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Clark JR, Batra A, Tessier RA, Greathouse K, Dickson D, Ammar A, Hamm B, Rosenthal LJ, Lombardo T, Koralnik IJ, Skolarus LE, Schroedl CJ, Budinger GRS, Wunderink RG, Dematte JE, Ungvari Z, Liotta EM. Impact of healthcare system strain on the implementation of ICU sedation practices and encephalopathy burden during the early COVID-19 pandemic. GeroScience 2024:10.1007/s11357-024-01336-4. [PMID: 39243283 DOI: 10.1007/s11357-024-01336-4] [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] [Received: 06/21/2024] [Accepted: 08/31/2024] [Indexed: 09/09/2024] Open
Abstract
The COVID-19 pandemic posed unprecedented challenges to healthcare systems worldwide, particularly in managing critically ill patients requiring mechanical ventilation early in the pandemic. Surging patient volumes strained hospital resources and complicated the implementation of standard-of-care intensive care unit (ICU) practices, including sedation management. The objective of this study was to evaluate the impact of an evidence-based ICU sedation bundle during the early COVID-19 pandemic. The bundle was designed by a multi-disciplinary collaborative to reinforce best clinical practices related to ICU sedation. The bundle was implemented prospectively with retrospective analysis of electronic medical record data. The setting was the ICUs of a single-center tertiary hospital. The patients were the ICU patients requiring mechanical ventilation for confirmed COVID-19 between March and June 2020. A learning health collaborative developed a sedation bundle encouraging goal-directed sedation and use of adjunctive strategies to avoid excessive sedative administration. Implementation strategies included structured in-service training, audit and feedback, and continuous improvement. Sedative utilization and clinical outcomes were compared between patients admitted before and after the sedation bundle implementation. Quasi-experimental interrupted time-series analyses of pre and post intervention sedative utilization, hospital length of stay, and number of days free of delirium, coma, or death in 21 days (as a quantitative measure of encephalopathy burden). The analysis used the time duration between start of the COVID-19 wave and ICU admission to identify a "breakpoint" indicating a change in observed trends. A total of 183 patients (age 59.0 ± 15.9 years) were included, with 83 (45%) admitted before the intervention began. Benzodiazepine utilization increased for patients admitted after the bundle implementation, while agents intended to reduce benzodiazepine use showed no greater utilization. No "breakpoint" was identified to suggest the bundle impacted any endpoint measure. However, increasing time between COVID-19 wave start and ICU admission was associated with fewer delirium, coma, and death-free days (β = - 0.044 [95% CI - 0.085, - 0.003] days/wave day); more days of benzodiazepine infusion (β = 0.056 [95% CI 0.025, 0.088] days/wave day); and a higher maximum benzodiazepine infusion rate (β = 0.079 [95% CI 0.037, 0.120] mg/h/wave day). The evidence-based practice bundle did not significantly alter sedation utilization patterns during the first COVID-19 wave. Sedation practices deteriorated and encephalopathy burden increased over time, highlighting that strategies to reinforce clinical practices may be hindered under conditions of extreme healthcare system strain.
