserved vasomotor baroreflex with lowered set point, preserved kidney function, decreased protein catabolism. These pharmacodynamic effects explain the interest for these drugs in the critical care setting. However, their exact role for sedation in critically ill-patients remains open for further studies. Given the few double-blind randomized multicentric trials available, the present non exhaustive analysis of the literature aims at presenting the utilization of alpha-2 agonists as potential first-line sedative agents, in the critical care setting. Suggestions regarding the use of alpha-2 agonists as sedatives are detailed.
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Affiliation(s)
- C Pichot
- Physiologie (EA 4612 : neurocardiologie), campus de la Doua, université de Lyon, 8, rue R.-Dubois, 69622 Lyon-Villeurbanne, France
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Ajisaka H, Okajima M, Goto Y, Taniguchi T, Inaba H. Effects of acute low-dose ethanol on inflammatory reactions to endotoxin-induced shock in rats. J Toxicol Sci 2012; 37:649-54. [PMID: 22688005 DOI: 10.2131/jts.37.649] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
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Bigham C, Bigham S, Jones C. Does the Bispectral Index Monitor have a Role in Intensive Care? J Intensive Care Soc 2012. [DOI: 10.1177/175114371201300410] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
| | - Sarah Bigham
- Registrar Intensive Care, St Mary's Hospital, Paddington
| | - Chris Jones
- Registrar, Anaesthesia, Royal Surrey County Hospital
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Devabhakthuni S, Armahizer MJ, Dasta JF, Kane-Gill SL. Analgosedation: A Paradigm Shift in Intensive Care Unit Sedation Practice. Ann Pharmacother 2012; 46:530-40. [DOI: 10.1345/aph.1q525] [Citation(s) in RCA: 92] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Objective: To critically evaluate the use of analgosedation in the management of agitation in critically ill mechanically ventilated patients. Data Sources: Literature was accessed through MEDLINE (1948-November 2011) and Cochrane Library (2011, issue 1) using the terms analgosedation, analgosedation, or analgesia-based sedation alone or in combination with intensive care unit or critically ill. Reference lists of related publications were also reviewed. Study Selection and Data Extraction: All articles published in English were evaluated. Randomized controlled trials examining critically ill mechanically ventilated patients older than 18 years were included. Data Synthesis: Limitations of current sedation practices include serious adverse drug events, prolonged mechanical ventilation time, and intensive care unit (ICU) length of stay. Studies have demonstrated that analgosedation, a strategy that manages patient pain and discomfort first, before providing sedative therapy, results in improved patient outcomes compared to standard sedative-hypnotic regimens. Nine randomized controlled trials comparing remifentanil-based analgosedation to other commonly used agents (fentanyl, midazolam, morphine, and propofol) for ICU sedation and 1 trial comparing morphine to daily sedation interruption with propofol or midazolam were reviewed. Remifentanil is an ideal agent for analgosedation due to its easy titratability and organ-in dependent metabolism. When compared to sedative-hypnotic regimens, remifentanil-based regimens were associated with shorter duration of mechanical ventilation, more rapid weaning from the ventilator, and shorter ICU length of stay. Compared to fentanyl-based regimens, remifentanil had similar efficacy with the exception of increased pain requirements upon remifentanil discontinuation. Analgosedation was well tolerated, with no significant differences in hemodynamic stability compared to sedative-hypnotic regimens. Conclusions: Analgosedation is an efficacious and well-tolerated approach to management of ICU sedation with improved patient outcomes compared to sedative-hypnotic approaches. Additional well-designed trials are warranted to clarify the role of analgosedation in the management of ICU sedation, including trials with nonopioid analgesics.
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Affiliation(s)
- Sandeep Devabhakthuni
- University of Pittsburgh Medical Center, Pittsburgh, PA; now, Assistant Professor of Pharmacy Practice and Science, School of Pharmacy, University of Maryland, Baltimore
| | - Michael J Armahizer
- University of Pittsburgh Medical Center; how, Critical Care Pharmacy Specialist, Cardiothoracic Intensive Care Unit, University of Pittsburgh Medical Center
| | - Joseph F Dasta
- The Ohio State University, Columbus; Adjunct Professor, The University of Texas, Austin
| | - Sandra L Kane-Gill
- Center for Pharmacoinformatics and Outcomes Research, University of Pittsburgh
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Abstract
In recent years, the importance of appropriate intra-operative anesthesia and analgesia during cardiac surgery has become recognized as a factor in postoperative recovery. This includes the early perioperative management of the neonate undergoing radical surgery and more recently the care surrounding fast-track and ultra fast-track surgery. However, outside these areas, relatively little attention has focused on postoperative sedation and analgesia within the pediatric intensive care unit (PICU). This reflects perceived priorities of the primary disease process over the supporting structure of PICU, with a generic approach to sedation and analgesia that can result in additional morbidities and delayed recovery. Management of the marginal patient requires optimisation of not only cardiac and other attendant pathophysiology, but also every aspect of supportive care. Individualized sedation and analgesia strategies, starting in the operating theater and continuing through to hospital discharge, need to be regarded as an important aspect of perioperative care, to speed the process of recovery.
