The AIR-SED Study: A Multicenter Cohort Study of SEDation Practices, Deep Sedation, and Coma Among Mechanically Ventilated AIR Transport Patients

Reducing Deep Sedation and Benzodiazepine Use in Mechanically Ventilated Patients During Critical Care Transport: A Quality Improvement Initiative

OBJECTIVE

Deep sedation of mechanically ventilated patients is associated with poorer outcomes, including longer hospital length of stay and more ventilator days. In contrast, light sedation is associated with decreased hospital and intensive care unit length of stay, lower ventilator days, and decreased mortality. This study sought to decrease the use of unindicated deep sedation and benzodiazepine use in mechanically ventilated patients during critical care transport. Previous work identified > 90% of intubated, nonparalyzed patients were deeply sedated in this critical care transport system.

METHODS

This study was conducted at a critical care transport service affiliated with a rural academic medical center. Chart review of all mechanically ventilated adults transported between January and November 2023 with no indication for deep sedation was performed. Improvement initiatives were implemented using Plan-Do-Study-Act cycles and included transport crew education, guideline revision, and enhanced performance feedback.

RESULTS

A 25% reduction in the proportion of deeply sedated patients was achieved.

CONCLUSION

Deep sedation is not universally indicated in critical care transport of mechanically ventilated patients. This quality improvement initiative achieved its main aim of reducing the proportion of deeply sedated patients by 25% with the implementation of 3 Plan-Do-Study-Act cycles.

Management of Patients With Cardiac Arrest Requiring Interfacility Transport: A Scientific Statement From the American Heart Association

People who experience out-of-hospital cardiac arrest often require care at a regional center for continued treatment after resuscitation, but many do not initially present to the hospital where they will be admitted. For patients who require interfacility transport after cardiac arrest, the decision to transfer between centers is complex and often based on individual clinical characteristics, resources at the presenting hospital, and available transport resources. Once the decision has been made to transfer a patient after cardiac arrest, there is little direct guidance on how best to provide interfacility transport. Accepting centers depend on transferring emergency departments and emergency medical services professionals to make important and nuanced decisions about postresuscitation care that may determine the efficacy of future treatments. The consequences of early care are greater when transport delays occur, which is common in rural areas or due to inclement weather. Challenges of providing interfacility transfer services for patients who have experienced cardiac arrest include varying expertise of clinicians, differing resources available to them, and nonstandardized communication between transferring and receiving centers. Although many aspects of care are insufficiently studied to determine implications for specific out-of-hospital treatment on outcomes, a general approach of maintaining otherwise recommended postresuscitation care during interfacility transfer is reasonable. This includes close attention to airway, vascular access, ventilator management, sedation, cardiopulmonary monitoring, antiarrhythmic treatments, blood pressure control, temperature control, and metabolic management. Patient stability for transfer, equity and inclusion, and communication also must be considered. Many of these aspects can be delivered by protocol-driven care.

Sedation Practices of Mechanically Ventilated Patients During Critical Care Transport

OBJECTIVE

Mechanically ventilated patients who receive deep levels of sedation have high mortality rates, longer lengths of stay, and longer duration of mechanical ventilation in the intensive care unit. Prior literature demonstrated a high frequency of deep sedation across all levels of care. Benzodiazepines have been attributed to similar morbidity and mortality findings.

METHODS

This study was a descriptive retrospective review of mechanically ventilated adult critical care transport patients from January 1, 2019, to March 11, 2020. Our primary outcome was the percentage of patients who were deeply sedated at handoff to the receiving facility. Deep sedation was defined as a Richmond Agitation Sedation Scale of -3 to -5. Our secondary outcomes were the percentage of patients who received benzodiazepines; the number of unplanned extubations, crew injuries, and unsafe patient care situations; and the incidence of ventilator dyssynchrony.

RESULTS

Five hundred fifty-three mechanically ventilated patients were transported. Ninety-three patients were excluded because they received paralytics during transport. Four hundred sixty patients were included in the analysis, 422 (91.7%) of whom were deeply sedated. Benzodiazepines were administered to 141 patients (30.6%). There were no differences observed in the secondary outcomes.

CONCLUSION

Deep sedation and benzodiazepine administration were frequent during critical care transport of mechanically ventilated patients.