Sedatives, analgesics, and paralytics in the ICU

Implementing Protocol-Based Therapy of Continuous Neuromuscular Blockade Provides Cost Minimization

Objective:

To compare empiric and protocol-based therapies of neuromuscular blockade in terms of cost and control of paralysis.

Methods:

Data were prospectively collected for nine months before and five months after a protocol was implemented in the 24-bed medical/surgical/neurologic intensive care unit as a physician-initiated, doublesided medication order form. Pancuronium was the preferred agent and vecuronium was an alternative for patients with renal dysfunction, hepatic dysfunction, or hemodynamic instability.

Results:

Twenty-nine empiric-therapy patients and 17 protocol-based therapy patients were comparatively evaluated. Length of stay in the intensive care unit and duration of neuromuscular blockade were similar between groups. Protocol adherence rate was 76.5%. Protocol-based therapy increased the hourly dose of pancuronium (0.29 ± 0.37 mg vs. 0.02 ± 0.10 mg; p < 0.005) and reduced the mean hourly cost of neuromuscular blockade compared with empiric therapy ($5.11 ± 4.76 Canadian [CDN] vs. $9.03 ± 7.03 CDN; p < 0.05). Vecuronium use did not change, but rocuronium and atracurium were not given after protocol implementation. The proportion of recorded train-of-four measurements representing adequate neuromuscular blockade increased (52.3% vs. 32.7%; p < 0.05) with protocol-based therapy.

Conclusions:

Compliance with a neuromuscular blocking protocol reduces drug costs and improves control of neuromuscular blockade.

National Survey of the Use of Sedating Drugs, Neuromuscular Blocking Agents, and Reversal Agents in the Intensive Care Unit

The objectives of this study were to describe the sedative, neuromuscular blocking agents (NMBA) and reversal agents utilized in adult intensive care units across the United States and determine the adherence to American College of Critical Care Medicine and Society of Critical Care Medicine (SCCM) guidelines. In addition, the authors assessed the use of written protocols, criteria used for selecting these agents, and monitoring practices. Questionnaires were mailed to attending physician members of SCCM in the spring of 1998. A cover letter was enclosed that explained the purpose of the survey asking the respondent to forward the questionnaire to a colleague if unable to complete. Four-hundred fifty-seven questionnaires were returned representing 393 different institutions for a response rate of 50.4% (393/780). Respondents were physicians (91.2%) practicing in a community (49.7%) or university teaching hospital (38.3%). The sedative agents used most often were opioids and benzodiazepines for > 72 hours, and NMBA utilized were vecuronium and pancuronium for > 24 hours. The most often cited indications for sedatives were agitation, anxiety/fear, and facilitation of intubation and maintenance of mechanical ventilation for NMBA. Only 32.6% used written protocols for sedatives and 46.8% for NMBA. Decisions regarding agent selection were based on clinician preference and experience and agent duration of action. Seventy-eight percent monitored sedative use primarily with the Glasgow Coma Scale and the modified Ramsay score. Monitoring of NMBA was used more frequently (91.3%) with peripheral nerve stimulation. The most common reversal agents used were naloxone and flumazenil for adverse drug effects. While many of the respondents indicated they used morphine and lorazepam for long-term sedation, the majority utilized midazolam and propofol for > 24 hours despite the recommendation of SCCM. Vecuronium was prescribed more routinely than pancuronium. The number of institutions utilizing protocols for any of these agents was low; instead, decisions were based on clinician preference.

The influence of music during mechanical ventilation and weaning from mechanical ventilation: A review

Mechanical ventilation (MV) causes many distressing symptoms. Weaning, the gradual decrease in ventilator assistance leading to termination of MV, increases respiratory effort, which may exacerbate symptoms and prolong MV. Music, a non-pharmacological intervention without side effects may benefit patients during weaning from mechanical ventilatory support. A narrative review of OVID Medline, PsychINFO, and CINAHL databases was conducted to examine the evidence for the use of music intervention in MV and MV weaning. Music intervention had a positive impact on ventilated patients; 16 quantitative and 2 qualitative studies were identified. Quantitative studies included randomized clinical trials (10), case controls (3), pilot studies (2) and a feasibility study. Evidence supports music as an effective intervention that can lesson symptoms related to MV and promote effective weaning. It has potential to reduce costs and increase patient satisfaction. However, more studies are needed to establish its use during MV weaning.

Comparative effects of flurbiprofen and fentanyl on natural killer cell cytotoxicity, lymphocyte subsets and cytokine concentrations in post-surgical intensive care unit patients: prospective, randomized study

PURPOSE

The purpose of this study was to compare the effect of the long-term administration of flurbiprofen and fentanyl in the intensive care unit on natural killer cell cytotoxicity (NKCC), lymphocyte subsets and cytokine levels.