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Affiliation(s)
- Jeffrey R Clark
- Northwestern University-Feinberg School of Medicine, Chicago, IL, USA
- Columbia University Irving Medical Center, New York, NY, USA
| | - Ayush Batra
- Ken & Ruth Davee Department of Neurology, Northwestern University-Feinberg School of Medicine, 625 N. Michigan Ave, Suite 1150, Chicago, IL, 60611, USA
| | - Robert A Tessier
- Northwestern University-Feinberg School of Medicine, Chicago, IL, USA
| | - Kasey Greathouse
- Northwestern University-Feinberg School of Medicine, Chicago, IL, USA
| | - Dan Dickson
- Northwestern University-Feinberg School of Medicine, Chicago, IL, USA
| | - Abeer Ammar
- Northwestern University-Feinberg School of Medicine, Chicago, IL, USA
| | - Brandon Hamm
- Department of Psychiatry and Behavioral Sciences, Northwestern University-Feinberg School of Medicine, Chicago, IL, USA
| | - Lisa J Rosenthal
- Department of Psychiatry and Behavioral Sciences, Northwestern University-Feinberg School of Medicine, Chicago, IL, USA
| | - Theresa Lombardo
- Northwestern University-Feinberg School of Medicine, Chicago, IL, USA
| | - Igor J Koralnik
- Ken & Ruth Davee Department of Neurology, Northwestern University-Feinberg School of Medicine, 625 N. Michigan Ave, Suite 1150, Chicago, IL, 60611, USA
| | - Lesli E Skolarus
- Ken & Ruth Davee Department of Neurology, Northwestern University-Feinberg School of Medicine, 625 N. Michigan Ave, Suite 1150, Chicago, IL, 60611, USA
| | - Clara J Schroedl
- Department of Medicine, Division of Pulmonary and Critical Care, Northwestern University-Feinberg School of Medicine, Chicago, IL, USA
| | - G R Scott Budinger
- Department of Medicine, Division of Pulmonary and Critical Care, Northwestern University-Feinberg School of Medicine, Chicago, IL, USA
| | - Richard G Wunderink
- Department of Medicine, Division of Pulmonary and Critical Care, Northwestern University-Feinberg School of Medicine, Chicago, IL, USA
| | - Jane E Dematte
- Department of Medicine, Division of Pulmonary and Critical Care, Northwestern University-Feinberg School of Medicine, Chicago, IL, USA
| | - Zoltan Ungvari
- Vascular Cognitive Impairment, Neurodegeneration and Healthy Brain Aging Program, Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
- Stephenson Cancer Center, University of Oklahoma, Oklahoma City, OK, USA
- Oklahoma Center for Geroscience and Healthy Brain Aging, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
- Department of Health Promotion Sciences, College of Public Health, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
- International Training Program in Geroscience, Doctoral College/Department of Public Health, Semmelweis University, Budapest, Hungary
| | - Eric M Liotta
- Ken & Ruth Davee Department of Neurology, Northwestern University-Feinberg School of Medicine, 625 N. Michigan Ave, Suite 1150, Chicago, IL, 60611, USA.
- International Training Program in Geroscience, Doctoral College/Department of Public Health, Semmelweis University, Budapest, Hungary.
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Shahn Z, Choudhri A, Jung B, Talmor D, Lehman LWH, Baedorf-Kassis E. Effects of aggressive and conservative strategies for mechanical ventilation liberation. J Crit Care 2023; 76:154275. [PMID: 36796189 DOI: 10.1016/j.jcrc.2023.154275] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 01/17/2023] [Accepted: 02/02/2023] [Indexed: 02/16/2023]
Abstract
BACKGROUND The optimal approach for transitioning from strict lung protective ventilation to support modes of ventilation when patients determine their own respiratory rate and tidal volume remains unclear. While aggressive liberation from lung protective settings could expedite extubation and prevent harm from prolonged ventilation and sedation, conservative liberation could prevent lung injury from spontaneous breathing. RESEARCH QUESTION Should physicians take a more aggressive or conservative approach to liberation? METHODS Retrospective cohort study of mechanically ventilated patients from the Medical Information Mart for Intensive Care IV database (MIMIC-IV version 1.0) estimating effects of incremental interventions modifying the propensity for liberation to be more aggressive or conservative relative to usual care, with adjustment for confounding via inverse probability weighting. Outcomes included in-hospital mortality, ventilator free days, and ICU free days. Analysis was performed on the entire cohort as well as subgroups differentiated by PaO2/FiO2 ratio, and SOFA. RESULTS 7433 patients were included. Strategies multiplying the odds of a first liberation relative to usual care at each hour had a large impact on time to first liberation attempt (43 h under usual care, 24 h (0.95 CI = [23,25]) with an aggressive strategy doubling liberation odds, and 74 h (0.95 CI = [69,78]) under a conservative strategy halving liberation odds). In the full cohort, we estimated aggressive liberation increased ICU-free days by 0.9 days (0.95 CI = [0.8,1.0]) and ventilator free days by 0.82 days (0.95 CI = [0.67,0.97]), but had minimal effect on mortality (only a 0.3% (0.95 CI = [-0.2%,0.8%]) difference between minimum and maximum rates). With baseline SOFA≥ 12 (n = 1355), aggressive liberation moderately increased mortality (58.5% [0.95 CI = (55.7%,61.2%)]) compared with conservative liberation (55.1% [0.95 CI = (51.6%,58.6%)]). INTERPRETATION Aggressive liberation may improve ventilator free and ICU free days with little impact on mortality in patients with SOFA score < 12. Trials are needed.
