V. Guidelines for sedation and analgesia during mechanical ventilation general overview

Evaluation of Postnatal Sedation in Full-Term Infants

Prolonged sedation in infants leads to a high incidence of physical dependence. We inquired: (1) "How long does it take to develop physical dependence to sedation in previously naïve full-term infants without known history of neurologic impairment?" and (2) "What is the relationship between length of sedation to length of weaning and hospital stay?". The retrospective study included full-term patients over a period of one year that were <1 year of age and received opioids and benzodiazepines >72 hours. Quantification of fentanyl, morphine, and midazolam were compared among three time periods: <5 days, 5-30 days, and >30 days using t-test or one-way analysis of variance. Identified full-term infants were categorized into surgical (14/44) or medical (10/44) groups, while those with neurological involvement (20/44) were excluded. Physical dependence in full-term infants occurred following sedation ≥5 days. Infants with surgical disease received escalating doses of morphine and midazolam when administered >30 days. A positive association between length of sedation and weaning period was found for both respiratory (p < 0.01) and surgical disease (p = 0.012) groups, while length of sedation is related to hospital stay for the respiratory (p < 0.01) but not the surgical disease group (p = 0.1). Future pharmacological directions should lead to standardized sedation protocols and evaluate patient neurocognitive outcomes.

Reliability and Validity of the Critical-Care Pain Observation Tool: A Rapid Synthesis of Evidence

Staff in a tertiary hospital critical care unit in Doha, Qatar, suggested that the Critical-Care Pain Observation Tool (CPOT) would be a better tool for assessing pain in ventilated and sedated patients than current local practice. We undertook a rapid synthesis of evidence to establish whether current research supports use of CPOT for assessing pain in ventilated and sedated patients in a critical care setting. CPOT has been shown in reviews and more recent primary studies to be reliable and valid for most patients unable to self-report in critical care settings. This finding is supported by several guidelines. Studies also suggest that CPOT is feasible for use in research and clinical practice though training of observers is important. Further research may be warranted to strengthen current evidence, particularly in patients with neurological trauma.

Comparison of clinical practice guidelines for the management of pain, agitation, and delirium in critically ill adult patients

Guideline‐based management approaches for pain, agitation, and delirium (PAD) in critically ill adult patients are widely believed to result in good outcomes. However, there are some differences in the recommendations and evidence levels among the management guidelines established for PAD. To identify and compare the current management guidelines, we used the PubMed database. The PAD guidelines and Federación Panamericana e Ibérica de Sociedades de Medicina Crítica y Terapia Intensiva (FEPIMCTI) guidelines were identified from our search. We compared the main aspects of these two guidelines as well as the Japanese guidelines for the management of PAD (J‐PAD guidelines). The PAD, FEPIMCTI, and J‐PAD guidelines contained a total of 4, 12, and 5 sections, having 32, 138, and 37 recommendations, respectively, pertaining to routine monitoring of pain in adult patients in the intensive care unit. Intravenous opioids were recommended as the first‐line drug of choice for treating pain. Sedative titrated to maintain a light, rather than deep, level of sedation can be given unless clinically contraindicated. Although neither the PAD nor J‐PAD guidelines recommend use of a pharmacologic delirium prevention protocol or treatment with any pharmacological agent to reduce the duration of delirium, the FEPIMCTI guidelines provide such recommendations. The FEPIMCTI guidelines provide suggestions on which analgesics to use for several different cases and present algorithms for sedation and analgesia. The outlines of the three guidelines are similar, and all reinforce the management of PAD to improve patient outcomes.

Sepsis and Critical Illness Research Center investigators: protocols and standard operating procedures for a prospective cohort study of sepsis in critically ill surgical patients

INTRODUCTION

Sepsis is a common, costly and morbid cause of critical illness in trauma and surgical patients. Ongoing advances in sepsis resuscitation and critical care support strategies have led to improved in-hospital mortality. However, these patients now survive to enter state of chronic critical illness (CCI), persistent low-grade organ dysfunction and poor long-term outcomes driven by the persistent inflammation, immunosuppression and catabolism syndrome (PICS). The Sepsis and Critical Illness Research Center (SCIRC) was created to provide a platform by which the prevalence and pathogenesis of CCI and PICS may be understood at a mechanistic level across multiple medical disciplines, leading to the development of novel management strategies and targeted therapies.

METHODS

Here, we describe the design, study cohort and standard operating procedures used in the prospective study of human sepsis at a level 1 trauma centre and tertiary care hospital providing care for over 2600 critically ill patients annually. These procedures include implementation of an automated sepsis surveillance initiative, augmentation of clinical decisions with a computerised sepsis protocol, strategies for direct exportation of quality-filtered data from the electronic medical record to a research database and robust long-term follow-up.