METHODS

In this prospective study, patients scheduled for at least 48 h sedation after neck surgery were randomly assigned to two groups called group N and group F. Group N patients were sedated with propofol and flurbiprofen after surgery (n = 12), while group F patients were sedated with propofol and fentanyl (n = 13). The NKCC, lymphocyte subsets, and plasma levels of tumor necrosis factor (TNF)-α, interleukin (IL)-1β, IL-6, and IL-10 were measured before and at the end of surgery, on postoperative day (POD) 1 and POD2.

RESULTS

The NKCC was significantly higher on POD1 in group N than in group F (14.5 ± 11.2 versus 6.3 ± 4.1%, p < 0.05), the difference between the groups disappearing on POD2. Lymphocyte subsets and plasma levels of cytokines were not significantly different between the two groups during the study period.

CONCLUSIONS

Transient suppressive effects on NKCC were observed in the fentanyl group as compared to the flurbiprofen group. This suggests that when choosing postoperative analgesics, physicians should bear in mind the potential immunosuppressive effects of these agents in patients requiring prolonged sedation in the intensive care unit.

A critical appraisal of sedation, analgesia and delirium in neurocritical care

Administering analgesics, sedatives and antipsychotics is challenging in the Neurological Intensive Care Unit (NICU). We reviewed this literature and our current practice to better inform the critical care practitioner and to identify gaps for future research. We electronically searched observational, intervention and outcome studies addressing sedation, analgesia and delirium in the NICU, and their bibliographies. Practice patterns were assessed in three critical care units with specialized neurological care in Montreal. Bedside pain assessment tools are psychometrically validated in the neuro-critically ill but sedation and delirium tools are not. Rigorous pain and sedation assessments appear feasible; delirium screening has not been tested. Publications addressing outcomes and responses to pharmacologic treatment lack consistency, rigor or both. In daily practice, pharmacologic management varies greatly. Clearly, little information exists on analgesia, sedation and delirium in the NICU. Systematic evaluation of pain improves outcome. No evidence-based therapeutic recommendations can be proffered.

Impact of sustained neuromuscular blockade on outcome of mechanically ventilated children

BACKGROUND

Neuromuscular blocking agents (NMBA) are commonly administered to critically ill children in pediatric intensive care units (PICU) in the USA and Europe. Although NMBA are frequently used in PICU patients, their role in the PICU setting has not yet been clearly defined. The aim of this study was to describe the sustained administration of NMBA and its impact on outcome of PICU patients.

METHODS

A 3-year retrospective cohort study was conducted to compare mechanically-ventilated patients who received NMBA for at least 12 h with patients who did not (control group).

RESULTS

A total of 317 consecutive patients were ventilated over 3473 days. Patients were similar in age, weight and severity scores. Thirty-four children (10.7%) received NMBA. Compared with controls, the neuromuscular blockade (NMB) group had a longer duration of mechanical ventilation (13.7 vs 5.5 days, P= 0.000), longer PICU stay (20 vs 11 days, P= 0.000) and increased occurrence of ventilator-associated pneumonia (6.6 vs 4.1/1000 ventilator days, P= 0.010). The NMB use was not associated with higher mortality (8.8% vs 17.6%, P= 0.287) or longer hospital stay (30.5 vs 23 days, P= 0.117).

CONCLUSION

Although the use of NMBA was not associated with greater mortality, we found that sustained use of NMBA is associated with prolonged mechanical ventilation, longer PICU stay and higher incidence of ventilator-associated pneumonia when compared with controls. Larger studies are necessary to confirm these findings.

A review of the evidence for music intervention to manage anxiety in critically ill patients receiving mechanical ventilatory support

Critically ill patients receiving mechanical ventilatory support experience profound anxiety with this common treatment modality. Music intervention is one adjunctive therapy that can be implemented to allay anxiety. This article reviews the evidence support music as an adjunctive intervention with mechanically ventilated patients.

Analgesia and sedation in the intensive care unit: an overview of the issues

Analgesic and sedative medications are widely used in intensive care units to achieve patient comfort and tolerance of the intensive care unit environment, and to eliminate pain, anxiety, delirium and other forms of distress. Surveys and prospective cohort studies have revealed wide variability in medication selection, monitoring using sedation scales, and implementation of structured treatment algorithms among practitioners in different countries and regions of the world. Successful management of analgesia and sedation incorporates a patient-based approach that includes detection and management of predisposing and causative factors, including delirium; monitoring using analgesia and sedation scales and other instruments; proper medication selection, with an emphasis on analgesia-based drugs; and incorporation of structured strategies that have been demonstrated to reduce likelihood of excessive or prolonged sedation.

