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Shu Wen Toh T, R. R. P, Ho KHY, Sultana R, Couban R, Choong K, Lee JH. Daily Sedation Interruption vs Continuous Sedation in Pediatric Patients Receiving Mechanical Ventilation: A Systematic Review and Meta-analysis. JAMA Netw Open 2024; 7:e2426225. [PMID: 39110460 PMCID: PMC11307139 DOI: 10.1001/jamanetworkopen.2024.26225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2024] [Accepted: 06/09/2024] [Indexed: 08/10/2024] Open
Abstract
Importance The effectiveness of daily sedation interruption (DSI, defined as temporary interruption of sedation) has yet to be demonstrated in critically ill pediatric patients. Objective To compare the clinical outcomes of DSI vs continuous intravenous (IV) sedation in patients receiving invasive mechanical ventilation (MV) support in the pediatric intensive care unit (PICU). Data Sources A systematic search for studies was conducted using predefined keywords and Medical Subject Headings in 5 major databases (PubMed, Embase, Web of Science, CINAHL [Cumulated Index to Nursing and Allied Health Literature], and Cochrane Central Register of Controlled Trials) from database inception to October 31, 2023. Study Selection Retrospective and prospective observational studies, randomized clinical trials (RCTs), and systematic reviews were assessed for inclusion. Studies were eligible if they compared DSI to continuous IV sedation in patients aged 18 years or younger requiring MV in the PICU. Data Extraction and Synthesis Study characteristics, including the types of sedation, sedation protocols, and clinical outcomes, were extracted. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) reporting guideline was followed. A random-effects model was used to pool results from articles for the meta-analysis. Main Outcomes and Measures The primary outcomes of interest were duration of MV and length of PICU stay. Secondary outcomes included total sedative dose requirement, adverse events (eg, complications associated with MV, withdrawal, and delirium), and mortality. Results A total of 6 RCTs with 2810 pediatric patients (1569 males [55.8%]; mean age, 26.5 [95% CI, 15.0-37.9] months) were included in the final analysis; patients had a mean PRISM (Pediatric Risk of Mortality) score of 13.68 (95% CI, 10.75-16.61). Compared with continuous IV sedation, DSI was associated with a reduction in length of PICU stay (5 studies, n = 2770; mean difference [MD], -1.45 [95% CI, -2.75 to -0.15] days; P = .03]. There was no difference in MV duration (5 studies, n = 2750; MD, -0.93 [95% CI, -1.89 to 0.04] days; P = .06), total doses of midazolam (3 studies, n = 191; MD, -1.66 [95% CI, -3.95 to 0.63] mg/kg) and morphine used (2 studies, n = 189; MD, -2.63 [95% CI, -7.01 to 1.75] mg/kg), or adverse events (risk ratio [RR], 1.03 [95% CI, 0.74-1.42]; P = .88). There was no difference in mortality between patients exposed vs not exposed to DSI (RR, 0.89 [95% CI, 0.55-1.46]; P = .65). Conclusions and Relevance This systematic review and meta-analysis found that use of DSI in pediatric patients was associated with reduced length of PICU stay with no increase in adverse events. Further research is needed to ascertain whether this strategy is associated with improved neurodevelopmental outcomes in PICU survivors.
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Affiliation(s)
- Theresa Shu Wen Toh
- Department of Pediatric Subspecialties, Children’s Intensive Care Unit, KK Women’s and Children’s Hospital, Singapore
| | - Pravin R. R.
- Department of Pediatric Medicine, KK Women’s and Children’s Hospital, Singapore
| | - Karen Hwee Ying Ho
- Department of Pediatric Subspecialties, Children’s Intensive Care Unit, KK Women’s and Children’s Hospital, Singapore
| | - Rehena Sultana
- Center for Quantitative Medicine, Duke-NUS Medical School, The Academia, Singapore
| | - Rachel Couban
- Department of Anesthesia, McMaster University, Hamilton, Ontario, Canada
| | - Karen Choong
- Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada
- Department of Critical Care, McMaster University, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Jan Hau Lee
- Department of Pediatric Subspecialties, Children’s Intensive Care Unit, KK Women’s and Children’s Hospital, Singapore
- Paediatrics Academic Clinical Program, Duke-NUS Medical School, Singapore
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Giovanetti JN, Libera PHD, da Silva MLF, Boszczowski Í, Junior LCMC, de Albuquerque Pessoa Dos Santos Y, Forte DN, de Nardi R, Zigaib R, Park M. Eleven years impact of a stepwise educational program on healthcare associated infections and antibiotics consumption in an intensive care unit of a tertiary hospital in Brazil. J Crit Care 2024; 82:154783. [PMID: 38507842 DOI: 10.1016/j.jcrc.2024.154783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Revised: 10/26/2023] [Accepted: 03/10/2024] [Indexed: 03/22/2024]
Abstract
BACKGROUND Hospital acquired infections (HAI) and liberal use of broad-spectrum antibiotics are common in intensive care unit(ICU)s of low-middle income countries. We investigated the long-term association of a stepwise multifaceted educational program with the incidence of HAIs and antibiotics use in a Brazilian ICU. We also evaluated the program's cost impact. METHODS We retrieved data from a prospective daily collected database of a twelve bedrooms ICU, all admitted patients within a period of eleven years were enrolled. FINDINGS From 03/15/2007 to 09/11/2019, we admitted 3059 patients where 2406 (79%) survived the ICU stay. Median age was 51 years-old, and median SAPS3 was 53. The initial density of catheter related blood infection (4.3 events / 1000 patients-day), urinary tract infection (9.2 event / 1000 patients-day) and ventilator associated pneumonia (54.9 events / 1000 patients-day) felt during the observed period to (0.35 events / 1000 patients-day), (0 events / 1000 patients-day), and (1.5 events / 1000 patients-day) respectively. The days of antibiotic therapy also decreased from 797.9 days of therapy / 1000 patients day to 292.3 days of therapy / 1000 patients day. The total cost per patient also decreased. The adjusted mortality rate was steady during the studied period from 23.2% to 22.9%. INTERPRETATION A stepwise multifaceted educational program is an effective way to reduce hospital-associated infections, improve the rational use of antibiotics, and reduce costs. This impact occurred in a long term, and is probably consistent.
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Affiliation(s)
- Jakeline Neves Giovanetti
- Intensive Care Unit, Emergency Department, Hospital das Clínicas, University of São Paulo Medical School, São Paulo, Brazil
| | - Pedro Henrique Della Libera
- Intensive Care Unit, Emergency Department, Hospital das Clínicas, University of São Paulo Medical School, São Paulo, Brazil
| | | | - Ícaro Boszczowski
- Infection Control Department, Hospital das Clínicas, University of São Paulo Medical School, São Paulo, Brazil
| | | | | | - Daniel Neves Forte
- Intensive Care Unit, Emergency Department, Hospital das Clínicas, University of São Paulo Medical School, São Paulo, Brazil
| | - Raquel de Nardi
- Intensive Care Unit, Emergency Department, Hospital das Clínicas, University of São Paulo Medical School, São Paulo, Brazil
| | - Rogerio Zigaib
- Intensive Care Unit, Emergency Department, Hospital das Clínicas, University of São Paulo Medical School, São Paulo, Brazil
| | - Marcelo Park
- Intensive Care Unit, Emergency Department, Hospital das Clínicas, University of São Paulo Medical School, São Paulo, Brazil.
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Ceric A, Holgersson J, May TL, Skrifvars MB, Hästbacka J, Saxena M, Aneman A, Delaney A, Reade MC, Delcourt C, Jakobsen JC, Nielsen N. Effect of level of sedation on outcomes in critically ill adult patients: a systematic review of clinical trials with meta-analysis and trial sequential analysis. EClinicalMedicine 2024; 71:102569. [PMID: 38572080 PMCID: PMC10990717 DOI: 10.1016/j.eclinm.2024.102569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2024] [Revised: 03/11/2024] [Accepted: 03/13/2024] [Indexed: 04/05/2024] Open
Abstract
Background Sedation is routinely administered to critically ill patients to alleviate anxiety, discomfort, and patient-ventilator asynchrony. However, it must be balanced against risks such as delirium and prolonged intensive care stays. This study aimed to investigate the effects of different levels of sedation in critically ill adults. Methods Systematic review with meta-analysis and trial sequential analysis (TSA) of randomised clinical trials including critically ill adults admitted to the intensive care unit. CENTRAL, MEDLINE, Embase, LILACS, and Web of Science were searched from their inception to 13 June 2023. Risks of bias were assessed using the Cochrane risk of bias tool. Primary outcome was all-cause mortality. Aggregate data were synthesised with meta-analyses and TSA, and the certainty of the evidence was assessed using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach. This study is registered with PROSPERO: CRD42023386960. Findings Fifteen trials randomising 4352 patients were included, of which 13 were assessed high risk of bias. Meta-analyses comparing lighter to deeper sedation showed no evidence of a difference in all-cause mortality (risk ratio (RR) 0.94, 95% confidence interval (CI) 0.83-1.06; p = 0.28; 15 trials; moderate certainty evidence), serious adverse events (RR 0.99, CI 0.92-1.06; p = 0.80; 15 trials; moderate certainty evidence), or delirium (RR 1.01, 95% CI 0.94-1.09; p = 0.78; 11 trials; moderate certainty evidence). TSA showed that when assessing mortality, a relative risk reduction of 16% or more between the compared interventions could be rejected. Interpretation The level of sedation has not been shown to affect the risks of death, delirium, and other serious adverse events in critically ill adult patients. While TSA suggests that additional trials are unlikely to significantly change the conclusion of the meta-analyses, the certainty of evidence was moderate. This suggests a need for future high-quality studies with higher methodological rigor. Funding None.