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Affiliation(s)
- Andrew R Wolf
- Paediatric Intensive Care Unit, Bristol Children's Hospital, Upper Maudlin Street, Bristol, UK.
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Affiliation(s)
- C. Pichot
- Critical Care Unit, Memorial Hospital, St Lô, France
| | - M. Ghignone
- Critical Care Unit, Columbia Hospital, WPalm Beach, FL, USA
| | - L. Quintin
- Physiology (CNRS UMR 5123), University of Lyon, Lyon, France
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Sedation Management in the ICU: Are We at a Crossroads? J Intensive Care Soc 2010. [DOI: 10.1177/17511437100112s102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Fudickar A, Jacobsen JH, Weiler N, Scholz J, Bein B. Bilateral measurement of bispectral index and mid-latency auditory evoked potentials in patients with unilateral brain lesions. J Crit Care 2009; 24:545-50. [DOI: 10.1016/j.jcrc.2009.02.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2008] [Revised: 01/13/2009] [Accepted: 02/16/2009] [Indexed: 10/20/2022]
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von Dossow V, Moshirzadeh M, Kastrup M, Wernecke KD, Konertz W, Spies C. Performance of the A-line Autoregressive Index (AAI) and of the Bispectral Index (BIS) at assessing depth of short-term sedation following cardiac surgery. J Int Med Res 2009; 37:611-20. [PMID: 19589243 DOI: 10.1177/147323000903700303] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
This study evaluated the correlation and agreement between the Bispectral Index (BIS) or A-line Autoregressive Index (AAI) and a clinical scoring system, the Ramsay Sedation Scale (RSS), in 40 patients after elective cardiac surgery and admission to the intensive care unit. All patients received sedation with propofol according to the study protocol. BIS, AAI and RSS were documented at two different levels of sedation: deep sedation RSS 4 - 6; and slight sedation/extubation RSS 2 - 3. Both the BIS and AAI agreed well with the RSS (eta-coefficients of 0.902 and 0.836, respectively, for mean overall RSS stages). The systems agreed well among each other (overall intra-class correlations of 0.670 for consistency and 0.676 for absolute agreement). There was significant discrimination between RSS 2 - 3 and RSS 4 - 6 with BIS and AAI (BIS mean difference of 24.73, 95% confidence intervals [CI] 21.08 - 28.37; AAI mean difference of 20.90, 95% CI 14.64 - 27.16). In conclusion, BIS and AAI correlated well with RSS overall and also at different levels of sedation.
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Affiliation(s)
- V von Dossow
- Department of Anaesthesiology and Intensive Care Medicine, Campus Virchow-Klinikum and Campus Charité Mitte, Charité - University Medicine Berlin, Berlin, Germany
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Weir S, O'Neill A. Experiences of intensive care nurses assessing sedation/agitation in critically ill patients. Nurs Crit Care 2008; 13:185-94. [PMID: 18577170 DOI: 10.1111/j.1478-5153.2008.00282.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Patients admitted to the intensive care unit (ICU) will more often than not require sedative and analgesic drugs to enable them to tolerate the invasive procedures and therapies caused as a result of their underlying condition and/or necessary medical interventions. AIM This article reports a study exploring the perceptions and experiences of intensive care nurses using a sedation/agitation scoring (SAS) tool to assess and manage sedation and agitation amongst critically ill patients. The principle aims and objectives of this study were as follows: to explore nurse's everyday experiences using a sedation scoring tool; to explore and understand nurse's attitudes and beliefs of the various components of assessing and managing sedation among critically ill patients. METHOD Using a descriptive qualitative approach, semistructured interviews were carried out with a purposive sample of eight ICU nurses within a district general hospital ICU. The interviews focused on nurses own experiences and perceptions of using a sedation scoring tool in clinical practice. Burnards 14-stage thematic content analysis framework was employed to assist in the data analysis process. RESULTS Three key themes emerged that may have implications not only for clinical practice but for further research into the use of the SAS tool. Benefits to patient care as a direct result of using a sedation scoring tool. The concerns of nursing staff. The implications of using such a tool in clinical practice. CONCLUSION This paper reinforces the potential benefits to patients as a direct result of implementing the SAS scoring tool and clinical guidelines. Furthermore, it highlights the reluctance of a number of staff to adhere to such guidelines and discusses the concerns regarding less experienced nurses administering sedative agents. Attention was also drawn to the educational requirements of nursing and medical staff when using the SAS scoring tool.