Staff perceptions on the use of a sedation protocol in the intensive care setting

Sedation protocols are increasingly being investigated as a method of achieving improved patient outcomes whilst guiding the decision making of both nursing and medical practitioners. However, only a limited number of studies have investigated the perceptions of staff towards a sedation protocol during its implementation. This study was designed to survey the perceptions of staff regarding the implementation of a sedation protocol in an Australian intensive care unit (ICU). Questionnaires were distributed to all multidisciplinary team members who had used the sedation protocol. The response rate was 50% (n=70). The questionnaire combined the use of visual analogue scales plus a comments section to obtain qualitative data. The results revealed that staff perceived sedation management to be enhanced with the use of a protocol and therefore should be incorporated into routine clinical practice. Staff perceived that providing clear guidelines that facilitated decision making and assisted beginner practitioners enhanced sedation management. In addition, there was a perceived improvement in the patient outcomes, including a decrease in the frequency of over-sedation resulting in a reduced ICU stay. Positive perceptions may assist in the introduction of other interventional protocols. Other protocols may target areas where variability in clinical decision making exists, despite research evidence that supports specific therapeutic interventions. Further studies addressing protocol implementation for clinical interventions are warranted in other ICU settings.

Effect of a nurse-implemented sedation protocol on the incidence of ventilator-associated pneumonia*

OBJECTIVE

To determine whether the use of a nurse-implemented sedation protocol could reduce the incidence of ventilator-associated pneumonia in critically ill patients.

DESIGN

Two-phase (before-after), prospective, controlled study.

SETTING

University-affiliated, 11-bed medical intensive care unit.

PATIENTS

Patients requiring mechanical ventilation for >or=48 hrs and sedative infusion with midazolam or propofol alone.

INTERVENTIONS

During the control phase, sedatives were adjusted according to the physician's decision. During the protocol phase, sedatives were adjusted according to a protocol developed by a multidisciplinary team including nurses and physicians. The protocol was based on the Cambridge scale, and sedation level was adjusted every 3 hrs by the nurses. Standard practices, including weaning from the ventilator and diagnosis of VAP, were the same during both study phases.

MEASUREMENTS AND MAIN RESULTS

A total of 423 patients were enrolled (control group, n = 226; protocol group, n = 197). The incidence of VAP was significantly lower in the protocol group compared with the control group (6% and 15%, respectively, p = .005). By univariate analysis (log-rank test), only use of a nurse-implemented protocol was significantly associated with a decrease of incidence of VAP (p < .01). A nurse-implemented protocol was found to be independently associated with a lower incidence of VAP after adjustment on Simplified Acute Physiology Score II in the multivariate Cox proportional hazards model (hazard rate, 0.81; 95% confidence interval, 0.62-0.95; p = .03). The median duration of mechanical ventilation was significantly shorter in the protocol group (4.2 days; interquartile range, 2.1-9.5) compared with the control group (8 days; interquartile range, 2.2-22.0; p = .001), representing a 52% relative reduction. Extubation failure was more frequently observed in the control group compared with the protocol group (13% and 6%, respectively, p = .01). There was no significant difference in in-hospital mortality (38% vs. 45% in the protocol vs. control group, respectively, p = .22).

CONCLUSIONS

In patients receiving mechanical ventilation and requiring sedative infusions with midazolam or propofol, the use of a nurse-implemented sedation protocol decreases the rate of VAP and the duration of mechanical ventilation.

Economic evaluation of sustained sedation/analgesia in the intensive care unit

Lorazepam, midazolam, propofol and opioids are the primary agents that are used for sustained sedation and analgesia of critically ill patients. The choice of agent depends on safety profiles, expected outcomes, cost, patient characteristics and clinical experience. Few studies have comparatively evaluated the sedatives in terms of cost. Many factors, aside from drug costs, influence the total cost of sedation in the intensive care unit. This article reviews the cost parameters of intensive care unit sedation that are specific to the characteristics of commonly used sedatives and analgesics, evaluates economic studies and cost models, summarises alternative methods of sedation and analgesia, and provides practical recommendations for methods of cost containment, including daily sedation interruption, sedation monitoring and protocol implementation.

[Knowledge and application level of the Ramsay Scale by Mexican nurses specialized in intensive care]

INTRODUCTION

Among the intensive care specialized nursing staff, knowing the sedation level of the patient under their responsibility is of crucial importance. The present study evaluated the knowledge that nurses specialized in intensive care (NSIC) have on the Ramsay Scale (RS) and the way in which they apply it.

MATERIAL AND METHODS

Those personnel who were developing their activity in the intensive care units (ICU) of four public hospitals of the cities of Merida, Yucatan, Mexico were enrolled during May 2003. The information was obtained by applying an expressly designed questionnaire that contained both demographic endpoints (age, years of experience as NSIC and type of ICU) and those related with the RS (clinical components that it evaluates, operative definitions, frequency of use per week or day). 95% (95% CI) confidence intervals were applied and odds ratio (OR) was used to determined the likelihood of the event.

RESULTS

Of the 60 nurses interviewed, 75% did not know the RS. Age was a significant factor associated with its knowledge, since 11 of 23 with an age equal to or less than 38 years (47.8%) and 4 of 37 over 38 years (10.8%) knew what it evaluated (OR of 4 for the group of lower age, 95% CI 1.5 to 12.3, p = 0.002). Of 15 NSIC who knew what it evaluated, 9 (60%) also knew its operative definitions, and stated that they applied it adequately per day.

CONCLUSIONS

In this sample, there is an elevated percentage of NSIC who did not know the RS. Age was the factor associated with lack of knowledge.