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Affiliation(s)
- Ameldina Ceric
- Anesthesia & Intensive Care, Department of Clinical Sciences, Lund University, Skane University Hospital, Malmö, Sweden
| | - Johan Holgersson
- Lund University, Helsingborg Hospital, Department of Clinical Sciences Lund, Anesthesia & Intensive Care, Lund, Sweden
| | - Teresa L. May
- Maine Medical Center, Department of Critical Care, Portland, Maine, USA
| | - Markus B. Skrifvars
- Department of Emergency Care and Services, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Johanna Hästbacka
- Department of Anesthesiology and Intensive Care, Tampere University Hospital and Tampere University, Tampere, Finland
| | - Manoj Saxena
- Division of Critical Care, George Institute for Global Health, Australia
- St. George Hospital, South Eastern Sydney Local Health District, Sydney, Australia
| | - Anders Aneman
- Intensive Care Unit, Liverpool Hospital, South Western Sydney Local Health District, South Western Sydney Clinical School, University of New South Wales, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, Australia
| | - Anthony Delaney
- The George Institute for Global Health, Sydney, NSW, Australia
| | - Michael C. Reade
- Medical School, University of Queensland, Brisbane, QLD, Australia
| | - Candice Delcourt
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia
- Department of Clinical Medicine, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, NSW, Australia
| | - Janus Christian Jakobsen
- Copenhagen Trial Unit – Centre for Clinical Intervention Research, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Regional Health Research, The Faculty of Health Sciences, University of Southern Denmark, Denmark
| | - Niklas Nielsen
- Lund University, Helsingborg Hospital, Department of Clinical Sciences Lund, Anesthesia & Intensive Care, Lund, Sweden
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Gitti N, Renzi S, Marchesi M, Bertoni M, Lobo FA, Rasulo FA, Goffi A, Pozzi M, Piva S. Seeking the Light in Intensive Care Unit Sedation: The Optimal Sedation Strategy for Critically Ill Patients. Front Med (Lausanne) 2022; 9:901343. [PMID: 35814788 PMCID: PMC9265444 DOI: 10.3389/fmed.2022.901343] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Accepted: 05/20/2022] [Indexed: 12/12/2022] Open
Abstract
The clinical approach to sedation in critically ill patients has changed dramatically over the last two decades, moving to a regimen of light or non-sedation associated with adequate analgesia to guarantee the patient’s comfort, active interaction with the environment and family, and early mobilization and assessment of delirium. Although deep sedation (DS) may still be necessary for certain clinical scenarios, it should be limited to strict indications, such as mechanically ventilated patients with Acute Respiratory Distress Syndrome (ARDS), status epilepticus, intracranial hypertension, or those requiring target temperature management. DS, if not indicated, is associated with prolonged duration of mechanical ventilation and ICU stay, and increased mortality. Therefore, continuous monitoring of the level of sedation, especially when associated with the raw EEG data, is important to avoid unnecessary oversedation and to convert a DS strategy to light sedation as soon as possible. The approach to the management of critically ill patients is multidimensional, so targeted sedation should be considered in the context of the ABCDEF bundle, a holistic patient approach. Sedation may interfere with early mobilization and family engagement and may have an impact on delirium assessment and risk. If adequately applied, the ABCDEF bundle allows for a patient-centered, multidimensional, and multi-professional ICU care model to be achieved, with a positive impact on appropriate sedation and patient comfort, along with other important determinants of long-term patient outcomes.
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Affiliation(s)
- Nicola Gitti
- Department of Medical and Surgical Specialties, Radiological Science and Public Health, University of Brescia, Brescia, Italy
| | - Stefania Renzi
- Department of Medical and Surgical Specialties, Radiological Science and Public Health, University of Brescia, Brescia, Italy
| | - Mattia Marchesi
- Department of Medical and Surgical Specialties, Radiological Science and Public Health, University of Brescia, Brescia, Italy
| | - Michele Bertoni
- Department of Anesthesia, Critical Care and Emergency, Spedali Civili University Hospital, Brescia, Italy
| | - Francisco A. Lobo
- Institute of Anesthesiology, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
| | - Frank A. Rasulo
- Department of Medical and Surgical Specialties, Radiological Science and Public Health, University of Brescia, Brescia, Italy
- Department of Anesthesia, Critical Care and Emergency, Spedali Civili University Hospital, Brescia, Italy
| | - Alberto Goffi
- Interdepartmental Division of Critical Care Medicine, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Matteo Pozzi
- Department of Emergency and Intensive Care, San Gerardo Hospital, Monza, Italy
| | - Simone Piva
- Department of Medical and Surgical Specialties, Radiological Science and Public Health, University of Brescia, Brescia, Italy
- Department of Anesthesia, Critical Care and Emergency, Spedali Civili University Hospital, Brescia, Italy
- *Correspondence: Simone Piva,
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Chen TJ, Traynor V, Wang AY, Shih CY, Tu MC, Chuang CH, Chiu HY, Chang HC(R. Comparative Effectiveness of Non-Pharmacological Interventions for Preventing Delirium in Critically Ill Adults: A Systematic Review and Network Meta-Analysis. Int J Nurs Stud 2022; 131:104239. [DOI: 10.1016/j.ijnurstu.2022.104239] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Revised: 03/10/2022] [Accepted: 03/22/2022] [Indexed: 11/16/2022]
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Upadhyay PJ, Vet NJ, Goulooze SC, Krekels EHJ, de Wildt SN, Knibbe CAJ. Midazolam Infusion and Disease Severity Affect the Level of Sedation in Children: A Parametric Time-to-Event Analysis. Pharm Res 2021; 38:1711-1720. [PMID: 34664207 PMCID: PMC8523120 DOI: 10.1007/s11095-021-03113-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Accepted: 09/16/2021] [Indexed: 12/02/2022]
Abstract
Aim In critically ill mechanically ventilated children, midazolam is used first line for sedation, however its exact sedative effects have been difficult to quantify. In this analysis, we use parametric time-to-event (PTTE) analysis to quantify the effects of midazolam in critically ill children. Methods In the PTTE analysis, data was analyzed from a published study in mechanically ventilated children in which blinded midazolam or placebo infusions were administered during a sedation interruption phase until, based on COMFORT-B and NISS scores, patients became undersedated and unblinded midazolam was restarted. Using NONMEM® v.7.4.3., restart of unblinded midazolam was analysed as event. Patients in the trial were divided into internal and external validation cohorts prior to analysis. Results Data contained 138 events from 79 individuals (37 blinded midazolam; 42 blinded placebo). In the PTTE model, the baseline hazard was best described by a constant function. Midazolam reduced the hazard for restart of unblinded midazolam due to undersedation by 51%. In the blinded midazolam group, time to midazolam restart was 26 h versus 58 h in patients with low versus high disease severity upon admission (PRISM II < 10 versus > 21), respectively. For blinded placebo, these times were 14 h and 33 h, respectively. The model performed well in an external validation with 42 individuals. Conclusion The PTTE analysis effectively quantified the effect of midazolam in prolonging sedation and also the influence of disease severity on sedation in mechanically ventilated critically ill children, and provides a valuable tool to quantify the effect of sedatives. Clinical trial number and registry URL: Netherlands Trial Register, Trial NL1913 (NTR2030), date registered 28 September 2009 https://www.trialregister.nl/trial/1913. Supplementary Information The online version contains supplementary material available at 10.1007/s11095-021-03113-w.
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Affiliation(s)
- Parth J Upadhyay
- Gorlaeus Laboratories, Division of Systems Biomedicine and Pharmacology, Leiden Academic Centre for Drug Research (LACDR), Leiden University, PO Box 9502, 2300RA, Leiden, The Netherlands
| | - Nienke J Vet
- Department of Paediatrics, St Antonius Hospital, Nieuwegein, The Netherlands
| | - Sebastiaan C Goulooze
- Gorlaeus Laboratories, Division of Systems Biomedicine and Pharmacology, Leiden Academic Centre for Drug Research (LACDR), Leiden University, PO Box 9502, 2300RA, Leiden, The Netherlands
| | - Elke H J Krekels
- Gorlaeus Laboratories, Division of Systems Biomedicine and Pharmacology, Leiden Academic Centre for Drug Research (LACDR), Leiden University, PO Box 9502, 2300RA, Leiden, The Netherlands
| | - Saskia N de Wildt
- Department of Pharmacology & Toxicology, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Catherijne A J Knibbe
- Gorlaeus Laboratories, Division of Systems Biomedicine and Pharmacology, Leiden Academic Centre for Drug Research (LACDR), Leiden University, PO Box 9502, 2300RA, Leiden, The Netherlands. .,Department of Clinical Pharmacy, St Antonius Hospital, Nieuwegein, The Netherlands.
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Chen TJ, Chung YW, Chen PY, Hu SH, Chang CC, Hsieh SH, Wang BC, Chiu HY. Effects of daily sedation interruption in intensive care unit patients undergoing mechanical ventilation: A meta-analysis of randomized controlled trials. Int J Nurs Pract 2021; 28:e12948. [PMID: 33881193 DOI: 10.1111/ijn.12948] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Revised: 02/10/2021] [Accepted: 03/21/2021] [Indexed: 12/25/2022]
Abstract
AIM This study aimed to assess the effects of daily sedation interruption on the mechanical ventilation duration and relevant outcomes in mechanically ventilated patients in the intensive care unit (ICU). BACKGROUND Previously, three meta-analyses on the association of daily sedation interruption with the mechanical ventilation duration have reported conflicting findings, and these did not support current guideline recommendations that daily sedation interruption can be routinely used in mechanically ventilated adult ICU patients. DESIGN This was a systematic review and meta-analysis of randomized controlled studies. DATA SOURCES Data were from PubMed, Embase, Cochrane Library, CINAHL, ProQuest dissertation and theses, Airiti Library, China National Knowledge Infrastructure, Wanfang Data Chinese, Science Direct and PsycINFO databases. REVIEW METHODS Two reviewers independently assessed, extracted and appraised the included studies. Then, pooled estimates were calculated using a random-effects model. RESULTS In total, 45 studies involving 5493 participants were included. Compared with controls, daily sedation interruption significantly reduced the mechanical ventilation duration, ICU stay length, sedation duration, and tracheostomy and ventilator-associated pneumonia risks (all p ≤ 0.001). Moreover, the Acute Physiology and Chronic Health Evaluation II score and study quality were significant moderators. CONCLUSION Daily sedation interruption could substantially reduce the duration of mechanical ventilation, particularly when it was applied to patients with high disease severity. SUMMARY STATEMENT What is already known about this topic? Daily sedation interruption has been associated with reductions in excessive sedation and excessive use of sedative agents. The findings on the effects of daily sedation interruption on the mechanical ventilation duration have been inconsistent. What this paper adds? Daily sedation interruption could effectively reduce the mechanical ventilation duration, intensive care unit stay length, sedation duration, and tracheostomy and ventilator-associated pneumonia risks in intensive care unit patients. Applying daily sedation interruption to patients with high disease severity yielded a larger reduction in the mechanical ventilation duration. The implications of this paper: There is a need to adopt daily sedation interruption as routine care to reduce the mechanical ventilation duration, especially in higher disease severity population.