ETHICS AND DISSEMINATION

This study has been registered at ClinicalTrials.gov, approved by the University of Florida Institutional Review Board and is actively enrolling subjects. Dissemination of results is forthcoming.

Is pain really undertreated? Challenges of addressing pain in trauma patients during prehospital transport and trauma resuscitation

BACKGROUND

Prior research has documented the inadequacy of pain management for trauma patients in the emergency department (ED), with rates of pain assessment and opioid administration averaging about 50%. Such rates, however, may be misleading and do not adequately capture the complexity of pain management practices in a trauma population. The goal of the study was to determine if pain was undertreated at the study hospital or if patient acuity explained the timing and occurrence of pain treatment in the prehospital setting and the ED.

METHODS

A retrospective study was performed at a Level 1 adult trauma centre in the Midwest. The trauma registry was used to identify patients who received a trauma activation during the study period (June-November 2012; N=313). Using the first set of patient vitals and ISS, patients were grouped into three categories: physiologically stable with low injury severity (n=132); physiologically stable with moderate to severe injury (n=122); and physiologically unstable with severe injury (n=56). Differences were assessed with Kruskal-Wallis and chi-square tests.

RESULTS

Patients who were physiologically unstable were the least likely to receive a standardised pain assessment and the least likely to receive an opioid in the ED. Patients who were physiologically stable at entry to the ED but sustained a severe injury were the most likely to receive an opioid. Time to first pain assessment and time to first opioid did not differ by patient acuity.

CONCLUSIONS

Results confirm that patient acuity greatly affects the ability to effectively and appropriately manage pain in the initial hours after injury. This study contributes to the literature by noting areas for improvement but also in explaining why delaying pain treatment may be appropriate in certain patient populations.

An International Normalized Ratio-Based Definition of Acute Traumatic Coagulopathy Is Associated With Mortality, Venous Thromboembolism, and Multiple Organ Failure After Injury

OBJECTIVES

Acute traumatic coagulopathy is associated with adverse outcomes including death. Previous studies examining acute traumatic coagulopathy's relation with mortality are limited by inconsistent criteria for syndrome diagnosis, inadequate control of confounding, and single-center designs. In this study, we validated the admission international normalized ratio as an independent risk factor for death and other adverse outcomes after trauma and compared two common international normalized ratio-based definitions for acute traumatic coagulopathy.

DESIGN

Multicenter prospective observational study.

SETTING

Nine level I trauma centers in the United States.

PATIENTS

A total of 1,031 blunt trauma patients with hemorrhagic shock.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

International normalized ratio exhibited a positive adjusted association with all-cause in-hospital mortality, hemorrhagic shock-associated in-hospital mortality, venous thromboembolism, and multiple organ failure. Acute traumatic coagulopathy affected 50% of subjects if defined as an international normalized ratio greater than 1.2 and 21% of subjects if defined by international normalized ratio greater than 1.5. After adjustment for potential confounders, acute traumatic coagulopathy defined as an international normalized ratio greater than 1.5 was significantly associated with all-cause death (odds ratio [OR], 1.88; p < 0.001), hemorrhagic shock-associated death (OR, 2.44; p = 0.001), venous thromboembolism (OR, 1.73; p < 0.001), and multiple organ failure (OR, 1.38; p = 0.02). Acute traumatic coagulopathy defined as an international normalized ratio greater than 1.2 was not associated with an increased risk for the studied outcomes.

CONCLUSIONS

Elevated international normalized ratio on hospital admission is a risk factor for mortality and morbidity after severe trauma. Our results confirm this association in a prospectively assembled multicenter cohort of severely injured patients. Defining acute traumatic coagulopathy by using an international normalized ratio greater than 1.5 but not an international normalized ratio greater than 1.2 identified a clinically meaningful subset of trauma patients who, adjusting for confounding factors, experienced more adverse outcomes. Targeting future therapies for acute traumatic coagulopathy to patients with an international normalized ratio greater than 1.5 may yield greater returns than using a lower international normalized ratio threshold.

Acute respiratory distress syndrome after trauma: development and validation of a predictive model

OBJECTIVE

To determine early clinical predictors of acute respiratory distress syndrome after major traumatic injury and characterize the performance of this acute respiratory distress syndrome prediction model, and two previously published acute respiratory distress syndrome prediction models, in an independent cohort of severely injured patients.

DESIGN

Prospective cohort study.

SETTING

University-affiliated level I trauma center in Seattle, WA, and nine hospitals participating in the Inflammation and Host Response to Injury Consortium.