Patients’ Recollections of Therapeutic Paralysis in the Intensive Care Unit

• Background Neuromuscular blocking agents used for therapeutic purposes, such as facilitating mechanical ventilation and relieving life-threatening agitation, paralyze patients but leave them fully conscious. Aggressive sedation or analgesia is necessary to reduce awareness, relieve fear, produce comfort, decrease anxiety, induce unconsciousness, and minimize possible complications such as posttraumatic stress syndrome. Little information is available on the extent to which patients experience awareness during therapeutic paralysis.

• Objectives To determine and describe the remembered experiences of critical care patients who were given neuromuscular blocking agents and sedatives and/or analgesics to facilitate mechanical ventilation, improve hemodynamic stability, and improve oxygenation.

• Methods A phenomenological approach with in-depth interviews with 11 patients was used. Data were analyzed by using the constant comparative approach.

• Results A total of 4 themes and 3 subthemes were identified. The first theme was back and forth between reality and the unreal, between life and death; the subtheme was having weird dreams. The second theme was loss of control; the 2 subthemes were (1) fighting or being tied down and (2) being scared. The third theme was almost dying, and the fourth theme was feeling cared for.

• Conclusions Patients can remember having both negative and positive experiences during neuromuscular blockade. Steps to improve the experiences of patients receiving neuromuscular blockers include improving assessment parameters, developing and using sedation/analgesia guidelines, and investing in quality improvement programs to provide assessment of awareness during therapeutic paralysis and follow-up and referral as necessary. Ways to decrease the use of neuromuscular blockers would also be useful.

Pharmacoeconomic Modeling of Lorazepam, Midazolam, and Propofol for Continuous Sedation in Critically Ill Patients

STUDY OBJECTIVE

To compare the expected costs of short-, intermediate-, and long-term sedation (< 24, 24-72, and > 72 hrs, respectively) with propofol, lorazepam, and midazolam in an intensive care unit.

METHODS

Decision-analysis models were constructed for each sedative and each duration by using institutional costs associated with drug administration and adverse events (including personnel time). Costs were expressed in 2002 U.S. dollars. Adverse events were agitation, hypertriglyceridemia and/or pancreatitis, hypotension, nutritional changes, ventilator-associated pneumonia, and prolonged awakening and/or extubation. MEDLINE and EMBASE databases were searched to obtain durations of sedation, the incidence of outcomes, and cost estimates of outcomes. The ability to maintain specific levels of sedation was assumed equivalent among the sedatives. Univariate sensitivity analyses were conducted to determine the cost-driving variables, and probabilistic sensitivity analyses were conducted by using second-order Monte Carlo simulations.

RESULTS

Weighted mean durations of sedation from 50 studies were 13.46 (short term), 45.27 (intermediate term), and 119.78 (long term) hours. Expected costs for sedation with lorazepam, midazolam, and propofol, respectively, were 497 dollars, 294 dollars, and 272 dollars short term; 932 dollars, 587 dollars, and 674 dollars intermediate term; and 1604 dollars, 1737 dollars, and 2033 dollars long term. Propofol was least costly in 86% of the short-term simulations, midazolam was least costly in 97.5% of the intermediate-term simulations, and lorazepam was least costly in 84% of the long-term simulations. The most important cost-driver for all sedatives was drug cost. Prolonged extubation after sedation was an important cost-driver for lorazepam and midazolam, especially as sedation was lengthened.

CONCLUSION

Propofol, midazolam, and lorazepam had the lowest expected costs for short-, intermediate-, and long-term sedation, respectively. Many factors aside from drug costs influenced the cost of sedation.

Use of Sedatives and Neuromuscular Blockers in a Cohort of Patients Receiving Mechanical Ventilation

OBJECTIVE

To describe the use of sedatives and neuromuscular blocking agents (NMBs) and their impact in outcome in an international cohort of patients receiving mechanical ventilation.

METHODS

We analyzed the database of a prospective, multicenter cohort of 5,183 adult patients who received mechanical ventilation for > 12 h. We considered that a patient received a given agent when it was administered for at least 3 h in a 24-h period.

RESULTS

A total of 3,540 patients (68%; 95% confidence interval [CI], 67 to 69%) received a sedative at any time while receiving mechanical ventilation. The median number of days of use was 3 (interquartile range [IQR], 2 to 6 days). The persistent use of sedative was associated with more days of mechanical ventilation (median, 4 days [IQR, 2 to 8 days], vs 3 days [IQR, 2 to 4 days] in patients who did not receive sedatives [p < 0.001]); more weaning days (median, 2 days [IQR, 1 to 3 days], vs 2 days [IQR, 1 to 5 days] in patients who did not receive sedatives [p < 0.001]); and longer length of stay in the ICU (median, 8 days [IQR, 5 to 15 days], vs 5 days [IQR, 3 to 9 days] in patients who did not receive sedatives [p < 0.001]). Six hundred eighty-six patients (13%; 95% CI, 12 to 14%) received an NMB for at least 1 day. The median number of days of use was 2 (IQR, 1 to 4 days). The administration of an NMB was independently related with age, a normal previous functional status, main reason of mechanical ventilation (patients with ARDS received more NMBs), and with patient management (patients requiring permissive hypercapnia, prone position, high level of positive end-expiratory pressure, and high airways pressure).