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Affiliation(s)
- Stephanie Weir
- Intensive Care Unit, Crosshouse Hospital, Kilmarnock, UK.
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Variability in the concentrations of intravenous drug infusions prepared in a critical care unit. Intensive Care Med 2008; 34:1441-7. [DOI: 10.1007/s00134-008-1113-9] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2007] [Accepted: 03/20/2008] [Indexed: 11/26/2022]
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Walsh TS, Ramsay P, Lapinlampi TP, Särkelä MOK, Viertiö-Oja HE, Meriläinen PT. An assessment of the validity of spectral entropy as a measure of sedation statein mechanically ventilated critically ill patients. Intensive Care Med 2007; 34:308-15. [PMID: 17898996 DOI: 10.1007/s00134-007-0858-x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2007] [Accepted: 09/04/2007] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To assess whether the Entropy Module (GE Healthcare, Helsinki, Finland), a device to measure hypnosis in anesthesia, is a valid measure of sedation state in critically ill patients by comparing clinically assessed sedation state with Spectral Entropy DESIGN Prospective observational study. SETTING Teaching hospital general ICU. PATIENTS AND PARTICIPANTS 30 intubated, mechanically ventilated patients without primary neurological diagnoses or drug overdose receiving continuous sedation. INTERVENTIONS Monitoring of EEG and fEMG activity via forehead electrodes for up to 72h and assessments of conscious level using a modified Ramsay Sedation Scale. MEASUREMENTS AND RESULTS 475 trained observer assessments were made and compared with concurrent Entropy numbers. Median State (SE) and Response (RE) Entropy values decreased as Ramsay score increased, but wide variation occurred, especially in Ramsay 4-6 categories. Discrimination between different sedation scores [mean (SEM) P(K) value: RE 0.713 (0.019); SE 0.710 (0.019)] and between lighter (Ramsay 1-3) vs.deeper (Ramsay 4-6) sedation ranges was inadequate [P(K): RE 0.750 (0.025); SE 0.748 (0.025)]. fEMG power decreased with increasing Ramsay score but was often significant even at Ramsay 4-6 states. Frequent "on-off" effects occurred for both RE and SE, which were associated with fEMG activity. Values switched from low to high values even in deeply sedated patients. High Entropy values during deeper sedation were strongly associated with simultaneous high relative fEMG powers. CONCLUSIONS Entropy of the frontal EEG does not discriminate sedation state adequately for clinical use in ICU patients. Facial EMG is a major confounder in clinical sedation ranges.
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Affiliation(s)
- Timothy S Walsh
- Edinburgh Royal Infirmary, 51 Little France Crescent, Old Dalkeith Road, EH16 4SA Edinburgh, Scotland.
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Park G, Lane M, Rogers S, Bassett P. A comparison of hypnotic and analgesic based sedation in a general intensive care unit †. Br J Anaesth 2007; 98:76-82. [PMID: 17158127 DOI: 10.1093/bja/ael320] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Sedation of the critically ill patient has several components including hypnosis and analgesia. Hypnotic-based sedation (HBS), where midazolam and/or propofol are used, with morphine or another analgesic added as needed has been common. The advent of remifentanil has allowed greater use of analgesia-based sedation (ABS) where relief of discomfort from the tracheal tube or pain are the important objectives, and hypnosis is given as necessary. Method. We compared HBS and ABS (remifentanil-based sedation) within a general intensive care unit (ICU). During the first study period of 12 weeks, 111 patients received HBS. After the development of new guidelines for the use of remifentanil in the ICU, a second 12 week study period used an analgesia-based regimen, with hypnotics added only if needed. RESULTS Ninety-six patients received ABS, and 79 received remifentanil. It was possible to manage 29 (37%) of the patients receiving remifentanil without the use of supplementary hypnotic agents. In the remaining 63% the use of remifentanil was associated with a reduction in the amount and duration of propofol used. Significantly more patients receiving ABS had satisfactory levels of sedation during synchronized intermittent mandatory ventilation (19 [2,55] vs 50 [14,83], P<0.001). CONCLUSIONS The use of ABS allowed patients to be managed more comfortably, either without a hypnotic drug or with less hypnotic drug, than using conventional HBS.