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Affiliation(s)
- Ting-Jhen Chen
- School of Nursing, College of Nursing, Taipei Medical University, Taipei, Taiwan
| | - Yi-Wei Chung
- Department of Cardiology, Taipei Medical University Shuang Ho Hospital, New Taipei City, Taiwan
| | - Pin-Yuan Chen
- Department of Neurosurgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Sophia H Hu
- Department of Nursing, School of Nursing, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Chuen-Chau Chang
- Department of Anesthesiology, Taipei Medical University Hospital, Taipei, Taiwan
| | - Shu-Hua Hsieh
- Department of Nursing, Far Eastern Memorial Hospital, New Taipei City, Taiwan
| | - Bo-Cyuan Wang
- Department of Nursing, New Taipei City Municipal Tucheng Hospital, New Taipei City, Taiwan
| | - Hsiao-Yean Chiu
- School of Nursing, College of Nursing, Taipei Medical University, Taipei, Taiwan
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Aitken LM, Kydonaki K, Blackwood B, Trahair LG, Purssell E, Sekhon M, Walsh TS. Inconsistent relationship between depth of sedation and intensive care outcome: systematic review and meta-analysis. Thorax 2021; 76:1089-1098. [PMID: 33859048 DOI: 10.1136/thoraxjnl-2020-216098] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Revised: 01/08/2021] [Accepted: 03/16/2021] [Indexed: 12/29/2022]
Abstract
PURPOSE To determine the effect of depth of sedation on intensive care mortality, duration of mechanical ventilation, and other clinically important outcomes. METHODS We searched MEDLINE, Embase, Cochrane Register of Controlled Trials, Cumulative Index to Nursing and Allied Health Literature, PsycINFO from 2000 to 2020. Randomised controlled trials (RCTs) and cohort studies that examined the effect of sedation depth were included. Two reviewers independently screened, selected articles, extracted data and appraised quality. Data on study design, population, setting, patient characteristics, study interventions, depth of sedation and relevant outcomes were extracted. Quality was assessed using Critical Appraisal Skills Programme tools. RESULTS We included data from 26 studies (n=7865 patients): 8 RCTs and 18 cohort studies. Heterogeneity of studies was substantial. There was no significant effect of lighter sedation on intensive care mortality. Lighter sedation did not affect duration of mechanical ventilation in RCTs (mean difference (MD): -1.44 days (95% CI -3.79 to 0.91)) but did in cohort studies (MD: -1.52 days (95% CI -2.71 to -0.34)). No statistically significant benefit of lighter sedation was identified in RCTs. In cohort studies, lighter sedation improved time to extubation, intensive care and hospital length of stay and ventilator-associated pneumonia. We found no significant effects for hospital mortality, delirium or adverse events. CONCLUSION Evidence of benefit from lighter sedation is limited, with inconsistency between observational and randomised studies. Positive effects were mainly limited to low quality evidence from observational studies, which could be attributable to bias and confounding factors.
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Affiliation(s)
- Leanne M Aitken
- School of Health Sciences, City, University of London, London, UK
| | - Kalliopi Kydonaki
- School of Health and Social Care, Edinburgh Napier University, Edinburgh, UK
| | - Bronagh Blackwood
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast Faculty of Medicine Health and Life Sciences, Belfast, UK
| | - Laurence G Trahair
- Adelaide Medical School, The University of Adelaide, Adelaide, South Australia, Australia
| | - Edward Purssell
- School of Health Sciences, City, University of London, London, UK
| | - Mandeep Sekhon
- School of Population Health & Environmental Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Timothy S Walsh
- Department of Anaesthesia, Critical Care & Pain Medicine and Usher Institute, The University of Edinburgh, Edinburgh, UK
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9
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Burry LD, Cheng W, Williamson DR, Adhikari NK, Egerod I, Kanji S, Martin CM, Hutton B, Rose L. Pharmacological and non-pharmacological interventions to prevent delirium in critically ill patients: a systematic review and network meta-analysis. Intensive Care Med 2021; 47:943-960. [PMID: 34379152 PMCID: PMC8356549 DOI: 10.1007/s00134-021-06490-3] [Citation(s) in RCA: 51] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Accepted: 07/19/2021] [Indexed: 02/07/2023]
Abstract
PURPOSE To compare the effects of prevention interventions on delirium occurrence in critically ill adults. METHODS MEDLINE, Embase, PsychINFO, CINAHL, Web of Science, Cochrane Library, Prospero, and WHO international clinical trial registry were searched from inception to April 8, 2021. Randomized controlled trials of pharmacological, sedation, non-pharmacological, and multi-component interventions enrolling adult critically ill patients were included. We performed conventional pairwise meta-analyses, NMA within Bayesian random effects modeling, and determined surface under the cumulative ranking curve values and mean rank. Reviewer pairs independently extracted data, assessed bias using Cochrane Risk of Bias tool and evidence certainty with GRADE. The primary outcome was delirium occurrence; secondary outcomes were durations of delirium and mechanical ventilation, length of stay, mortality, and adverse effects. RESULTS Eighty trials met eligibility criteria: 67.5% pharmacological, 31.3% non-pharmacological and 1.2% mixed pharmacological and non-pharmacological interventions. For delirium occurrence, 11 pharmacological interventions (38 trials, N = 11,993) connected to the evidence network. Compared to placebo, only dexmedetomidine (21/22 alpha2 agonist trials were dexmedetomidine) probably reduces delirium occurrence (odds ratio (OR) 0.43, 95% Credible Interval (CrI) 0.21-0.85; moderate certainty). Compared to benzodiazepines, dexmedetomidine (OR 0.21, 95% CrI 0.08-0.51; low certainty), sedation interruption (OR 0.21, 95% CrI 0.06-0.69; very low certainty), opioid plus benzodiazepine (OR 0.27, 95% CrI 0.10-0.76; very low certainty), and protocolized sedation (OR 0.27, 95% CrI 0.09-0.80; very low certainty) may reduce delirium occurrence but the evidence is very uncertain. Dexmedetomidine probably reduces ICU length of stay compared to placebo (Ratio of Means (RoM) 0.78, CrI 0.64-0.95; moderate certainty) and compared to antipsychotics (RoM 0.76, CrI 0.61-0.98; low certainty). Sedative interruption, protocolized sedation and opioids may reduce hospital length of stay compared to placebo, but the evidence is very uncertain. No intervention influenced mechanical ventilation duration, mortality, or arrhythmia. Single and multi-component non-pharmacological interventions did not connect to any evidence networks to allow for ranking and comparisons as planned; pairwise comparisons did not detect differences compared to standard care. CONCLUSION Compared to placebo and benzodiazepines, we found dexmedetomidine likely reduced the occurrence of delirium in critically ill adults. Compared to benzodiazepines, sedation-minimization strategies may also reduce delirium occurrence, but the evidence is uncertain.
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Affiliation(s)
- Lisa D. Burry
- grid.416166.20000 0004 0473 9881Department of Pharmacy, Mount Sinai Hospital, Room 18-377, 600 University Avenue, Toronto, ON M5G 1X5 Canada ,grid.416166.20000 0004 0473 9881Department Medicine, Mount Sinai Hospital, Toronto, Canada ,grid.17063.330000 0001 2157 2938Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Canada
| | - Wei Cheng
- grid.47100.320000000419368710Department of Biostatistics, Yale School of Public Health, New Haven, CT USA
| | - David R. Williamson
- grid.14848.310000 0001 2292 3357Pharmacy Department, Université de Montréal, Montréal, Canada ,grid.414056.20000 0001 2160 7387Pharmacy Department and Research Centre, CIUSSS-NIM Hôpital du Sacré-Cœur de Montréal, Montréal, Canada
| | - Neill K. Adhikari
- grid.413104.30000 0000 9743 1587Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Canada ,grid.17063.330000 0001 2157 2938Interdepartmental Division of Critical Care, University of Toronto, Toronto, Canada
| | - Ingrid Egerod
- grid.475435.4Intensive Care Unit 4131, Rigshospitalet, University of Copenhagen, Copenhagen Ø, Denmark
| | - Salmaan Kanji
- grid.412687.e0000 0000 9606 5108Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada ,grid.412687.e0000 0000 9606 5108Department of Pharmacy, The Ottawa Hospital, Ottawa, Canada
| | - Claudio M. Martin
- grid.412745.10000 0000 9132 1600Division of Critical Care, London Health Sciences Centre, London, Canada ,grid.39381.300000 0004 1936 8884Department of Medicine, The University of Western Ontario, London, Canada
| | - Brian Hutton
- grid.412687.e0000 0000 9606 5108Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada ,grid.28046.380000 0001 2182 2255School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
| | - Louise Rose
- grid.13097.3c0000 0001 2322 6764Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King’s College London, London, UK
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Nedergaard HK, Jensen HI, Stylsvig M, Olsen HT, Strøm T, Toft P. Effect of non-sedation on post-traumatic stress and psychological health in survivors of critical illness-A substudy of the NONSEDA randomized trial. Acta Anaesthesiol Scand 2020; 64:1136-1143. [PMID: 32470147 DOI: 10.1111/aas.13648] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Revised: 03/23/2020] [Accepted: 05/10/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Critical illness can cause post-traumatic stress and impaired mental health. The NONSEDA trial was a Scandinavian multicenter RCT, assessing non-sedation versus sedation with a daily wake-up call during mechanical ventilation in critically ill adults. The aim of this substudy was to assess the effect of non-sedation on post-traumatic stress and mental health. METHODS This substudy is based on all participating patients from a single NONSEDA trial site (Kolding, Denmark). Patients were randomized to sedation or non-sedation within the first 24 hours of mechanical ventilation. Three months after ICU discharge survivors were examined by a neuropsychologist for post-traumatic stress, anxiety and depression, and filled out the SF-36 questionnaire regarding quality of life. RESULTS The two groups of survivors were similar with regard to baseline characteristics, length of admission and mechanical ventilation. Sedated patients received more propofol and midazolam. Doses of morphine and haloperidole were equal. PRIMARY OUTCOME the number of patients with post-traumatic stress disorder did not differ between groups (non-sedated: 2 patients vs sedated: 0, P = .23). SECONDARY OUTCOMES there were no differences between groups in Beck Anxiety Index (median, non-sedated: 0 vs sedated: 0, P = .62), Beck Depression Index (median, non-sedated: 7 vs sedated: 4, P = .24), SF-36 mental component score (mean, non-sedated: 46.7 vs sedated: 47.5, P = .73) or number of patients with symptoms of post-traumatic stress (8 in both groups, P = .89). CONCLUSION Levels of PTSD, anxiety and depression and quality of life regarding mental health were similar between the non-sedated and sedated group.