CONCLUSIONS

The use of sedatives is very common, and their use is associated with a longer duration of mechanical ventilation, weaning time, and stay in the ICU. NMBs are used in 13% of the patients and are associated with longer duration of mechanical ventilation, weaning time, stay in the ICU, and higher mortality.

Sedation, analgesia, and neuromuscular blockade for high-frequency oscillatory ventilation

OBJECTIVE

To provide a comprehensive review of the issue related to the administration of sedative, analgesic, and neuromuscular blocking agents (NMBA) to patients who are receiving ventilatory support for acute respiratory distress syndrome (ARDS) with high-frequency oscillatory ventilation.

RESULTS

Sedative, analgesic, and NMBA are used with great frequency in patients with severe ARDS who are undergoing high-frequency oscillatory ventilation. In particular, the use of NMBA has been higher than for other ARDS populations. Important considerations for effective treatment include careful patient evaluation, patient-based medication selection, identification of treatment goals with periodic re-assessment, titration of medications to objective parameters such as sedation scales and peripheral nerve stimulation, use of intermittent therapy when feasible, implementation of drug interruption strategies, and discontinuation of medications at the earliest possible time. It is important to recognize that patients evolve from severe ARDS through phases of recovery to the resolution of respiratory failure and that ventilatory management, as well as sedative and related medication requirements, will vary markedly over the course of this process.

CONCLUSIONS

A multidisciplinary, structured approach that is based on the considerations described should help achieve optimal results in this challenging patient population.

Relative-assessed psychological factors predict sedation requirement in critically ill patients

OBJECTIVE

Sedation is frequently required in critically ill, mechanically ventilated patients. Sedation and analgesia requirements may vary substantially among patients. This study examined whether psychological factors predict amount of sedation requirements beyond the effects of other biomedical parameters.

METHODS

This study used a prospective correlative design in an eight-bed medical intensive care unit at a tertiary university hospital. Fifty-five adult patients requiring mechanical ventilation were included. We evaluated by questionnaires three psychological factors of patients--hostility, anxiety and desire for control (DC)--as completed by patients' relatives at entry to the intensive care unit. Daily doses of sedatives required were monitored. The primary outcome measurement was midazolam dose expressed in mg/kg/h.

RESULTS

There was a statistically significant correlation between psychological factors and midazolam dose (mg/kg/h): r values = 0.40 for anxiety, 0.43 for hostility, and 0.46 for DC. Age and pulmonary edema were inversely related to midazolam requirements, whereas smoking, chronic obstructive pulmonary disease, fentanyl dose, and therapeutic intervention scoring system were positively correlated with midazolam doses. In a multiple regression, DC accounted for an additional and significant 5.4% of the variance in midazolam after controlling statistically for the effects of the significant background and biomedical predictors. In the final regression equation, DC and fentanyl were the only significant factors associated with higher sedation requirement.

CONCLUSION

Premorbid psychological profile independently predicts sedation requirement in critically ill, mechanically ventilated patients. Early identification of such a profile may help in sedation management and patient care. The possible mechanisms and clinical implications are discussed.

Sedation algorithm in critically ill patients without acute brain injury

OBJECTIVE

To determine whether use of a sedation algorithm to promote a high level of tolerance to the intensive care environment and preserve consciousness affected time to arousal and duration of mechanical ventilation in patients without acute brain injury.

DESIGN

Two-phase, prospective, controlled study.

SETTING

University-affiliated medical intensive care unit.

PATIENTS

: Patients without acute brain injury requiring mechanical ventilation for at least 24 hrs.

INTERVENTIONS

During the control phase, sedatives and analgesics were adjusted according to the physician's decision. During the algorithm phase, sedatives and analgesics were adjusted according to an algorithm developed by a multidisciplinary team including nurses and physicians. The algorithm was based on regular assessments of consciousness and tolerance to the intensive care unit environment using the Adaptation to Intensive Care Environment instrument and was designed to achieve tolerance and maintain a high level of consciousness. Standard practices, including weaning from the ventilator, were the same during both study phases.

MEASUREMENTS AND MAIN RESULTS

A total of 102 patients were enrolled (control group, n = 54; algorithm group, n = 48). Median duration of mechanical ventilation was significantly shorter in the algorithm group (4.4 days [interquartile range, 2.1-9.8]) compared with the control group (10.3 days [3.5-17.2], p = .014), representing a 57.3% reduction. In Cox multivariate analysis, the risk of remaining on mechanical ventilation was 0.48 times (95% confidence interval, 0.29-0.78) lower for algorithm patients compared with controls. The median time to arousal was also significantly shorter in patients in the algorithm group (2 days [2-5]) compared with the control group (4 days [2-9], p = .006).