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Affiliation(s)
- Zach Shahn
- IBM Research, Yorktown Heights, NY 10598, USA; MIT-IBM Watson AI Lab, Cambridge, MA, USA; CUNY School of Public Health, New York City, New York, USA.
| | - Aman Choudhri
- Institute for Medical Engineering & Science, Massachusetts Institute of Technology, Cambridge, MA 02142, USA
| | - Boris Jung
- Medical Intensive Care Unit, Lapeyronie Teaching Hospital, Montpellier University, Montpellier, France; Department of Anesthesia, Pain and Critical Care, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02115, USA; Division of Pulmonary and Critical Care, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02115, USA
| | - Daniel Talmor
- Department of Anesthesia, Pain and Critical Care, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02115, USA
| | - Li-Wei H Lehman
- Institute for Medical Engineering & Science, Massachusetts Institute of Technology, Cambridge, MA 02142, USA; MIT-IBM Watson AI Lab, Cambridge, MA, USA
| | - Elias Baedorf-Kassis
- Department of Anesthesia, Pain and Critical Care, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02115, USA; Division of Pulmonary and Critical Care, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02115, USA
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Kassis EB, Beitler JR, Talmor D. Lung-protective sedation: moving toward a new paradigm of precision sedation. Intensive Care Med 2023; 49:91-94. [PMID: 36239747 DOI: 10.1007/s00134-022-06901-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Accepted: 09/24/2022] [Indexed: 01/24/2023]
Affiliation(s)
- Elias Baedorf Kassis
- Division of Pulmonary and Critical Care Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, 375 Longwood Ave, MASCO Building, Boston, MA, 02215, USA.
| | - Jeremy R Beitler
- Columbia Respiratory Critical Care Trials Group, Columbia University College of Physicians and Surgeons and New York-Presbyterian Hospital, New York, NY, USA
| | - Daniel Talmor
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
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Knitter J, Bailey OF, Poongkunran C, Martinez AF, Martinez L, Kobayashi U, Combs D, Lane R, Zareba W, Parthasarathy S. Comparison of Physiological Performance of Four Adaptive Servo Ventilation Devices in Patients with Complex Sleep Apnea. Am J Respir Crit Care Med 2019; 199:925-928. [PMID: 30605350 PMCID: PMC6444654 DOI: 10.1164/rccm.201807-1303le] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
| | | | | | | | | | | | | | | | | | - Sairam Parthasarathy
- University of Arizona Health Sciences Center for Sleep and Circadian SciencesTucson, Arizona
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Riachy M, Khayat G, Ibrahim I, Aoun Z, Dabar G, Bazarbachi T, Khalil N, Habr B. A randomized double-blind controlled trial comparing three sedation regimens during flexible bronchoscopy: Dexmedetomidine, alfentanil and lidocaine. CLINICAL RESPIRATORY JOURNAL 2017; 12:1407-1415. [PMID: 28779544 DOI: 10.1111/crj.12669] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/24/2017] [Accepted: 07/09/2017] [Indexed: 12/01/2022]
Abstract
INTRODUCTION No standardized sedation protocol is available for flexible bronchoscopy (FB). OBJECTIVES The aim of this study was to evaluate the efficacy and safety of three regimens used for sedation during FB. METHODS This randomized double-blind controlled trial assessed patients undergoing bronchoscopy and receiving lidocaine alone (C) or combined with dexmedetomidine (D) or alfentanil (A). Tolerance was assessed using the bronchoscopy score, and level of sedation was assessed using the Nursing Instrument for the Communication of Sedation. Safety was evaluated in terms of pulmonary function and vital signs. RESULTS A total of 162 patients were enrolled. The bronchoscopy score was identical in all groups. Group D subjects were the most sedated (P = .013), whereas group A subjects were the least agitated. Linear regression showed a negative association between bronchoscopy score and age in A (β = -0.06; P = .001). Positive predictors of bronchoscopy score were female gender (β = 1.96; P = .003) in D and obesity (β = 2.41; P = .012), longer procedures (β = 0.08; P = .009) and female gender (β = 1.15; P = .038) in C. Longer procedures (β = -0.12; P = .010) was a negative predictor of bronchoscopy score in D. Desaturation, hypoxia and heart rate changes were most prevalent in group A. Hypotension was mostly observed in D. CONCLUSIONS No consistent differences were present between the three regimens; however, each was more appropriate in certain patient profiles. We consequently proposed a protocol as a first step towards standardizing sedation practice in FB in a patient-tailored manner. A more comprehensive and detailed protocol including other sedative agents with their corresponding doses should be developed.