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Affiliation(s)
- Helene K. Nedergaard
- Department of Anesthesiology and Intensive Care Lillebaelt Hospital KoldingUniversity Hospital of Southern Denmark Kolding Denmark
- Department of Clinical Research University of Southern Denmark Odense Denmark
| | - Hanne I. Jensen
- Department of Anesthesiology and Intensive Care Lillebaelt Hospital KoldingUniversity Hospital of Southern Denmark Kolding Denmark
- Department of Regional Health Research University of Southern Denmark Odense Denmark
| | | | - Hanne T. Olsen
- Department of Clinical Research University of Southern Denmark Odense Denmark
- Department of Anesthesiology and Intensive Care Odense University Hospital Svendborg Denmark
| | - Thomas Strøm
- Department of Anesthesiology and Intensive Care Odense University Hospital Odense Denmark
| | - Palle Toft
- Department of Anesthesiology and Intensive Care Odense University Hospital Odense Denmark
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Deng LX, Cao L, Zhang LN, Peng XB, Zhang L. Non-pharmacological interventions to reduce the incidence and duration of delirium in critically ill patients: A systematic review and network meta-analysis. J Crit Care 2020; 60:241-248. [PMID: 32919363 DOI: 10.1016/j.jcrc.2020.08.019] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Revised: 08/12/2020] [Accepted: 08/18/2020] [Indexed: 12/26/2022]
Abstract
OBJECTIVE To compare non-pharmacological interventions in their ability to prevent delirium in critically ill patients, and find the optimal regimen for treatment. METHODS Literature searches were conducted using PubMed, Embase, CINAHL, and Cochrane Library databases until the end of June 2019. We estimated the risk ratios (RRs) for the incidence of delirium and in-hospital mortality and found the mean difference (MD) for delirium duration and the length of ICU stay. The probabilities of interventions were ranked based on clinical outcomes. The study was registered on PROSPERO (CRD42020160757). RESULTS Twenty-six eligible studies were included in the network meta-analysis. Studies were grouped into seven intervention types: physical environment intervention (PEI), sedation reducing (SR), family participation (FP), exercise program (EP), cerebral hemodynamics improving (CHI), multi-component studies (MLT) and usual care (UC). In term of reducing the incidence of delirium, the two most effective interventions were FP (risk ratio (RR) 0.19, 95% confidence interval (CI) 0.08 to 0.44; surface under the cumulative ranking curve (SUCRA) = 94%) and MLT (RR 0.43, 95% CI 0.30 to 0.57; SUCRA = 68%) compared with observation. Although all interventions demonstrated nonsignificant efficacy in regards to delirium duration and the length of the patient's stay in the ICU, MLT (SUCRA = 78.6% and 71.2%, respectively) was found to be the most effective intervention strategy. In addition, EP (SUCRA = 97.2%) facilitated a significant reduction in hospital mortality, followed in efficacy by MLT (SUCRA = 73.2%), CHI (SUCRA = 35.8%), PEI (SUCRA = 34.8%), and SR (SUCRA = 31.8%). CONCLUSIONS Multi-component strategies are overall the optimal intervention techniques for preventing delirium and reducing ICU length of stay in critically ill patients by way of utilizing several interventions simultaneously. Additionally, family participation as a method of patient-centered care resulted in better outcomes for reducing the incidence of delirium.
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Affiliation(s)
- Lu-Xi Deng
- Department of Critical Care Medicine, Xiangya Hospital, Central South University, China.
| | - Lan Cao
- Teaching and Research Section of Clinical Nursing, Xiangya Hospital, Central South University, China.
| | - Li-Na Zhang
- Department of Critical Care Medicine, Xiangya Hospital, Central South University, China
| | - Xiao-Bei Peng
- Department of Critical Care Medicine, Xiangya Hospital, Central South University, China
| | - Lei Zhang
- Department of Critical Care Medicine, Xiangya Hospital, Central South University, China
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12
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Besen BAMP, Nassar Júnior AP, Lacerda FH, Silva CMDD, Souza VTD, Martins EVDN, Lopes ATA, Brandão CE, Oliveira LFD. Pain management protocol implementation and opioid consumption in critical care: an interrupted time series analysis. Rev Bras Ter Intensiva 2020; 31:447-455. [PMID: 31967218 PMCID: PMC7009002 DOI: 10.5935/0103-507x.20190085] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2019] [Accepted: 09/11/2019] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVE To evaluate the impact of an opioid-sparing pain management protocol on overall opioid consumption and clinical outcomes. METHODS This was a single-center, quasi-experimental, retrospective, before and after cohort study. We used an interrupted time series to analyze changes in the levels and trends of the utilization of different analgesics. We used bivariate comparisons in the before and after cohorts as well as logistic regression and quantile regression for adjusted estimates. RESULTS We included 988 patients in the preintervention period and 1,838 in the postintervention period. Fentanyl consumption was slightly increasing before the intervention (β = 16; 95%CI 7 - 25; p = 0.002) but substantially decreased in level with the intervention (β = - 128; 95%CI -195 - -62; p = 0.001) and then progressively decreased (β = - 24; 95%CI -35 - -13; p < 0.001). There was an increasing trend in the utilization of dipyrone. The mechanical ventilation duration was significantly lower (median difference: - 1 day; 95%CI -1 - 0; p < 0.001), especially for patients who were mechanically ventilated for a longer time (50th percentile difference: -0.78; 95%CI -1.51 - -0.05; p = 0.036; 75th percentile difference: -2.23; 95%CI -3.47 - -0.98; p < 0.001). CONCLUSION A pain management protocol could reduce the intensive care unit consumption of fentanyl. This strategy was associated with a shorter mechanical ventilation duration.
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Affiliation(s)
- Bruno Adler Maccagnan Pinheiro Besen
- Unidade de Terapia Intensiva, Hospital da Luz - São Paulo (SP), Brasil.,Unidade de Terapia Intensiva Clínica, Disciplina de Emergências Clínicas, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo - São Paulo (SP), Brasil
| | | | - Fábio Holanda Lacerda
- Unidade de Terapia Intensiva, Hospital da Luz - São Paulo (SP), Brasil.,Unidade de Terapia Intensiva Clínica, Disciplina de Emergências Clínicas, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo - São Paulo (SP), Brasil.,Unidade de Terapia Intensiva, Hospital AC Camargo Cancer Center - São Paulo (SP), Brasil
| | - Carla Marchini Dias da Silva
- Unidade de Terapia Intensiva, Hospital da Luz - São Paulo (SP), Brasil.,Unidade de Terapia Intensiva, Hospital AC Camargo Cancer Center - São Paulo (SP), Brasil
| | | | | | | | - Carlos Eduardo Brandão
- Unidade de Terapia Intensiva, Hospital da Luz - São Paulo (SP), Brasil.,Unidade de Terapia Intensiva, Hospital AC Camargo Cancer Center - São Paulo (SP), Brasil
| | - Lucas Fernandes de Oliveira
- Unidade de Terapia Intensiva, Hospital da Luz - São Paulo (SP), Brasil.,Unidade de Terapia Intensiva, Hospital AC Camargo Cancer Center - São Paulo (SP), Brasil
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13
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Long L, Ren S, Gong Y, Zhao H, He C, Shen L, Zhao H, Ma P. Different depths of sedation versus risk of delirium in adult mechanically ventilated patients: A systematic review and meta-analysis. PLoS One 2020; 15:e0236014. [PMID: 32673352 PMCID: PMC7365415 DOI: 10.1371/journal.pone.0236014] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2019] [Accepted: 06/27/2020] [Indexed: 01/04/2023] Open
Abstract
Background Delirium is multifactorial. This study aimed at determining the association between different depths of sedation and the risk of delirium in adult mechanically ventilated patients. Methods A systematic literature retrieval was conducted in databases including Cochrane Central Register of Controlled Trials, PubMed, Embase, Cumulative Index to Nursing and Allied Health Literature for publications available till December 2019 without limitation in study type, and followed by a secondary retrieval for related literature. STATA15.1 and WinBugs 14.3 were used in statistical analyses for different sedation depths as the intervention. The main endpoint was delirium occurrence. Secondary endpoints were agitation-related adverse events and mortality. Results We included 18 studies comprising 8001 mechanically ventilated patients. Different sedation depths were not associated with the occurrence of delirium (OR = 1.00, 95%CI: 0.64–1.58, P = 0.993). Among the 18 enrolled studies, this finding was not confounded by the dosage of benzodiazepines (OR = 0.96, 95%CI: 0.79–1.17, P = 0.717) in eight randomized controlled trials(RCTs) or the patients’ disease severity(OR 0.95, 95%CI: 0.79–1.13, P = 0.548) in 10 RCTs. However, contrasting results were found in non-RCTs. The deeper sedation group had a significantly increased risk for death(OR = 1.82, 95% CI: 1.23–2.69, P = 0.003), whereas lighter sedation seemed a potential risk for agitation-related adverse events (OR = 0.61, 95%CI: 0.45–0.84, P = 0.002). Conclusions It is inconclusive whether significantly different sedation depths would change the risk of delirium in adult mechanically ventilated patients. Trial registration number The study was registered in PROSPERO(http://www.crd.york.ac.uk/PROSPERO/) under registration number CRD42019145276.