CONCLUSIONS

The use of a sedation algorithm to promote tolerance to the intensive care environment and preserve consciousness in patients without acute brain injury resulted in a marked decrease in the duration of mechanical ventilation. This reduction was at least partly attributable to a shorter time to arousal after initiation of mechanical ventilation.

Pain management in the intensive care unit

Pain management is an essential component of quality care delivery for the critically ill patient. Because outcomes are difficult to predict in the intensive care unit (ICU), high-quality pain management and palliative therapy should be a goal for every patient. For those patients actively dying, palliation may be among the main benefits offered by the health care team. Appropriate palliation of pain begins with the use of effective strategies for recognizing, evaluating,and monitoring pain. Skill in pain management requires knowledge of both pharmacologic and nonpharmacologic therapies. This article focuses on expertise in the use of opiates to facilitate confident and appropriate pain therapy. To optimize palliative therapy, symptoms are best addressed by interdisciplinary care teams guided by models that acknowledge a continuum of curative therapies and palliative care.

Advances and Controversies in Adult ICU Sedation, Part 1: An Overview of the Importance of Sedation and Agitation and Subjective Assessment Tools for Patient Evaluation

This feature examines the impact of pharmacologic interventions on the treatment of the critically ill patient—an area of health care that has become increasingly complex. It will review recent advances (including evolving and controversial data) in drug therapy for adult ICU patients and assess these new modalities in terms of clinical, humanistic, and economic outcomes. Direct questions or comments to Gil Fraser, PharmD, at fraseg@mmc.org .

Protocols and guidelines in critical care: development and implementation

Variation in clinical management has been associated with suboptimal outcomes and increased costs. Guidelines, protocols, and clinical pathways have evolved as a strategy to standardize care, principally by limiting variation, thereby reducing complications, decreasing length of stay and improving outcomes. However, the nature of critical care makes it difficult to conduct blinded, randomized, and controlled clinical trials, the specific type of science required for evidenced-based medicine and guideline development. Areas in which ICU-based guidelines have been successful include, among others, sedation and neuromuscular blockade use, ventilator management, antibiotic selection, and vascular surgical interventions.

Neuromuscular-blocking drugs. Use and misuse in the intensive care unit

The use of NMB agents for more than 24 to 48 hours in critically ill patients is associated with many potential complications. Neuromuscular-blocking drugs should be used only when their use is essential for optimal patient care. The indications for neuromuscular blockade must be defined clearly, and patients should be evaluated during treatment for the need for continued muscle relaxation. The smallest doses of NMB agents that will accomplish clinical goals should be used. This dosage can be determined through clinical evaluations and peripheral nerve monitoring. It is essential that all patients treated with NMB drugs receive appropriate sedation and analgesia. Myopathies, neuropathies, and alterations of the neuromuscular junction can occur in the ICU setting, and nondepolarizing muscle relaxants seem to be involved in the development of these disorders. Clinicians should be aware of risk factors that may predispose certain patients to neuromuscular complications, including sepsis and the use of high-dose steroids. Neuromuscular-blocking agents should be avoided in these patients if possible. Although not proved, early recognition and treatment of iatrogenic neuromuscular complications may improve patient outcome.

Sedative and analgesic practice in the intensive care unit: the results of a European survey

Sedation and analgesia are important aspects of patient care on the intensive care unit (ICU), yet relatively little information is available on common sedative and analgesic practice. We sought to assess international differences in the prescription of sedative and analgesic drugs in western European ICUs by means of a short, self-administered questionnaire. Six hundred and forty-seven intensive care physicians from 16 western European countries replied to the questionnaire. Midazolam was used as a sedative often or always by 63% of respondents and propofol by 35%. There were considerable international variations, with midazolam being preferred over propofol in France, Germany, the Netherlands, Norway and Austria. For analgesia, the drugs most commonly used were morphine (33%), fentanyl (33%) and sufentanil (24%). Morphine was preferred over fentanyl and sufentanil in Norway, UK and Ireland, Sweden, Switzerland, the Netherlands, and Spain and Portugal. Fentanyl was preferred in France, Germany and Italy. Sufentanil was preferred in Belgium and Luxemburg and in Austria. Multivariate analysis showed that the combination of midazolam with fentanyl was most often used in France; propofol with morphine in Sweden, the UK and Ireland, and Switzerland; midazolam with morphine in Norway; and propofol with sufentanil in Belgium and Luxemburg, Germany and Italy. The use of a sedation scale varied from 72% in the UK and Ireland to 18% in Austria. When used, the most common sedation scale was the Ramsay scale. This study demonstrates substantial international differences in sedative and analgesic practices in western European ICUs.