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Affiliation(s)
- G Park
- John Farman Intensive Care Unit, Addenbrooke's Hospital Hills Road, Cambridge CB2 2QQ, UK.
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28
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Abstract
BACKGROUND In the intensive care unit (ICU), analgesia and sedation are used to improve the comfort and safety of patients undergoing intensive care therapies. However, continuous administration of sedatives prolongs the time on mechanical ventilation and ICU stay. These adverse effects can be reduced by clear definition of the goals of sedation combined with a sedation protocol. METHODS The adherence to the local sedation guideline of a university affiliated ICU was monitored prospectively before and after intervention: reinforcement of the guideline. The primary endpoints of the study were the occurrence of daily interruption or tapering of sedation and achievement of the target Ramsay scale level (days: 2-3, nights: 3-4) according to the guideline. RESULTS Comparing sedation before and after the intervention (166 and 170 ICU days), no significant differences were observed in the occurrence of daily interruption or tapering of sedatives, 94/129 (73%) vs. 109/139 (78%) of sedation days, nor in the Ramsay scale level during the day, 4 (3-5) vs. 4 (3-5), or in the night, 5 (4-5) vs. 5 (4-5), respectively. After the intervention, Ramsay scale recordings were made more frequently, 280/398 (70%) vs. 234/380 (62%) of the nurses' shifts (P < 0.01). CONCLUSION Adherence to the local sedation guideline was not high, and no significant change was seen after this simple intervention. Continuous education and discussion on the desirable and undesirable effects of sedation, followed by multidisciplinary re-evaluation of the current guideline, are due in our unit.
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Affiliation(s)
- M Tallgren
- Department of Anaesthesia and Intensive Care Medicine, Meilahti Hospital, Helsinki University Hospital, Helsinki, Finland.
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Muellejans B, Matthey T, Scholpp J, Schill M. Sedation in the intensive care unit with remifentanil/propofol versus midazolam/fentanyl: a randomised, open-label, pharmacoeconomic trial. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2006; 10:R91. [PMID: 16780597 PMCID: PMC1550941 DOI: 10.1186/cc4939] [Citation(s) in RCA: 93] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/26/2006] [Revised: 03/08/2006] [Accepted: 05/08/2006] [Indexed: 01/15/2023]
Abstract
Introduction Remifentanil is an opioid with a unique pharmacokinetic profile. Its organ-independent elimination and short context-sensitive half time of 3 to 4 minutes lead to a highly predictable offset of action. We tested the hypothesis that with an analgesia-based sedation regimen with remifentanil and propofol, patients after cardiac surgery reach predefined criteria for discharge from the intensive care unit (ICU) sooner, resulting in shorter duration of time spent in the ICU, compared to a conventional regimen consisting of midazolam and fentanyl. In addition, the two regimens were compared regarding their costs. Methods In this prospective, open-label, randomised, single-centre study, a total of 80 patients (18 to 75 years old), who had undergone cardiac surgery, were postoperatively assigned to one of two treatment regimens for sedation in the ICU for 12 to 72 hours. Patients in the remifentanil/propofol group received remifentanil (6- max. 60 μg kg-1 h-1; dose exceeds recommended labelling). Propofol (0.5 to 4.0 mg kg-1 h-1) was supplemented only in the case of insufficient sedation at maximal remifentanil dose. Patients in the midazolam/fentanyl group received midazolam (0.02 to 0.2 mg kg-1 h-1) and fentanyl (1.0 to 7.0 μg kg-1 h-1). For treatment of pain after extubation, both groups received morphine and/or non-opioid analgesics. Results The time intervals (mean values ± standard deviation) from arrival at the ICU until extubation (20.7 ± 5.2 hours versus 24.2 h ± 7.0 hours) and from arrival until eligible discharge from the ICU (46.1 ± 22.0 hours versus 62.4 ± 27.2 hours) were significantly (p < 0.05) shorter in the remifentanil/propofol group. Overall costs of the ICU stay per patient were equal (approximately €1,700 on average). Conclusion Compared with midazolam/fentanyl, a remifentanil-based regimen for analgesia and sedation supplemented with propofol significantly reduced the time on mechanical ventilation and allowed earlier discharge from the ICU, at equal overall costs.