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Affiliation(s)
- Ling Long
- Department of Intensive Care Unit, Hebei General Hospital, Shijiazhuang City, Hebei Province, China
| | - Shan Ren
- Department of Intensive Care Unit, Hebei General Hospital, Shijiazhuang City, Hebei Province, China
| | - Yichun Gong
- SICU, the 8th Medical Center, General Hospital of PLA, Beijing City, China
| | - Haotian Zhao
- Ultrasound Department, Hebei General Hospital, Shijiazhuang City, Hebei Province, China
| | - Cong He
- Department of Intensive Care Unit, Hebei General Hospital, Shijiazhuang City, Hebei Province, China
| | - Limin Shen
- Department of Intensive Care Unit, Hebei General Hospital, Shijiazhuang City, Hebei Province, China
| | - Heling Zhao
- Department of Intensive Care Unit, Hebei General Hospital, Shijiazhuang City, Hebei Province, China
| | - Penglin Ma
- Department of Intensive Care Unit, Hebei General Hospital, Shijiazhuang City, Hebei Province, China
- Critical Care Medicine Department, Peking University Third Hospitial, Beijing City, China
- * E-mail:
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14
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Wong IMJ, Thangavelautham S, Loh SCH, Ng SY, Murfin B, Shehabi Y. Sedation and Delirium in the Intensive Care Unit—A Practice-Based Approach. ANNALS OF THE ACADEMY OF MEDICINE, SINGAPORE 2020. [DOI: 10.47102/annals-acadmed.sg.202013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Introduction: Critically ill patients often require sedation for comfort and to
facilitate therapeutic interventions. Sedation practice guidelines provide an evidencebased framework with recommendations that can help improve key sedation-related
outcomes. Materials and Methods: We conducted a narrative review of current
guidelines and recent trials on sedation. Results: From a practice perspective, current
guidelines share many limitations including lack of consensus on the definition
of light sedation, optimal frequency of sedation assessment, optimal timing for
light sedation and consideration of combinations of sedatives. We proposed several
strategies to address these limitations and improve outcomes: 1) early light sedation
within the first 48 hours with time-weighted monitoring (overall time spent in
light sedation in the first 48 hours—sedation intensity—has a dose-dependent
relationship with mortality risk, delirium and time to extubation); 2) provision of
analgesia with minimal or no sedation where possible; 3) a goal-directed and balanced
multimodal approach that combines the benefits of different agents and minimise
their side effects; 4) use of dexmedetomidine and atypical antipsychotics as a
sedative-sparing strategy to reduce weaning-related agitation, shorten ventilation
time and accelerate physical and cognitive rehabilitation; and 5) a bundled approach
to sedation that provides a framework to improve relevant clinical outcomes.
Conclusion: More effort is required to develop a practical, time-weighted sedation
scoring system. Emphasis on a balanced, multimodal appraoch that targets light
sedation from the early phase of acute critical illness is important to achieve optimal
sedation, lower mortality, shorten time on ventilator and reduce delirium.
Ann Acad Med Singapore;49:215–25
Key words: Analgesia, Benzodiazepine, Critical Care, Dexmedetomidine, Propofol
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Affiliation(s)
- Irene MJ Wong
- Division of Anaesthesiology and Perioperative Medicine, Singapore General Hospital, Singapore
| | | | | | - Shin Yi Ng
- Division of Anaesthesiology and Perioperative Medicine, Singapore General Hospital, Singapore
| | - Brendan Murfin
- Faculty of Medicine Nursing and Health Sciences, Monash University, Australia
| | - Yahya Shehabi
- Faculty of Medicine Nursing and Health Sciences, Monash University, Australia
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Barcellos RDA, Chatkin JM. Impact of a multidisciplinary checklist on the duration of invasive mechanical ventilation and length of ICU stay. J Bras Pneumol 2020; 46:e20180261. [PMID: 32236341 PMCID: PMC7572285 DOI: 10.36416/1806-3756/e20180261] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2018] [Accepted: 09/30/2019] [Indexed: 12/03/2022] Open
Abstract
Objective: To assess the impact that implementing a checklist during daily multidisciplinary rounds has on the duration of invasive mechanical ventilation (IMV) and length of ICU stay. Methods: This was a non-randomized clinical trial in which the pre-intervention and post-intervention duration of IMV and length of ICU stay were evaluated in a total of 466 patients, including historical controls, treated in three ICUs of a hospital in the city of Caxias do Sul, Brazil. We evaluated 235 and 231 patients in the pre-intervention and post-intervention periods, respectively. The following variables were studied: age; gender; cause of hospitalization; diagnosis on admission; comorbidities; the Simplified Acute Physiology Score 3; the Sequential Organ Failure Assessment score; days in the ICU; days on IMV; reintubation; readmission; in-hospital mortality; and ICU mortality. Results: After the implementation of the checklist, the median (interquartile range) for days in the ICU and for days on IMV decreased from 8 (4-17) to 5 (3-11) and from 5 (1-12) to 2 (< 1-7), respectively, and the differences were significant (p ≤ 0.001 for both). Conclusions: The implementation of the checklist during daily multidisciplinary rounds was associated with a reduction in the duration of IMV and length of ICU stay among the patients in our sample.
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Affiliation(s)
- Ruy de Almeida Barcellos
- . Programa de Pós-Graduação em Medicina e Ciências da Saúde, Pontifícia Universidade Católica do Rio Grande do Sul, Porto Alegre (RS) Brasil
| | - José Miguel Chatkin
- . Programa de Pós-Graduação em Medicina e Ciências da Saúde, Pontifícia Universidade Católica do Rio Grande do Sul, Porto Alegre (RS) Brasil
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16
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Wang CT, Mao Y, Zhao L, Ma B. The impact of analgosedation on mortality and delirium in critically ill patients: A systematic review and meta-analysis. Intensive Crit Care Nurs 2019; 54:7-14. [DOI: 10.1016/j.iccn.2019.06.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2018] [Revised: 06/06/2019] [Accepted: 06/20/2019] [Indexed: 11/15/2022]
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17
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Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU. Crit Care Med 2019; 46:e825-e873. [PMID: 30113379 DOI: 10.1097/ccm.0000000000003299] [Citation(s) in RCA: 1789] [Impact Index Per Article: 357.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To update and expand the 2013 Clinical Practice Guidelines for the Management of Pain, Agitation, and Delirium in Adult Patients in the ICU. DESIGN Thirty-two international experts, four methodologists, and four critical illness survivors met virtually at least monthly. All section groups gathered face-to-face at annual Society of Critical Care Medicine congresses; virtual connections included those unable to attend. A formal conflict of interest policy was developed a priori and enforced throughout the process. Teleconferences and electronic discussions among subgroups and whole panel were part of the guidelines' development. A general content review was completed face-to-face by all panel members in January 2017. METHODS Content experts, methodologists, and ICU survivors were represented in each of the five sections of the guidelines: Pain, Agitation/sedation, Delirium, Immobility (mobilization/rehabilitation), and Sleep (disruption). Each section created Population, Intervention, Comparison, and Outcome, and nonactionable, descriptive questions based on perceived clinical relevance. The guideline group then voted their ranking, and patients prioritized their importance. For each Population, Intervention, Comparison, and Outcome question, sections searched the best available evidence, determined its quality, and formulated recommendations as "strong," "conditional," or "good" practice statements based on Grading of Recommendations Assessment, Development and Evaluation principles. In addition, evidence gaps and clinical caveats were explicitly identified. RESULTS The Pain, Agitation/Sedation, Delirium, Immobility (mobilization/rehabilitation), and Sleep (disruption) panel issued 37 recommendations (three strong and 34 conditional), two good practice statements, and 32 ungraded, nonactionable statements. Three questions from the patient-centered prioritized question list remained without recommendation. CONCLUSIONS We found substantial agreement among a large, interdisciplinary cohort of international experts regarding evidence supporting recommendations, and the remaining literature gaps in the assessment, prevention, and treatment of Pain, Agitation/sedation, Delirium, Immobility (mobilization/rehabilitation), and Sleep (disruption) in critically ill adults. Highlighting this evidence and the research needs will improve Pain, Agitation/sedation, Delirium, Immobility (mobilization/rehabilitation), and Sleep (disruption) management and provide the foundation for improved outcomes and science in this vulnerable population.
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Evaluations of Morphine and Fentanyl for Mechanically Ventilated Patients With Respiratory Disorders in Intensive Care: A Systematic Review of Methodological Trends and Reporting Quality. Value Health Reg Issues 2019; 19:7-25. [PMID: 30634071 DOI: 10.1016/j.vhri.2018.11.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Revised: 10/28/2018] [Accepted: 11/02/2018] [Indexed: 11/21/2022]
Abstract
BACKGROUND Mechanically ventilated patients with respiratory disorders may require sedatives, such as opioids. OBJECTIVES To define methodological trends, gaps, and the reporting quality of the comparative clinical and economic evaluations of fentanyl and morphine in ventilated patients in the intensive care unit. METHODS We conducted a literature review of the MEDLINE, Embase, OVID, ScienceDirect, Springer Link, and EconLit databases, comparing studies in the management of ventilated patients with respiratory disorders in the intensive care unit using either fentanyl or morphine, or both. We assessed the methodological aspects of the literature characteristics and trends of, for example, modeling, data sources, cost calculation, and data analysis, appraising the quality of reporting via the CONsolidated Standards Of Reporting Trials, STrengthening the Reporting of OBservational studies in Epidemiology, and the Consolidated Health Economic Evaluation Reporting Standards checklists. RESULTS Among 1327 articles, 33 (comprising 22 in adults, 8 in neonates, and 3 in pediatrics) met the inclusion criteria. No head-to-head morphine versus fentanyl evaluations explicitly confined to subjects with respiratory conditions were undertaken. Studies relied on various scales to measure the sedation level as a primary study outcome, limiting the comparability of study conclusions. Seven articles of adults were identified to be economic studies from the hospital perspective. On the basis of different endpoints, the same sedation regimen performed differently in various studies. None of the randomized controlled trials, observational cohorts, or pharmacoeconomics studies met most of the assessed reporting quality criteria. CONCLUSIONS Our review identified poor reporting quality and high heterogeneity of methods used, potentially limiting the degree to which studies could be interpreted, decisions could be influenced, and findings could be generalized.