Anaesthesia for procedures in the intensive care unit

Taking in charge severely ill patients in the intensive care environment to manage complex procedures is a performance requiring highly specific knowledge. Close collaboration between anaesthetists and intensive care specialists is likely to improve the safety and quality of medical care. Three forms of anaesthetic care should be considered in clinical practice: sedation and analgesia; monitored anaesthetic care; and general anaesthesia or conduction block anaesthesia. Even in the field of sedation and analgesia, the anaesthesiologist can offer expertise on new anaesthetic techniques like: the most recent concepts of balanced anaesthesia in terms of pharmacokinetics and dynamics, favouring the use of short-acting agents and of sedative-opioid combinations. New modes of administration and monitoring intravenous anaesthesia have been developed, with potential application in the intensive care unit. These include the use of target-controlled administration of intravenous drugs, and of electroencephalographic signals to monitor the level of sedation.

End-of-life care in the intensive care unit: where are we now?

A growing body of evidence and experience has effaced what were once thought to be clear distinctions between "critical illness" and "terminal illness" and has exposed the problems of postponing palliative care for intensive care patients until death is obviously imminent. Integration of palliative care as a component of comprehensive intensive care is now seen as more appropriate for all critically ill patients, including those pursuing aggressive treatments to prolong life. At present, however, data on which to base practice in this integrated model remain insufficient, and forces of the healthcare economy and other factors may constrain its application. The purpose of this article is to map where we are now in seeking to improve palliative care in the intensive care unit. We review existing evidence, which suggests that both symptom management and communication about preferences and goals of care warrant improvement and that prevailing practices for limitation of life-sustaining treatments are inconsistent and possibly irrational. We also address the need for assessment tools for research and quality improvement. We discuss recent initiatives and ongoing obstacles. Finally, we identify areas for further exploration and suggest guiding principles.

Epidemiology of psychiatric medication use in patients recovering from critical illness at a long-term acute-care facility

STUDY OBJECTIVES

To describe the pharmacoepidemiology of psychotropic medication prescription in patients recovering from life-threatening medical and surgical illness.

DESIGN

Retrospective analysis of a random sample of medical records.

SETTING

Regional referral center.

PATIENTS

Eighty-nine randomly selected patients transferred from an ICU to the study facility.

INTERVENTIONS

None.

MEASUREMENTS AND RESULTS

Patients had been treated at the referring ICU for 33 +/- 24 days (mean +/- SD) and remained at the study hospital for 64 +/- 52 days. Most of the patients had prolonged respiratory failure. Nearly half of the patients (47%) received an antidepressant medication while at the facility, and 48% received at least one dose of a benzodiazepine on the first day after transfer. In the sample of 75 patients not prescribed an antidepressant before transfer, 37% were started on therapy with an agent, usually within 3 weeks and predominantly in the selective serotonin reuptake inhibitor or psychostimulant class. Younger patients and those evaluated by a mental health specialist were more likely to be prescribed an antidepressant, compared to other patients. Forty percent of patients were still receiving at least one dose of a benzodiazepine in a 24-h period after their third week at the facility.

CONCLUSION

Although the efficacy of antidepressant pharmacotherapy in patients with comparable severity of medical illness has not been established, a substantial proportion of patients recovering from critical illness at a specialized facility are prescribed antidepressant medications. Benzodiazepine exposure is frequent after transfer, and the prevalence in patients who remain at the facility minimally decreases over time.

A prospective evaluation of empiric versus protocol-based sedation and analgesia

STUDY OBJECTIVE

To compare empiric and protocol-based therapies of sedation and analgesia in terms of pharmacologic cost, effects on mechanical ventilation and intensive care unit (ICU) stay, and quality of sedation and analgesia.

DESIGN

Prospective study.

SETTING

A 24-bed medical-surgical-neurologic ICU.

PATIENTS

Seventy-two patients evaluated during empiric therapy and 86 during protocol-based therapy.

INTERVENTION

Assessment of data collected for 4 months before and 5 months after an evidence-based sedation and analgesia protocol was implemented.

MEASUREMENTS AND MAIN RESULTS

Protocol adherence rate was 83.7%. The hourly cost (Canadian dollars) of sedation was less with protocol-based therapy ($5.68 +/- 4.27 vs $7.69 +/- 5.29, p<0.01) likely due to increased lorazepam use. Pharmacologic cost savings may be negated since sedation duration tended to be longer (122.7 +/- 142.8 vs 88.0 +/- 94.8 hrs, p<0.1) and extubation may have been delayed (61.6 +/- 97.4 vs 39.1 +/- 54.7 hrs, p=0.13) with protocol use. Duration of ICU stay after sedation was discontinued was not significantly different before and after protocol implementation. With the protocol, however, the percentage of modified Ramsay sedation scores representing discomfort decreased from 22.4 to 11% (p<0.001) and the percentage at a score of 4 increased from 17.2% to 29.6% (p<0.01). The percentage of modified visual analog measurements representing pain decreased from 9.6 to 5.9% (p<0.05) with the protocol. When data were stratified according to duration of sedation, the benefits and delayed extubation associated with protocol-based therapy were limited to patients requiring long-term sedation.

CONCLUSION

Compliance with this protocol reduced drug costs and enhanced the quality of sedation and analgesia for patients requiring long-term sedation. Protocol-based therapy with lorazepam may have delayed extubation but did not delay ICU discharge.