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Affiliation(s)
- Moussa Riachy
- Department of Pulmonary and Critical Care, Hôtel Dieu de France University Hospital, Beirut, Lebanon
| | - Georges Khayat
- Department of Pulmonary and Critical Care, Hôtel Dieu de France University Hospital, Beirut, Lebanon
| | - Ihab Ibrahim
- Department of Pulmonary and Critical Care, Hôtel Dieu de France University Hospital, Beirut, Lebanon
| | - Zeina Aoun
- Department of Pulmonary and Critical Care, Hôtel Dieu de France University Hospital, Beirut, Lebanon
| | - Georges Dabar
- Department of Pulmonary and Critical Care, Hôtel Dieu de France University Hospital, Beirut, Lebanon
| | - Taha Bazarbachi
- Department of Pulmonary and Critical Care, Hôtel Dieu de France University Hospital, Beirut, Lebanon
| | - Nadine Khalil
- Department of Pulmonary and Critical Care, Hôtel Dieu de France University Hospital, Beirut, Lebanon
| | - Bassem Habr
- Department of Pulmonary and Critical Care, Hôtel Dieu de France University Hospital, Beirut, Lebanon
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Nigoghossian CD, Dzierba AL, Etheridge J, Roberts R, Muir J, Brodie D, Schumaker G, Bacchetta M, Ruthazer R, Devlin JW. Effect of Extracorporeal Membrane Oxygenation Use on Sedative Requirements in Patients with Severe Acute Respiratory Distress Syndrome. Pharmacotherapy 2016; 36:607-16. [DOI: 10.1002/phar.1760] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
| | - Amy L. Dzierba
- Department of Pharmacy; NewYork-Presbyterian Hospital; New York New York
| | - Joshua Etheridge
- School of Pharmacy; Northeastern University; Boston Massachusetts
| | - Russel Roberts
- Department of Pharmacy; Tufts Medical Center; Boston Massachusetts
| | - Justin Muir
- Department of Pharmacy; NewYork-Presbyterian Hospital; New York New York
| | - Daniel Brodie
- Division of Pulmonary and Critical Care Medicine; Columbia College of Physicians and Surgeons; New York New York
| | - Greg Schumaker
- Division of Pulmonary; Critical Care Medicine and Sleep Medicine; Tufts Medical Center; Boston Massachusetts
| | - Matthew Bacchetta
- Division of Pulmonary and Critical Care Medicine; Columbia College of Physicians and Surgeons; New York New York
| | - Robin Ruthazer
- Biostatistical Research Center; Tufts Medical Center; Boston Massachusetts
| | - John W. Devlin
- School of Pharmacy; Northeastern University; Boston Massachusetts
- Division of Pulmonary; Critical Care Medicine and Sleep Medicine; Tufts Medical Center; Boston Massachusetts
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7
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Serpa Neto A, Simonis FD, Barbas CSV, Biehl M, Determann RM, Elmer J, Friedman G, Gajic O, Goldstein JN, Horn J, Juffermans NP, Linko R, de Oliveira RP, Sundar S, Talmor D, Wolthuis EK, de Abreu MG, Pelosi P, Schultz MJ. Association between tidal volume size, duration of ventilation, and sedation needs in patients without acute respiratory distress syndrome: an individual patient data meta-analysis. Intensive Care Med 2014; 40:950-7. [PMID: 24811940 DOI: 10.1007/s00134-014-3318-4] [Citation(s) in RCA: 96] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2014] [Accepted: 04/21/2014] [Indexed: 12/27/2022]
Abstract