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Affiliation(s)
- Bernd Muellejans
- Department of Anaesthesiology and Intensive Care Medicine, Heart Centre Mecklenburg-Vorpommern, Germany
| | - Thomas Matthey
- Department of Anaesthesiology and Intensive Care Medicine, Heart Centre Mecklenburg-Vorpommern, Germany
| | | | - Markus Schill
- Medical Department, GlaxoSmithKline, Munich, Germany
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Tonner PH, Paris A, Scholz J. Monitoring consciousness in intensive care medicine. Best Pract Res Clin Anaesthesiol 2006; 20:191-200. [PMID: 16634425 DOI: 10.1016/j.bpa.2005.08.011] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Sedation and analgesia are important components of care for critically ill patients. Avoiding over-as well as undersedation is of utmost importance as both states carry considerable risks and may influence outcome. The management of sedation has changed dramatically over the past two decades from providing a dosage level by which the patient was kept in a deep stage of anaesthesia to a current dosing strategy allowing the administration of drugs in line with individual need, resulting in most cases in a slightly sedated, cooperative patient. The importance of monitoring the level of sedation and analgesia has only recently been realised. Most importantly, regularly determining the appropriate level of sedation and analgesia as well as monitoring the desired level of sedation will help to minimise the adverse effects of sedation. Clinical sedation scales are, however, subjective, and most lack proper validation. Thus, an objective measure of sedation, such as the use of processed electroencephalogram (EEG) parameters is desirable. Processed EEG algorithms such as the bispectral index were initially introduced into clinical practice as a tool to assess the depth of anaesthesia objectively in the operating room. However, patients under general anaesthesia differ from those in an intensive care unit. Accordingly, most results from studies evaluating the performance of processed EEG parameters in critically ill patients have not been satisfactory. At present, monitoring sedation with processed EEG parameters cannot generally be recommended. However, in special situations such as deep sedation and neuromuscular blockade, in which clinical sedation scales are prone to failure, the bispectral index may help to assess the level of sedation.
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Affiliation(s)
- Peter H Tonner
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Schleswig-Holstein, Campus Kiel, Schwanenweg 21, 24105 Kiel, Germany.
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Martin J, Franck M, Fischer M, Spies C. Sedation and analgesia in German intensive care units: how is it done in reality? Results of a patient-based survey of analgesia and sedation. Intensive Care Med 2006; 32:1137-42. [PMID: 16741692 DOI: 10.1007/s00134-006-0214-6] [Citation(s) in RCA: 70] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2005] [Accepted: 05/02/2006] [Indexed: 11/29/2022]
Abstract
OBJECTIVE This study carried out the first patient-oriented survey on the practice of analgesia and sedation in German intensive care units, examining whether the goals of early spontaneous breathing and awake, cooperative patients are achieved. DESIGN A postal survey was sent to 261 hospitals in Germany. Each hospital received three patient-oriented forms with questions regarding current agents and techniques for analgesia and sedation of a specific patient. Responses were obtained from 220 (84%) hospitals which returned 305 questionnaires. RESULTS Patients' Ramsay sedation scale was significantly higher in all phases of analgesia and sedation, indicating that the patients were more deeply sedated than currently intended by the therapist. Propofol was used for most of the patients during short-term sedation (57%) and during weaning (48%). The preferred agent for sedation longer than 72[Symbol: see text]h was midazolam (66%). CONCLUSION The choice of agents and techniques for analgesia and sedation in the intensive care unit thus follows the German guidelines. The fact that the patients were more deeply sedated than intended by the therapist in all phases of sedation may be due to the low use of sedation scales and clinical practice guidelines or to the lack of training in using these techniques.
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Affiliation(s)
- Jörg Martin
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, Hospital am Eichert, Eichertstrasse 3, 73035 Göppingen, Germany.