Music therapy as a nursing intervention for patients supported by mechanical ventilation

Music therapy is a nonpharmacologic nursing intervention that can be used as a complementary adjunct in the care of patients supported by mechanical ventilation. This article details the theoretical basis of music therapy for relaxation and anxiety reduction, highlights the research testing the intervention in such patients, and discusses areas of needed research to extend further the implementation of music therapy in critical care nursing practice in an effort to promote a healing environment for patients.

Procedural anesthesia at the bedside

Procedural anesthesia at the bedside offers patients relief from anxiety, discomfort, and pain and may expedite the procedure by increasing patient cooperation. Prospective planning requires knowledge of the condition of the patient and an assessment of the anesthetic requirements of the proposed procedure. The spectrum of anesthetic options includes sedation and analgesia, monitored anesthesia care, to total intravenous anesthesia (see Fig. 1). Identification of the at-risk patient and modifying the anesthetic should reduce complications (see Box 3). The choice of pharmaceuticals varies depending on the level of anticipated anesthesia. Personnel requirements also vary. Although an anesthesiologist is not required to administer medications and monitor the patient for sedation and analgesia or monitored anesthesia care, TIVA requires the services of an anesthesiologist. Costs are influenced by the personnel requirements and length of the procedure, which sets the drug requirements and drug costs. In the end, personal experience combined with knowledge should guide the provider to offer efficacious and cost-effective procedural anesthesia in the ICU.

Adjuncts to analgesia. Sedation and neuromuscular blockade

This article provides an overview of some of the current issues involved in sedation and anxiolysis in the intensive care unit. The problems involved in trying to monitor sedation levels are discussed, as are some of the newer options available for physiologic monitoring of the central nervous system. The problem of abnormal mental states in the intensive care unit and the range of antidepressant therapy now available are also covered. The importance of sleep deprivation and the properties of the neuromuscular blockers are also discussed.

Determinants of psychotropic drug usage in a general intensive care unit

During a 3-month period, determinants of psychotropic drug utilization (sex, age, length of stay, reason for admission, disease severity) and data on psychotropic consumption (type of medication--antidepressants, benzodiazepines and antipsychotics--dosage and length of treatment) were retrospectively collected in a general intensive care unit of a Dutch university hospital. Daily exposure to psychotropics was standardized in number of Defined Daily Doses (DDD). Benzodiazepines were used by 35.8% of all patients (137) during their stay in the ICU whereas 17.5% of all patients used a neuroleptic agent. Antidepressants were hardly prescribed. High doses of benzodiazepines (9.9 DDDs) and low doses of antipsychotics (0.5 DDDs) were prescribed, which probably reflect the unusual nature of this critically ill group of patients compared with the reference group for DDD's. Clear patterns of determinants of psychotropic drug use in ICU patients were found and both benzodiazepines, antipsychotics and combined use of these agents could be associated with the determinants assessed. The time patterns we found in terms of length of stay give clues for further investigations in order to rationalize psychotropic drug use in the management of severely ill and complex patients.

The effect of ICU sedation guidelines and pharmacist interventions on clinical outcomes and drug cost

OBJECTIVE

To measure the effect of evidence-based intensive care unit (ICU) sedation guidelines and interventions by a pharmacist to promote these guidelines on the weaning time from mechanical ventilation and sedation drug cost.

DESIGN

Before-after study.

SETTING

A 15-bed medical-surgical ICU at a tertiary-care teaching hospital.

PATIENTS

100 patients (2 groups of 50 consecutive patients) on mechanical ventilation (assist or pressure control mode for > or = 6 h) who were successfully discharged from the ICU.

METHODS

ICU sedation guidelines were developed through physician, nursing, and pharmacy consensus using a physician survey and literature overview as points of reference and were implemented into practice. Prospectively, data on the time required to wean patients from mechanical ventilation (successful trial of T-piece, pressure support, or intermittent mandatory ventilation leading to extubation) and total drug costs for sedation were measured and compared between groups. All prospective ICU pharmacist interventions pertaining to sedation were documented.

RESULTS

New sedation guidelines promoted lorazepam use in preference to midazolam and suggested propofol for patients not successfully sedated with high-dose lorazepam, haloperidol, or morphine. Over the 2-month collection periods, there was no difference in the median weaning time between the pre- (16 h, range 2-607) and post- (18 h, range 1-284) guideline groups. Total sedation drug costs decreased from $4515 to $1152 ($US) (p = 0.081). Median sedation drug costs decreased from $11.27 (range $0-1340) to $3.55 (range $0-250), with the amount (mg) of midazolam and propofol used decreasing by 86% and 100%, respectively. The ICU pharmacist successfully recommended a change from midazolam to lorazepam in 12 of 50 patients, 5 of whom had received midazolam for more than 24 hours.

CONCLUSIONS

High compliance with ICU sedation guidelines promoting lorazepam rather than midazolam or propofol in mechanically ventilated patients led to a 75% decrease in sedation drug costs and did not adversely affect the clinicians' ability to wean patients from mechanical ventilation.