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Rasheed AM, Amirah M, Abdallah M, Awajeh AM, Parameaswari PJ, Al Harthy A. Delirium Incidence and Risk Factors in Adult Critically Ill Patients in Saudi Arabia. J Emerg Trauma Shock 2019; 12:30-34. [PMID: 31057281 PMCID: PMC6496996 DOI: 10.4103/jets.jets_91_18] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Accepted: 12/05/2018] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Delirium in intensive care units (ICUs) is associated with long ICU stay, long hospital stay and increased costs of treatment. Unfortunately, delirium in ICU is significantly underestimated and overlooked by healthcare providers. AIMS The aim of this tudy is to determine the incidence and associated risk factors of delirium among critically ill patients in Saudi Arabia. METHODS This is a prospective study. Patients were assessed for delirium using the confusion assessment method for the ICU. Delirium was the independent variable in this study. RESULTS Fifty-nine patients (17.3%) showed positive delirium at least once compared to 283 patients (82.7%) who did not show positive delirium. Certain factors for delirium found to be significantly correlated with delirium (P < 0.005); including receiving sedation, mode of sedation, receiving mechanical ventilation, resistance to mechanical ventilator, and baseline Glasgow Coma Scale. CONCLUSION Delirium occurred in >17% of our ICU patients. More efforts should be directed to consider ICU delirium and to minimize its triggering factors.
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Affiliation(s)
- Akram Mohammad Rasheed
- Department of Nursing Education and Development, King Saud Medical City, Riyadh, Saudi Arabia
| | - Mohammad Amirah
- Department of Nursing Education and Development, King Saud Medical City, Riyadh, Saudi Arabia
| | - Mohammad Abdallah
- Pharmaceutical Care Services, King Saud Medical City, Riyadh, Saudi Arabia
| | - Adel M. Awajeh
- Department of Nursing Education and Development, King Saud Medical City, Riyadh, Saudi Arabia
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20
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Herling SF, Greve IE, Vasilevskis EE, Egerod I, Bekker Mortensen C, Møller AM, Svenningsen H, Thomsen T. Interventions for preventing intensive care unit delirium in adults. Cochrane Database Syst Rev 2018; 11:CD009783. [PMID: 30484283 PMCID: PMC6373634 DOI: 10.1002/14651858.cd009783.pub2] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Delirium is defined as a disturbance in attention, awareness and cognition with reduced ability to direct, focus, sustain and shift attention, and reduced orientation to the environment. Critically ill patients in the intensive care unit (ICU) frequently develop ICU delirium. It can profoundly affect both them and their families because it is associated with increased mortality, longer duration of mechanical ventilation, longer hospital and ICU stay and long-term cognitive impairment. It also results in increased costs for society. OBJECTIVES To assess existing evidence for the effect of preventive interventions on ICU delirium, in-hospital mortality, the number of delirium- and coma-free days, ventilator-free days, length of stay in the ICU and cognitive impairment. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, BIOSIS, International Web of Science, Latin American Caribbean Health Sciences Literature, CINAHL from 1980 to 11 April 2018 without any language limits. We adapted the MEDLINE search for searching the other databases. Furthermore, we checked references, searched citations and contacted study authors to identify additional studies. We also checked the following trial registries: Current Controlled Trials; ClinicalTrials.gov; and CenterWatch.com (all on 24 April 2018). SELECTION CRITERIA We included randomized controlled trials (RCTs) of adult medical or surgical ICU patients receiving any intervention for preventing ICU delirium. The control could be standard ICU care, placebo or both. We assessed the quality of evidence with GRADE. DATA COLLECTION AND ANALYSIS We checked titles and abstracts to exclude obviously irrelevant studies and obtained full reports on potentially relevant ones. Two review authors independently extracted data. If possible we conducted meta-analyses, otherwise we synthesized data narratively. MAIN RESULTS The electronic search yielded 8746 records. We included 12 RCTs (3885 participants) comparing usual care with the following interventions: commonly used drugs (four studies); sedation regimens (four studies); physical therapy or cognitive therapy, or both (one study); environmental interventions (two studies); and preventive nursing care (one study). We found 15 ongoing studies and five studies awaiting classification. The participants were 48 to 70 years old; 48% to 74% were male; the mean acute physiology and chronic health evaluation (APACHE II) score was 14 to 28 (range 0 to 71; higher scores correspond to more severe disease and a higher risk of death). With the exception of one study, all participants were mechanically ventilated in medical or surgical ICUs or mixed. The studies were overall at low risk of bias. Six studies were at high risk of detection bias due to lack of blinding of outcome assessors. We report results for the two most commonly explored approaches to delirium prevention: pharmacologic and a non-pharmacologic intervention.Haloperidol versus placebo (two RCTs, 1580 participants)The event rate of ICU delirium was measured in one study including 1439 participants. No difference was identified between groups, (risk ratio (RR) 1.01, 95% confidence interval (CI) 0.87 to 1.17) (moderate-quality evidence). Haloperidol versus placebo neither reduced or increased in-hospital mortality, (RR 0.98, 95% CI 0.80 to 1.22; 2 studies; 1580 participants (moderate-quality evidence)); the number of delirium- and coma-free days, (mean difference (MD) -0.60, 95% CI -1.37 to 0.17; 2 studies, 1580 participants (moderate-quality of evidence)); number of ventilator-free days (mean 23.8 (MD -0.30, 95% CI -0.93 to 0.33) 1 study; 1439 participants, (high-quality evidence)); length of ICU stay, (MD 0.18, 95% CI -0.60 to 0.97); 2 studies, 1580 participants; high-quality evidence). None of the studies measured cognitive impairment. In one study there were three serious adverse events in the intervention group and five in the placebo group; in the other there were five serious adverse events and three patients died, one in each group. None of the serious adverse events were judged to be related to interventions received (moderate-quality evidence).Physical and cognitive therapy interventions (one study, 65 participants)The study did not measure the event rate of ICU delirium. A physical and cognitive therapy intervention versus standard care neither reduced nor increased in-hospital mortality, (RR 0.94, 95% CI 0.40 to 2.20, I² = 0; 1 study, 65 participants; very low-quality evidence); the number of delirium- and coma-free days, (MD -2.8, 95% CI -10.1 to 4.6, I² = 0; 1 study, 65 participants; very low-quality evidence); the number of ventilator-free days (within the first 28/30 days) was median 27.4 (IQR 0 to 29.2) and 25 (IQR 0 to 28.9); 1 study, 65 participants; very low-quality evidence, length of ICU stay, (MD 1.23, 95% CI -0.68 to 3.14, I² = 0; 1 study, 65 participants; very low-quality evidence); cognitive impairment measured by the MMSE: Mini-Mental State Examination with higher scores indicating better function, (MD 0.97, 95% CI -0.19 to 2.13, I² = 0; 1 study, 30 participants; very low-quality evidence); or measured by the Dysexecutive questionnaire (DEX) with lower scores indicating better function (MD -8.76, 95% CI -19.06 to 1.54, I² = 0; 1 study, 30 participants; very low-quality evidence). One patient experienced acute back pain accompanied by hypotensive urgency during physical therapy. AUTHORS' CONCLUSIONS There is probably little or no difference between haloperidol and placebo for preventing ICU delirium but further studies are needed to increase our confidence in the findings. There is insufficient evidence to determine the effects of physical and cognitive intervention on delirium. The effects of other pharmacological interventions, sedation, environmental, and preventive nursing interventions are unclear and warrant further investigation in large multicentre studies. Five studies are awaiting classification and we identified 15 ongoing studies, evaluating pharmacological interventions, sedation regimens, physical and occupational therapy combined or separately, and environmental interventions, that may alter the conclusions of the review in future.
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Affiliation(s)
- Suzanne Forsyth Herling
- Rigshospitalet, University of CopenhagenThe Neuroscience CentreBlegdamsvej 9CopenhagenDenmark2100
- Herlev and Gentofte Hospital, University of CopenhagenDepartment of AnaesthesiaHerlev Ringvej 75HerlevDenmark2730
| | - Ingrid E Greve
- Bispebjerg and Frederiksberg Hospitals, University of CopenhagenDepartment of Anaesthesia and Intensive careCopenhagenDenmark
| | - Eduard E Vasilevskis
- Division of General Internal Medicine and Public Health, Vanderbilt University and theTennessee Valley Geriatric Research, Education and Clinical Center (GRECC)Department of Medicine1215 21st Ave. S.6005 Medical Center East, NTNashvilleTNUSA37232‐8300
| | - Ingrid Egerod
- Rigshospitalet, University of CopenhagenIntensive Care Unit 4131Blegdamsvej 9Copenhagen ØDenmark2100
| | - Camilla Bekker Mortensen
- Zealand University HospitalIntensive Care Unit, Department of AnaesthesiologyLykkebækvej 1KøgeDenmark4600
| | - Ann Merete Møller
- Herlev and Gentofte Hospital, University of CopenhagenDepartment of AnaesthesiaHerlev Ringvej 75HerlevDenmark2730
- Herlev and Gentofte Hospital, University of CopenhagenCochrane AnaesthesiaHerlev RingvejHerlev Ringvej 75HerlevDenmark2730
- Herlev and Gentofte Hospital, University of CopenhagenCochrane Emergency and Critical CareHerlev Ringvej 75HerlevDenmark2730
| | - Helle Svenningsen
- VIA University CollegeFaculty of Health SciencesAarhus NDenmarkDK‐8200
| | - Thordis Thomsen
- Rigshospitalet, The Abdominal CentreDepartment of Nursing ResearchBlegdamsvej 9CopenhagenDenmark2200
- University of CopenhagenDepartment of Clinical MedicineCopenhagenDenmark
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Ai ZP, Gao XL, Zhao XL. Factors associated with unplanned extubation in the Intensive Care Unit for adult patients: A systematic review and meta-analysis. Intensive Crit Care Nurs 2018; 47:62-68. [PMID: 29653888 DOI: 10.1016/j.iccn.2018.03.008] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2017] [Revised: 03/24/2018] [Accepted: 03/30/2018] [Indexed: 02/08/2023]
Abstract
OBJECTIVES To explore factors associated with unplanned extubation in Intensive Care Unit for adult patients. RESEARCH METHODOLOGY A systematic review and meta-analysis were performed of studies identified through Pubmed, CINAHL, Cochrane Library, PsycINFO and Web of Science published from initiation to September 2017. Only articles in English were included. The Newcastle-Ottawa Scale was used to evaluate the quality of the included articles. RESULTS Ten eligible studies were identified, encompassing a total of 2092 patients (457 in the unplanned extubation group; 1635 in the control group). The subsequent meta-analysis identified significant risk factors for unplanned extubation are male [odds ratio (OR) 1.54, 95% CI 1.12-2.12; P = 0.008], confusion [OR 0.10, 95% CI 0.05-0.17; P < 0.00001], physical restraint [OR 3.10, 95% CI 2.21-4.34; P < 0.00001], higher GCS scores [mean difference (MD) 1.06, 95% CI 0.59-1.52; P < 0.00001] and lower APACHE II scores [MD -2.26, 95% CI -3.35- -1.16; P < 0.0001]. Renal disease is a protective factor for unplanned extubation [OR 0.32, 95% CI 0.15-0.70; P = 0.004]. CONCLUSION Patients were male, confused, having physical restraint, with higher GCS and lower APACHE II scores are significant risk factors for unplanned extubation in Intensive Care Unit adult patients.