PURPOSE Mechanical ventilation with lower tidal volumes (≤6 ml/kg of predicted body weight, PBW) could benefit patients without acute respiratory distress syndrome (ARDS). However, tidal volume reduction could be associated with increased patient discomfort and sedation needs, and consequent longer duration of ventilation. The aim of this individual patient data meta-analysis was to assess the associations between tidal volume size, duration of mechanical ventilation, and sedation needs in patients without ARDS. METHODS Studies comparing ventilation with different tidal volume sizes in patients without ARDS were screened for inclusion. Corresponding authors were asked to provide individual participant data. Patients were assigned to three groups based on tidal volume size (≤6 ml/kg PBW, 6-10 ml/kg PBW, or ≥10 ml/kg PBW). Ventilator-free days, alive at day 28, and dose and duration of sedation (propofol and midazolam), analgesia (fentanyl and morphine), and neuromuscular blockade (NMB) were compared. RESULTS Seven investigations (2,184 patients) were included in the analysis. The number of patients breathing without assistance by day 28 was higher in the group ventilated with tidal volume ≤6 ml/kg PBW compared to those ventilated with tidal volume ≥10 ml/kg PBW (93.1 vs. 88.6%; p = 0.027, respectively). Only two investigations (187 patients) could be included in the meta-analysis of sedation needs. There were neither differences in the percentage of study days that patients received sedatives, opioids, or NMBA nor in the total dose of benzodiazepines, propofol, opioids, and NMBA. CONCLUSIONS This meta-analysis suggests that use of lower tidal volumes in patients without ARDS at the onset of mechanical ventilation could be associated with shorter duration of ventilation. Use of lower tidal volumes seems not to affect sedation or analgesia needs, but this must be confirmed in a robust, well-powered randomized controlled trial.
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Affiliation(s)
- Ary Serpa Neto
- Department of Intensive Care, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands,
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8
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Clinical practice guidelines for evidence-based management of sedoanalgesia in critically ill adult patients. ACTA ACUST UNITED AC 2013. [DOI: 10.1016/j.medine.2013.04.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
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9
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Celis-Rodríguez E, Birchenall C, de la Cal M, Castorena Arellano G, Hernández A, Ceraso D, Díaz Cortés J, Dueñas Castell C, Jimenez E, Meza J, Muñoz Martínez T, Sosa García J, Pacheco Tovar C, Pálizas F, Pardo Oviedo J, Pinilla DI, Raffán-Sanabria F, Raimondi N, Righy Shinotsuka C, Suárez M, Ugarte S, Rubiano S. Guía de práctica clínica basada en la evidencia para el manejo de la sedoanalgesia en el paciente adulto críticamente enfermo. Med Intensiva 2013; 37:519-74. [DOI: 10.1016/j.medin.2013.04.001] [Citation(s) in RCA: 73] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2013] [Accepted: 04/16/2013] [Indexed: 01/18/2023]
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Hypercapnia in late-phase ALI/ARDS: providing spontaneous breathing using pumpless extracorporeal lung assist. Intensive Care Med 2009; 35:1100-5. [DOI: 10.1007/s00134-009-1426-3] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2008] [Accepted: 01/10/2009] [Indexed: 10/21/2022]
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Abstract
Mechanical ventilation using high tidal volume (VT) and transpulmonary pressure can damage the lung, causing ventilator-induced lung injury. Permissive hypercapnia, a ventilatory strategy for acute respiratory failure in which the lungs are ventilated with a low inspiratory volume and pressure, has been accepted progressively in critical care for adult, pediatric, and neonatal patients requiring mechanical ventilation and is one of the central components of current protective ventilatory strategies.