PATIENTS

Model derivation utilized data from 224 patients participating in a randomized controlled trial. All models were validated in an independent cohort of 1,762 trauma patients.

MEASUREMENTS AND MAIN RESULTS

Variables strongly associated with acute respiratory distress syndrome in bivariate analysis (p<.01) were entered into a multiple logistic regression equation to generate an acute respiratory distress syndrome predictive model. We evaluated the performance of all models using the area under the receiver operator characteristic curve. Acute respiratory distress syndrome occurred in 79 subjects (35%) belonging to the development cohort and in 423 subjects (24%) from the validation cohort. Multivariable predictors of acute respiratory distress syndrome after trauma included subject age, Acute Physiology and Chronic Health Evaluation II Score, injury severity score, and the presence of blunt traumatic injury, pulmonary contusion, massive transfusion, and flail chest injury (area under the receiver operator characteristic curve 0.79 [95% confidence interval 0.73, 0.85]). Validation of the prediction model resulted in an area under the receiver operator characteristic curve of 0.71 (95% confidence interval 0.68, 0.74). Our model's performance in the validation cohort was superior to that of two other published acute respiratory distress syndrome prediction models (0.65 [95% confidence interval 0.63, 0.68] and 0.66 [95% confidence interval 0.64, 0.69], p<.01 for all comparisons).

CONCLUSIONS

Using routinely available clinical data, our prediction model identifies patients at high risk for acute respiratory distress syndrome early after severe traumatic injury. This predictive model could facilitate enrollment of subjects into future clinical trials designed to prevent this serious complication.

Single-drug sedation with fentanyl for prehospital postintubation sedation in trauma patients

BACKGROUND

A fentanyl-only (FO) regimen for prehospital postintubation sedation in trauma patients was compared with the standard protocol (SP) of fentanyl + benzodiazepine.

METHODS

Intubated patients transported to a Level I trauma center from December 1, 2005, to April 30, 2009, were retrospectively reviewed. Before 2007, only SP was used; afterward both regimens were used. Groups were compared for hemodynamic and neurologic parameters in the prehospital setting and trauma bay, fluid volumes, time until general or neurosurgical intervention (NSI), and other outcomes.

RESULTS

Groups were comparable with respect to age, sex, mechanism, alcohol level, intensive care unit length of stay, and hospital length of stay. Comorbidities were similar except hypertension (p = 0.019), and stroke (p = 0.029) were more frequent in FO patients. Prehospital heart rate and Glasgow Coma Scale (GCS) were similar. Trauma bay hemodynamic parameters and fluid resuscitation volumes were comparable, but pupil nonreactivity was more frequent in the FO group both overall (p = 0.032) and when comparing only patients with traumatic brain injury (TBI; p = 0.014). The incidence of TBI was comparable. Although the frequency of craniotomy (13% FO vs. 7% SP) and mortality (17% FO vs. 11% SP) were not statistically different overall, in patients with TBI, there was a higher incidence of NSI (28% vs. 14%, p = 0.015), craniotomy (14% vs. 3%, p = 0.02), and time to initial NSI (446 minutes vs. 193 minutes, p = 0.042) in the FO patients.

CONCLUSIONS

In this study, an FO regimen was associated with similar hemodynamic but worse neurologic variables compared with the SP regimen. Prospective evaluation is warranted before adoption of this regimen, especially in TBI patients.

Benchmarking outcomes in the critically injured trauma patient and the effect of implementing standard operating procedures

OBJECTIVE

To determine and compare outcomes with accepted benchmarks in trauma care at 7 academic level I trauma centers in which patients were treated on the basis of a series of standard operating procedures (SOPs).

BACKGROUND

Injury remains the leading cause of death for those younger than 45 years. This study describes the baseline patient characteristics and well-defined outcomes of persons hospitalized in the United States for severe blunt trauma.

METHODS

We followed 1637 trauma patients from 2003 to 2009 up to 28 hospital days using SOPs developed at the onset of the study. An extensive database on patient and injury characteristics, clinical treatment, and outcomes was created. These data were compared with existing trauma benchmarks.

RESULTS

The study patients were critically injured and were in shock. SOP compliance improved 10% to 40% during the study period. Multiple organ failure and mortality rates were 34.8% and 16.7%, respectively. Time to recovery, defined as the time until the patient was free of organ failure for at least 2 consecutive days, was developed as a new outcome measure. There was a reduction in mortality rate in the cohort during the study that cannot be explained by changes in the patient population.