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Affiliation(s)
- Zhong-Ping Ai
- The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan, China.
| | - Xiao-Lan Gao
- The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan, China
| | - Xiao-Lei Zhao
- The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan, China
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Laerkner E, Egerod I, Olesen F, Hansen HP. A sense of agency: An ethnographic exploration of being awake during mechanical ventilation in the intensive care unit. Int J Nurs Stud 2017; 75:1-9. [DOI: 10.1016/j.ijnurstu.2017.06.016] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2017] [Revised: 06/26/2017] [Accepted: 06/28/2017] [Indexed: 02/07/2023]
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Fernandez-Gonzalo S, Turon M, De Haro C, López-Aguilar J, Jodar M, Blanch L. Do sedation and analgesia contribute to long-term cognitive dysfunction in critical care survivors? Med Intensiva 2017; 42:114-128. [PMID: 28851588 DOI: 10.1016/j.medin.2017.06.010] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2017] [Revised: 06/23/2017] [Accepted: 06/29/2017] [Indexed: 01/22/2023]
Abstract
Deep sedation during stay in the Intensive Care Unit (ICU) may have deleterious effects upon the clinical and cognitive outcomes of critically ill patients undergoing mechanical ventilation. Over the last decade a vast body of literature has been generated regarding different sedation strategies, with the aim of reducing the levels of sedation in critically ill patients. There has also been a growing interest in acute brain dysfunction, or delirium, in the ICU. However, the effect of sedation during ICU stay upon long-term cognitive deficits in ICU survivors remains unclear. Strategies for reducing sedation levels in the ICU do not seem to be associated with worse cognitive and psychological status among ICU survivors. Sedation strategy and management efforts therefore should seek to secure the best possible state in the mechanically ventilated patient and lower the prevalence of delirium, in order to prevent long-term cognitive alterations.
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Affiliation(s)
- S Fernandez-Gonzalo
- Research Department, Institut d'Investigació i Innovació Sanitària Parc Taulí (I3PT), Fundació Parc Taulí, Corporació Sanitària Universitària ParcTaulí, Sabadell, Spain; Centro de Investigación Biomédica En Red en Salud Mental (CIBERSAM), Instituto de Salud Carlos III, Madrid, Spain.
| | - M Turon
- Research Department, Institut d'Investigació i Innovació Sanitària Parc Taulí (I3PT), Fundació Parc Taulí, Corporació Sanitària Universitària ParcTaulí, Sabadell, Spain; Centro de Investigación Biomédica En Red en Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
| | - C De Haro
- Critical Care Department, ParcTaulí Sabadell, Hospital Universitari, Universitat Autònoma de Barcelona, Sabadell, Barcelona, Spain
| | - J López-Aguilar
- Research Department, Institut d'Investigació i Innovació Sanitària Parc Taulí (I3PT), Fundació Parc Taulí, Corporació Sanitària Universitària ParcTaulí, Sabadell, Spain; Centro de Investigación Biomédica En Red en Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
| | - M Jodar
- Centro de Investigación Biomédica En Red en Salud Mental (CIBERSAM), Instituto de Salud Carlos III, Madrid, Spain; Department of Clinical and Health Psychology, Universitat Autònoma de Barcelona, International Excellence Campus, Bellaterra, Spain; Neurology Department, ParcTaulí Sabadell, Hospital Universitari, Universitat Autònoma de Barcelona, Sabadell, Barcelona, Spain
| | - L Blanch
- Research Department, Institut d'Investigació i Innovació Sanitària Parc Taulí (I3PT), Fundació Parc Taulí, Corporació Sanitària Universitària ParcTaulí, Sabadell, Spain; Centro de Investigación Biomédica En Red en Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain; Critical Care Department, ParcTaulí Sabadell, Hospital Universitari, Universitat Autònoma de Barcelona, Sabadell, Barcelona, Spain
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Nassar Junior AP, Park M. Sedation protocols versus daily sedation interruption: a systematic review and meta-analysis. Rev Bras Ter Intensiva 2016; 28:444-451. [PMID: 28099642 PMCID: PMC5225920 DOI: 10.5935/0103-507x.20160078] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2016] [Accepted: 08/13/2016] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVE: The aim of this study was to systematically review studies that compared a mild target sedation protocol with daily sedation interruption and to perform a meta-analysis with the data presented in these studies. METHODS: We searched Medline, Scopus and Web of Science databases to identify randomized clinical trials comparing sedation protocols with daily sedation interruption in critically ill patients requiring mechanical ventilation. The primary outcome was mortality in the intensive care unit. RESULTS: Seven studies were included, with a total of 892 patients. Mortality in the intensive care unit did not differ between the sedation protocol and daily sedation interruption groups (odds ratio [OR] = 0.81; 95% confidence interval [CI] 0.60 - 1.10; I2 = 0%). Hospital mortality, duration of mechanical ventilation, intensive care unit and hospital length of stay did not differ between the groups either. Sedation protocols were associated with an increase in the number of days free of mechanical ventilation (mean difference = 6.70 days; 95%CI 1.09 - 12.31 days; I2 = 87.2%) and a shorter duration of hospital length of stay (mean difference = -5.05 days, 95%CI -9.98 - -0.11 days; I2 = 69%). There were no differences in regard to accidental extubation, extubation failure and the occurrence of delirium. CONCLUSION: Sedation protocols and daily sedation interruption do not appear to differ in regard to the majority of analyzed outcomes. The only differences found were small and had a high degree of heterogeneity.
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Affiliation(s)
- Antonio Paulo Nassar Junior
- Discipline of Clinical Emergency, Hospital das
Clínicas, Faculdade de Medicina, Universidade de São Paulo -
São Paulo (SP), Brazil
| | - Marcelo Park
- Discipline of Clinical Emergency, Hospital das
Clínicas, Faculdade de Medicina, Universidade de São Paulo -
São Paulo (SP), Brazil
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Park M, Pires-Neto RC, Nassar Junior AP. Awaking, exercising, sitting, walking and extubating: moving on the paradigms for mechanically ventilated patients. Rev Bras Ter Intensiva 2016; 26:203-4. [PMID: 25295813 PMCID: PMC4188455 DOI: 10.5935/0103-507x.20140030] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Affiliation(s)
- Marcelo Park
- Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brasil
| | - Ruy Camargo Pires-Neto
- Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brasil
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Protocolized sedation effect on post-ICU posttraumatic stress disorder prevalence: A systematic review and network meta-analysis. J Crit Care 2015; 30:1278-82. [PMID: 26315653 DOI: 10.1016/j.jcrc.2015.07.023] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2015] [Revised: 07/05/2015] [Accepted: 07/22/2015] [Indexed: 12/28/2022]
Abstract
PURPOSE Strategies aiming light sedation are associated with decreased length on mechanical ventilation. However, awake or easily arousable patients may be prone to greater prevalence of posttraumatic stress disorder (PTSD). These systematic review and meta-analysis aimed to evaluate the safety of light sedation strategies regarding the prevalence of PTSD. METHODS We searched MEDLINE, Scopus, and Web of Science from inception to November 2014 for randomized controlled trials that evaluated light sedation strategies and addressed PTSD prevalence in the follow-up as a specific outcome. Because not all trials performed the same comparisons, we performed a network meta-analysis to evaluate indirect comparisons. RESULTS Five studies fulfilled our inclusion criteria and were included in the meta-analysis. Two studies compared daily sedation interruption with usual care (92 patients), 2 studies compared a light sedation protocol with daily sedation interruption (47 patients), and 1 study compared light and deep sedation (102 patients). Compared with usual sedation care/deep sedation, neither daily interruption of sedation (odds ratio=0.66; 95% confidence interval, 0.22-1.98) nor a light sedation protocol (odds ratio=0.90, 95% confidence interval, 0.27-3.05) was associated with increased risks on long-term PTSD prevalence. CONCLUSION Light sedation strategies seem to be safe in terms of PTSD prevalence. However, the small number of included trials and patients may not be sufficient to drive strong statements.