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Tonner PH, Wei C, Bein B, Weiler N, Paris A, Scholz J. Comparison of two bispectral index algorithms in monitoring sedation in postoperative intensive care patients*. Crit Care Med 2005; 33:580-4. [PMID: 15753750 DOI: 10.1097/01.ccm.0000156291.04287.7f] [Citation(s) in RCA: 64] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Comparison of two versions of bispectral index (BIS) derived from the electroencephalogram in mechanically ventilated and continuously sedated patients after major abdominal surgery. DESIGN Prospective, cohort, observational, unblinded study. SETTING Surgical intensive care unit of a university hospital. PATIENTS Forty-six patients undergoing major abdominal surgery scheduled for postoperative mechanical ventilation and continuous sedation. INTERVENTIONS Patients were continuously sedated using propofol and sufentanil. MEASUREMENTS AND MAIN RESULTS Electrodes for determination of BIS were placed at the forehead of the patients according to the manufacturer's specifications immediately after arrival to the intensive care unit. The level of consciousness was assessed every 2 hrs by a clinical sedation scale (Ramsay sedation scale, levels 1-6). BIS, electromyographic activity, and signal quality index were recorded simultaneously at the same time as the Ramsay scale for 24 hrs or until patients were ready for extubation. BIS (version 2.10) and BIS XP (version 3.12) were determined at 2-hr intervals. BIS and BIS XP showed a high correlation of readings (rs = .79, p < .01). However, the methods did not yield identical results. Both variables were significantly influenced by electromyographic activity, especially at high values, whereas there was only a weak correlation with body temperature. Some of the deeply sedated patients (Ramsay 5 or 6) had BIS readings >80 (BIS, 16%; BIS XP, 13%; p = not significant). CONCLUSIONS The newer algorithm BIS XP did not perform better than the previous version BIS in patients after major surgery who were mechanically ventilated and sedated on an intensive care unit. This precludes the use of BIS or BIS XP for distinguishing, among deeply sedated ICU patients, those with and without preserved cerebral electrical activity.
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Affiliation(s)
- Peter H Tonner
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Schleswig-Holstein, Campus Kiel, Kiel, Germany
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Martin J, Parsch A, Franck M, Wernecke KD, Fischer M, Spies C. Practice of sedation and analgesia in German intensive care units: results of a national survey. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2005; 9:R117-23. [PMID: 15774043 PMCID: PMC1175921 DOI: 10.1186/cc3035] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/21/2004] [Accepted: 12/02/2004] [Indexed: 11/16/2022]
Abstract
Introduction Sedation and analgesia are provided by using different agents and techniques in different countries. The goal is to achieve early spontaneous breathing and to obtain an awake and cooperative pain-free patient. It was the aim of this study to conduct a survey of the agents and techniques used for analgesia and sedation in intensive care units in Germany. Methods A survey was sent by mail to 261 hospitals in Germany. The anesthesiologists running the intensive care unit were asked to fill in the structured questionnaire about their use of sedation and analgesia. Results A total of 220 (84%) questionnaires were completed and returned. The RAMSAY sedation scale was used in 8% of the hospitals. A written policy was available in 21% of hospitals. For short-term sedation in most hospitals, propofol was used in combination with sufentanil or fentanyl. For long-term sedation, midazolam/fentanyl was preferred. Clonidine was a common part of up to two-thirds of the regimens. Epidural analgesia was used in up to 68%. Neuromuscular blocking agents were no longer used. Conclusion In contrast to the US 'Clinical practice guidelines for the sustained use of sedatives and analgesics in the critically ill adult', our survey showed that in Germany different agents, and frequently neuroaxial techniques, were used.
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Affiliation(s)
- Jörg Martin
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, Hospital am Eichert, Göppingen, Germany.
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Abstract
Sedation and analgesia are relevant aspects for the adequate treatment of patients in an intensive care unit. Recent drug developments and new strategies for ventilation provide improved sedation management allowing better adaptation to the clinical background and individual needs of the patient. This article provides an overview on the application of different substance groups. Focus is placed on newly developed pharmaceuticals such as dexmedetomidine. Another aspect is scoring system-related and EEG-based monitoring of depth of sedation. Modern concepts of analgesia and sedation for ICU patients have been developed based on the interaction of different parameters such as adaptive sedation and analgesia management (ASAM).
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Affiliation(s)
- E Schaffrath
- Klinik für Anästhesiologie, Klinikum der Universität München.
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Walsh TS, Ramsay P, Kinnunen R. Monitoring sedation in the intensive care unit: can "black boxes" help us? Intensive Care Med 2004; 30:1511-3. [PMID: 15057513 DOI: 10.1007/s00134-004-2271-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/09/2004] [Indexed: 01/05/2023]
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