CONCLUSIONS

This study provides the current benchmark and the overall positive effect of implementing SOPs for severely injured patients. Over the course of the study, there were improvements in morbidity and mortality rates and increasing compliance with SOPs. Mortality was surprisingly low, given the degree of injury, and improved over the duration of the study, which correlated with improved SOP compliance.

[Daily interruption of sedation: always a quality indicator?]

The Spanish Society of Critical Care Medicine (SEMICYUC) has recently published an updated version of Quality Indicators in Critical Care. Daily sedative interruption is included among them. As this practice is controversial, research studies are revised and guidelines for its implementation are proposed.

Utilization patterns of central nervous system drugs: A cross-sectional study among the critically ill patients

Introduction:

Critically ill patients often receive central nervous system drugs due to primary disorder or complications secondary to multiorgan failure. The aim of the study was to evaluate the current utilization pattern of central nervous system drugs among patients in the medical intensive care unit.

Materials and Methods:

A prospective observational study carried out over a period of 1 year. The relevant data on drug prescription of each patient was collected from the inpatient case record. Drugs were classified into different groups based on WHO–ATC classification. The demographic data, clinical data, and utilization of different classes of drugs as well as individual drugs were analyzed.

Results:

A total of 325 consecutive patients were included for the analysis; 211 (65%) patients were males; 146 patients (45%) were above 55 years of age. Encephalopathy [63(19.38%)] and stroke [62(19%)] were the common central nervous system diagnoses. In a total of 1237 drugs, 68% of the drugs were prescribed by trade name. Midazolam (N05CD08) 142 (43.69%), morphine (N02AA01) 201 (61.84%), and atracurium (M03AC04) 82 (25.23%) were the most commonly used sedative, analgesic, and neuromuscular blocker, respectively. Phenytoin (N03AB02) 151 (46.46%) had maximum representation among antiepileptic agents.

Conclusions:

Utilization of drugs from multiple central nervous system drug classes was noticed. Rational use of drugs can be encouraged by prescription by brand name.

Early elevation in random plasma IL-6 after severe injury is associated with development of organ failure

Excessive proinflammatory activation after trauma plays a role in late morbidity and mortality, including the development of multiple organ dysfunction syndrome (MODS). To date, identification of patients at risk has been challenging. Results from animal and human studies suggest that circulating interleukin 6 (IL-6) may serve as a biomarker for excessive inflammation. The purpose of this analysis was to determine the association of IL-6 with outcome in a multicenter developmental cohort and in a single-center validation cohort. Severely injured patients with shock caused by hemorrhage were evaluated within a multicenter developmental cohort (n = 79). All had blood drawn within 12 h of injury. Plasma IL-6 was determined by multiplex proteomic analysis. Clinical and outcome data were prospectively obtained. Within this developmental cohort, a plasma IL-6 level was determined for the subsequent development of MODS by developing a receiver operating curve and defining the optimal IL-6 level using the Youden Index. This IL-6 level was then evaluated within a separate validation cohort (n = 56). A receiver operating curve was generated for IL-6 and MODS development, with an IL-6 level of 350 pg/mL having the highest sensitivity and specificity within the developmental cohort. IL-6 was associated with MODS after adjusting for Acute Physiology and Chronic Health Evaluation, Injury Severity Score, male sex, and blood transfusions with an odds ratio of 3.9 (95% confidence interval, 1.33 - 11.19). An IL-6 level greater than 350 pg/mL within the validation cohort was associated with an increase in MODS score, MODS development, ventilator days, intensive care unit length of stay, and hospital length of stay. However, this IL-6 level was not associated with either the development of nosocomial infection or mortality. Elevation in plasma IL-6 seems to correlate with a poor prognosis. This measurement may be useful as a biomarker for prognosis and serve to identify patients at higher risk of adverse outcome that would benefit from novel therapeutic interventions.

Early elevation in random plasma IL-6 after severe injury is associated with development of organ failure