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Affiliation(s)
- Alex Rogovik
- Pediatric Research in Emergency Therapeutics (PRETx) Program, Division of Pediatric Emergency Medicine, Ambulatory Care Building, BC Children's Hospital, 4480 Oak Street, Vancouver, BC, Canada
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13
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Abstract
A sedation strategy aimed at minimizing alteration of consciousness once comfort, analgesia and adaptation to the ventilator have been ensured is feasible in critically-ill patients requiring mechanical ventilation, even if, in patients with severe ARDS or ICH, the high dosages of sedatives and analgesics transiently required to provide perfect adaptation to the ventilator often preclude preservation of consciousness. The main components of a sedation algorithm include a clear objective of sedation-analgesia, regular assessments of patient status using validated clinical tools and a precise yet simple dosage adaptation schedule. Development and implementation of a sedation algorithm requires a multidisciplinary approach and an important input from both physicians and nurses. However, several methodologically-correct interventional studies have shown that using an algorithm to administrate sedatives and analgesics results in a significant reduction of MV duration, reaching 50% in some studies. This might translate into a real benefit for the patient point of view provided that preserving patient's comfort remains a constant concern for the caregivers. There is no reliable evidence to date to use propofol rather than midazolam as a sedative agent. Indeed, the way the sedative drug is used, as part of a sedation algorithm, is very likely more important than the selection of the drug itself. Analgesia-based sedation, promoting the use of morphinics alone before the adjunction of hypnotics, represents a new alternative to the traditional combined administration of hypnotics and morphinics. However data on the impact of analgesia-based sedation on patients' outcomes remain sparse to date.
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Affiliation(s)
- B De Jonghe
- Réanimation médicochirurgicale, centre hospitalier de Poissy, 10, rue du Champ-Gaillard, 78300 Poissy, France.
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Abstract
ICU-acquired neuromyopathy (NMAR) and delirium are the two most frequent and severe neurological complications of intensive care medicine. Their mechanisms still remain to be elucidated. The objective of this review is to address the potential role of sedation in occurrence of these complications. There is no evidence that sedation is involved in NMARs. However, the hypothesis that muscle inactivity induced by sedation fosters NMAR is an argument to discontinue or reduce sedatives infusion whenever possible. It is also recommended not to administer propofol more than 48 h at an infusion rate above 5 mg/kg per hour in patients with systemic inflammatory response syndrome, because of the risk of propofol infusion syndrome, which includes notably rhabdomyolysis. The relationship between delirium and sedation are controversial because in most studies, patients were considered delirious though being still sedated and multivariate analysis was lacking. One study showed that lorazepam given continuously was an independent risk factor for daily transition to delirium 24 h later with a 20% increase risk of every unit dose (expressed as log(e)mg). The impact of deepness, daily interruption or titration of sedation on the prevalence of delirium has never been assessed but it seems that deep sedation has to be avoided.
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Affiliation(s)
- T Sharshar
- Service de réanimation, hôpital Raymond-Poincaré, 104, boulevard Raymond-Poincaré, 92380 Garches, France.
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Celis-Rodríguez E, Besso J, Birchenall C, de la Cal M, Carrillo R, Castorena G, Ceraso D, Dueñas C, Gil F, Jiménez E, Meza J, Muñoz M, Pacheco C, Pálizas F, Pinilla D, Raffán F, Raimondi N, Rubiano S, Suárez M, Ugarte S. Guía de práctica clínica basada en la evidencia para el manejo de la sedo-analgesia en el paciente adulto críticamente enfermo. Med Intensiva 2007; 31:428-71. [DOI: 10.1016/s0210-5691(07)74853-2] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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16
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Bibliography: current world literature. Curr Opin Anaesthesiol 2007; 20:157-63. [PMID: 17413401 DOI: 10.1097/aco.0b013e3280dd8cd1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Ramnath VR, Hess DR, Thompson BT. Conventional mechanical ventilation in acute lung injury and acute respiratory distress syndrome. Clin Chest Med 2007; 27:601-13; abstract viii. [PMID: 17085249 DOI: 10.1016/j.ccm.2006.06.009] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Acute lung injury and acute respiratory distress syndrome are inflammatory conditions involving a broad spectrum of lung injury from mild respiratory abnormality to severe respiratory derangement. Regardless of cause (direct or indirect lung injury), pulmonary physiology and mechanics are altered, leading to hypoxemic respiratory failure. the use of positive pressure ventilation itself may cause lung injury (ventilator-induced lung injury, or VILI). VILI may amplify preexisting injury, delay lung recovery, and result in adverse outcomes. This article examines the evidence supporting lung-protective ventilation strategies and addresses the methods, outcomes, and potential obstacles to implementation of such approaches.
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Affiliation(s)
- Venktesh R Ramnath
- Pulmonary and Critical Care Unit, Department of Medicine, Bulfinch 148, Massachusetts General Hospital, Boston, MA 02114, USA
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