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Minhas MA, Velasquez AG, Kaul A, Salinas PD, Celi LA. Effect of Protocolized Sedation on Clinical Outcomes in Mechanically Ventilated Intensive Care Unit Patients: A Systematic Review and Meta-analysis of Randomized Controlled Trials. Mayo Clin Proc 2015; 90:613-23. [PMID: 25865475 PMCID: PMC6469349 DOI: 10.1016/j.mayocp.2015.02.016] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2014] [Revised: 01/24/2015] [Accepted: 02/19/2015] [Indexed: 12/17/2022]
Abstract
OBJECTIVE To assess the effects of protocolized sedation (algorithm or daily interruption) compared with usual care without protocolized sedation on clinical outcomes in mechanically ventilated adult intensive care unit (ICU) patients via a systematic review and meta-analysis of randomized controlled trials (RCTs). METHODS We searched Ovid MEDLINE, EMBASE, Cochrane CENTRAL, Web of Science, and ClinicalTrials.gov from their inception to February 28, 2013. A random-effects model was used to synthesize risk ratios (RRs) and weighted mean differences (WMDs). RESULTS Of 4782 records screened, 6 RCTs including 1243 patients met the inclusion criteria. Protocolized sedation was associated with significant reductions in overall mortality (RR, 0.85; 95% CI, 0.74 to 0.97; P=.02; number needed to treat, 20; P=.11), ICU length of stay (WMD, -1.73 days; 95% CI, -3.32 to -0.14 days; P=.03), hospital length of stay (WMD, -3.55 days; 95% CI, -5.98 to -1.12 days; P=.004), and tracheostomy (RR, 0.69; 95% CI, 0.50 to 0.96; P=.03; number needed to treat, 16.6; P=.04; 5 RCTs) compared with usual care. Protocolized sedation produced no significant differences in duration of mechanical ventilation (WMD, -1.04 days; 95% CI, -2.54 to 0.47 days; P=.18), reintubation (RR, 0.78; 95% CI, 0.52 to 1.15; P=.21; 3 RCTs), and self-extubation (RR, 1.49; 95% CI, 0.46 to 4.82; P=.51; 4 RCTs) compared with usual care. Included studies did not report delirium incidence. CONCLUSION In mechanically ventilated adults in closed, nonspecialty ICUs, protocolized sedation seems to decrease overall mortality (15%), ICU and hospital lengths of stay (1.73 and 3.55 days, respectively), and tracheostomy (31%) compared with usual care without protocolized sedation.
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Affiliation(s)
- Mahad A Minhas
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH.
| | - Adrian G Velasquez
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH; Department of Critical Care, Newport Hospital, Newport, RI; Department of Medicine-Section of Critical Care, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Anubhav Kaul
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH; Department of Medicine, Lahey Hospital and Medical Center, Burlington, MA
| | - Pedro D Salinas
- Department of Medicine-Section of Critical Care, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Leo A Celi
- Division of Pulmonary-Critical Care and Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, MA
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Evaluation of a minimal sedation protocol using ICU sedative consumption as a monitoring tool: a quality improvement multicenter project. Crit Care 2014; 18:580. [PMID: 25673553 PMCID: PMC4234844 DOI: 10.1186/s13054-014-0580-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2014] [Accepted: 10/07/2014] [Indexed: 11/23/2022] Open
Abstract
Introduction Oversedation frequently occurs in ICUs. We aimed to evaluate a minimal sedation policy, using sedative consumption as a monitoring tool, in a network of ICUs targeting decrement of oversedation and mechanical ventilation (MV) duration. Methods A prospective quality improvement project was conducted in ten ICUs within a network of nonteaching hospitals in Brazil during a 2-year period (2010 to 2012). In the first 12 months (the preintervention period), we conducted an audit to identify sedation practice and barriers to current guideline-based practice regarding sedation. In the postintervention period, we implemented a multifaceted program, including multidisciplinary daily rounds, and monthly audits focusing on sedative consumption, feedback and benchmarking purposes. To analyze the effect of the campaign, we fit an interrupted time series (ITS). To account for variability among the network ICUs, we fit a hierarchical model. Results During the study period, 21% of patients received MV (4,851/22,963). In the postintervention period, the length of MV was lower (3.91 ± 6.2 days versus 3.15 ± 4.6 days; mean difference, −0.76 (95% CI, −1.10; −0.43), P <0.001) and 28 ventilator-free days were higher (16.07 ± 12.2 days versus 18.33 ± 11.6 days; mean difference, 2.30 (95% CI, 1.57; 3.00), P <0.001) than in the preintervention period. Midazolam consumption (in milligrams per day of MV) decreased from 329 ± 70 mg/day to 163 ± 115 mg/day (mean difference, −167 (95% CI, −246; −87), P <0.001). In contrast, consumption of propofol (P = 0.007), dexmedetomidine (P = 0.017) and haloperidol (P = 0.002) increased in the postintervention period, without changes in the consumption of fentanyl. Through ITS, age (P = 0.574) and Simplified Acute Physiology Score III (P = 0.176) remained stable. The length of MV showed a secular effect (secular trend β1 = −0.055, P = 0.012) and a strong decrease immediately after the intervention (intervention β2 = −0.976, P <0.001). The impact was maintained over the course of one year, despite the waning trend for the intervention’s effect (postintervention trend β3 = 0.039, P = 0.095). Conclusions By using a light sedation policy in a group of nonteaching hospitals, we reproduced the benefits that have previously been demonstrated in controlled settings. Furthermore, systematic monitoring of sedative consumption should be a feasible instrument for supporting the implementation of a protocol on a large scale. Electronic supplementary material The online version of this article (doi:10.1186/s13054-014-0580-3) contains supplementary material, which is available to authorized users.
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Burry L, Rose L, McCullagh IJ, Fergusson DA, Ferguson ND, Mehta S. Daily sedation interruption versus no daily sedation interruption for critically ill adult patients requiring invasive mechanical ventilation. Cochrane Database Syst Rev 2014; 2014:CD009176. [PMID: 25005604 PMCID: PMC6517142 DOI: 10.1002/14651858.cd009176.pub2] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND Daily sedation interruption (DSI) is thought to limit drug bioaccumulation, promote a more awake state, and thereby reduce the duration of mechanical ventilation. Available evidence has shown DSI to either reduce, not alter, or prolong the duration of mechanical ventilation. OBJECTIVES The primary objective of this review was to compare the total duration of invasive mechanical ventilation for critically ill adult patients requiring intravenous sedation who were managed with DSI versus those with no DSI. Our other objectives were to determine whether DSI influenced mortality, intensive care unit (ICU) and hospital lengths of stay, adverse events, the total doses of sedative drug administered, and quality of life. SEARCH METHODS We searched, from database inception to February 2014, the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2014, Issue 1); MEDLINE (OvidSP); EMBASE (OvidSP); CINAHL (EBSCOhost); Latin American and Caribbean Health Sciences Literature (LILACS); Web of Science Science Citation Index; Database of Abstracts of Reviews of Effects (DARE); the Health Technology Assessment Database (HTA Database); trial registration websites, and reference lists of relevant articles. We did not apply language restrictions. The reference lists of all retrieved articles were reviewed for additional, potentially relevant studies. SELECTION CRITERIA We included randomized controlled trials that compared DSI with sedation strategies that did not include DSI in mechanically ventilated, critically ill adults. DATA COLLECTION AND ANALYSIS Two authors independently extracted data and three authors assessed risk of bias. We contacted study authors for additional information as required. We combined data in forest plots using random-effects modelling. A priori subgroups and sensitivity analyses were performed. MAIN RESULTS Nine trials were used in the analysis (n = 1282 patients). These trials were found to be predominantly at low risk of bias. We did not find strong evidence of an effect of DSI on the total duration of ventilation. Pooled data from nine trials demonstrated a 13% reduction in the geometric mean, with relatively wide confidence intervals (CI) indicating imprecision (95% CI 26% reduction to 2% increase, moderate quality evidence). Similarly, we did not find strong evidence of an effect on ICU length of stay (-10%, 95% CI -20% to 3%, n = 9 trials, moderate quality evidence) or hospital length of stay (-6%, 95% CI -18% to 8%, n = 8 trials, moderate quality evidence). Heterogeneity for these three outcomes was moderate and statistically significant. The risk ratio for ICU mortality was 0.96 (95% CI 0.77 to 1.21, n = 7 trials, moderate quality evidence), for rate of accidental endotracheal tube removal 1.07 (95% CI 0.55 to 2.12, n = 6 trials, moderate quality evidence), for catheter removal 1.48 (95% CI 0.76 to 2.90, n = 4 trials), and for incidence of new onset delirium 1.02 (95% CI 0.91 to 1.13, n = 3 trials, moderate quality evidence). Differences in the doses of any drug used or quality of life score (Short Form (SF)-36) did not reach statistical significance. Tracheostomy was performed less frequently in the DSI group (RR 0.73, 95% CI 0.57 to 0.92, n = 6 trials, moderate quality evidence). Sensitivity analysis of unlogged data resulted in similar findings. Post hoc analysis to further explain heterogeneity, based on study country of origin, showed that studies conducted in North America resulted in a reduction in the duration of mechanical ventilation (-21%, 95% CI -33% to -5%, n = 5 trials). AUTHORS' CONCLUSIONS We have not found strong evidence that DSI alters the duration of mechanical ventilation, mortality, length of ICU or hospital stay, adverse event rates, drug consumption, or quality of life for critically ill adults receiving mechanical ventilation compared to sedation strategies that do not include DSI. We advise that caution should be applied when interpreting and applying the findings as the overall effect of treatment is always < 1 and the upper limit of the CI is only marginally higher than the no-effect line. These results should be considered unstable rather than negative for DSI given the statistical and clinical heterogeneity identified in the included trials.
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Affiliation(s)
- Lisa Burry
- Mount Sinai Hospital, Leslie Dan Faculty of Pharmacy, University of TorontoDepartment of Pharmacy600 University Avenue, Room 18‐377TorontoONCanadaM5G 1X5
| | - Louise Rose
- Sunnybrook Health Sciences Centre and Sunnybrook Research InstituteDepartment of Critical Care MedicineTorontoCanada
| | - Iain J McCullagh
- Newcastle Hospitals NHS Foundation Trust and University of NewcastleDepartment of Perioperative and Critical Care Medicine, Freeman HospitalFreeman RdHigh HeatonNewcastle upon TyneTyne and WearUKNE7 7DN
| | - Dean A Fergusson
- Ottawa Hospital Research InstituteClinical Epidemiology Program501 Smyth RoadOttawaONCanadaK1H 8L6
| | - Niall D Ferguson
- University Health Network and Mount Sinai Hospital, University of TorontoInterdepartmental Division of Critical Care Medicine600 University AveSuite 18‐206TorontoONCanadaM5G 1X5
| | - Sangeeta Mehta
- Mount Sinai Hospital, University of TorontoInterdepartmental Division of Critical Care Medicine600 University Ave, Rm 1504TorontoONCanadaM5G 1X5
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