Excessive proinflammatory activation after trauma plays a role in late morbidity and mortality, including the development of multiple organ dysfunction syndrome (MODS). To date, identification of patients at risk has been challenging. Results from animal and human studies suggest that circulating interleukin 6 (IL-6) may serve as a biomarker for excessive inflammation. The purpose of this analysis was to determine the association of IL-6 with outcome in a multicenter developmental cohort and in a single-center validation cohort. Severely injured patients with shock caused by hemorrhage were evaluated within a multicenter developmental cohort (n = 79). All had blood drawn within 12 h of injury. Plasma IL-6 was determined by multiplex proteomic analysis. Clinical and outcome data were prospectively obtained. Within this developmental cohort, a plasma IL-6 level was determined for the subsequent development of MODS by developing a receiver operating curve and defining the optimal IL-6 level using the Youden Index. This IL-6 level was then evaluated within a separate validation cohort (n = 56). A receiver operating curve was generated for IL-6 and MODS development, with an IL-6 level of 350 pg/mL having the highest sensitivity and specificity within the developmental cohort. IL-6 was associated with MODS after adjusting for Acute Physiology and Chronic Health Evaluation, Injury Severity Score, male sex, and blood transfusions with an odds ratio of 3.9 (95% confidence interval, 1.33 - 11.19). An IL-6 level greater than 350 pg/mL within the validation cohort was associated with an increase in MODS score, MODS development, ventilator days, intensive care unit length of stay, and hospital length of stay. However, this IL-6 level was not associated with either the development of nosocomial infection or mortality. Elevation in plasma IL-6 seems to correlate with a poor prognosis. This measurement may be useful as a biomarker for prognosis and serve to identify patients at higher risk of adverse outcome that would benefit from novel therapeutic interventions.

The incidence of sub-optimal sedation in the ICU: a systematic review

Introduction

Patients in intensive care units (ICUs) are generally sedated for prolonged periods. Over-sedation and under-sedation both have negative effects on patient safety and resource use. We conducted a systematic review of the literature in order to establish the incidence of sub-optimal sedation (both over- and under-sedation) in ICUs.

Methods

We searched Medline, Embase and CINAHL (Cumulative Index to Nursing and Allied Health Literature) online literature databases from 1988 to 15 May 2008 and hand-searched conferences. English-language studies set in the ICU, in sedated adult humans on mechanical ventilation, which reported the incidence of sub-optimal sedation, were included. All abstracts were reviewed twice by two independent reviewers, with all conflicts resolved by a third reviewer, to check that they met the review inclusion criteria. Full papers of all included studies were retrieved and were again reviewed twice against inclusion criteria. Data were doubly extracted. Study aims, design, population, comparisons made, and data on the incidence of sub-optimal, optimal, over-sedation or under-sedation were extracted.

Results

There was considerable variation between included studies in the definition of optimal sedation and in the scale or method used to assess sedation. Across all included studies, a substantial incidence of sub-optimal sedation was reported, with a greater tendency toward over-sedation.

Conclusions

Our review suggests that improvements in the consistent definition and measurement of sedation may improve the quality of care of patients within the ICU.

Sedation management in the mechanically ventilated critically ill patient

Sedation management in the mechanically ventilated critically ill patient is a topic of continuing interest in the critical care literature. The wide variety of clinical practices described in the literature with regard to sedation management has limited the implementation of evidence-based practice guidelines. Common themes for a coherent sedation management strategy include articulation of indications for sedation, initial and daily evaluation of sedation goals, sedation-level assessment, appropriate sedative selection, effective sedation management strategy, and efficient sedation weaning strategy. We provide a summary of the literature on key aspects of sedation in clinical practice. Evidence-based recommendations are provided for clinicians involved in the management of sedation in mechanically ventilated patients.

Early supplemental parenteral nutrition is associated with increased infectious complications in critically ill trauma patients

BACKGROUND

Parenteral nutrition (PN) is often used in severely injured patients when caloric goals are not achieved enterally. The purpose of this study is to determine whether early administration of parenteral nutrition is associated with an increased risk for infection after severe injury.

STUDY DESIGN

Retrospective cohort study of severely injured blunt trauma patients enrolled from eight trauma centers participating in the "Inflammation and the Host Response to Injury" (Glue Grant) study. We compared patients receiving PN within 7 days after injury with a control group that did not receive early PN. We then focused on patients who tolerated at least some enteral nutrition (EN) during the first week and evaluated the potential influence of supplemental PN on outcomes in this "enteral tolerant" subgroup. Primary outcomes included occurrence of a nosocomial infection after the first postinjury week. Secondary outcomes included type of infection and hospital mortality.

RESULTS

Of 567 patients enrolled, 95 (17%) received early PN. Early PN use was associated with a greater risk of nosocomial infection (relative risk [RR] = 2.1; 95% CI, 1.6 to 2.6; p < 0.001). In the enteral-tolerant subgroup (n = 249), early PN was also associated with an increase in nosocomial infections (RR = 1.6; 95% CI, 1.2 to 2.1; p = 0.005) in part because of an increased risk of bloodstream infection (RR = 2.8; 95% CI, 1.5 to 5.3; p = 0.002). Mortality tended to be higher in patients receiving additional EN and PN versus EN alone (RR = 2.3; 95% CI, 1.0 to 5.2; p = 0.06).

CONCLUSIONS

In critically ill trauma patients who are able to tolerate at least some EN, early PN administration can contribute to increased infectious morbidity and worse clinical outcomes.