A prospective randomised pilot study of sedation regimens in a general ICU population: a reality-based medicine study

Efficacy of Pectoral Nerve Block using Bupivacaine with or without Magnesium Sulfate

Background:

Worldwide, breast cancer is the main common cancer among females. In the United States, it affects one in eight women during their lifespan. In breast cancer surgery, chronic pain can be developed from poorly managed acute postoperative pain. The aim of the study was to use a safe, easy, and less complicated method of regional block for reducing the postoperative pain after mastectomy, which will reduce the incidence of chronic postmastectomy pain.

Materials and Methods:

Ninety adult female patients with American Society of Anesthesiologists Physical Status I, II, and III were allocated randomly into three groups: Group C had general anesthesia; Group B had ultrasound-guided pectoral nerve block (PECS block) (28mL 0.25% bupivacaine+2mL normal saline) plus general anesthesia; and Group M had ultrasound-guided PECS block (total 28 mL of Bupivacaine 0.25%+2mL of magnesium sulfat 50%) plus general anesthesia.

Results:

The intraoperative fentanyl (μg) used was significantly lower in Group B (110.4 ± 26.3) and Group M (108.7 ± 14.1) than in Group C (214.3 ± 20.1) and also the same as regards the total postoperative pethidine (mg) in Group C (220 ± 25.5), Group B (100.6 ± 24.3), and Group M (52.3 ± 12.3). The Group M was the least group suffered from postoperative pain at all times of measurement.

Conclusion:

The Group M was the least group suffered from postoperative pain at all times of measurement.

Protocolized sedation effect on post-ICU posttraumatic stress disorder prevalence: A systematic review and network meta-analysis

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.

Should Benzodiazepine Sedation be Delivered by Infusion or Bolus?

Benzodiazepine sedation for mechanically ventilated patients in intensive care (ICU) is common practice worldwide. We performed a literature review to investigate whether benzodiazepine sedation is best delivered by continuous infusion or intermittent bolus. PubMed, Ovid and Cochrane databases were searched. Only four studies, involving 481 patients, were found. Three were randomised controlled trials and one was an observational cohort study; all used different benzodiazepines, sometimes in conjunction with opiates. The studies measured different outcomes including mechanical ventilation duration, length of ICU and hospital stay, quality and complications of sedation and mortality. Use of intermittent sedation or opiate boluses alone reduced mechanical ventilation duration, ICU and hospital length of stay. However such limited data means that the optimal mode of delivery for benzodiazepine sedation remains unresolved.

Electroacupuncture reduces the dose of midazolam monitored by the bispectral index in critically ill patients with mechanical ventilation: an exploratory study

OBJECTIVE

Electroacupuncture, a modern variation on a traditional Chinese treatment, might be useful for sedation and analgesia. This study aims to investigate whether electroacupuncture can modify the dose of midazolam monitored by the bispectral index (BIS) in critically ill patients with mechanical ventilation.

METHODS

Orotracheally intubated patients undergoing mechanical ventilation were randomly assigned into three groups (groups A, B and C). All patients were given an intravenous infusion of midazolam. Patients in group A received no additional treatment. Patients in group B were given acupuncture without electrical stimulation at acupuncture points GV24 and EX-HN3 (Yintang) for 6 h simultaneously, and patients in group C were given electroacupuncture to the same points as in group B.

RESULTS

Maintaining the BIS between 60 and 80, the hourly mean one dose of midazolam within the first 6 h after sedation in group C was 0.05 (±0.02 mg/kg per hour), which was significantly lower than both group A (0.08 ± 0.03 mg/kg per hour, p<0.001) and group B (0.07 ± 0.01 mg/kg per hour, p<0.021). The doses in groups A and B showed no significant difference. Between-group comparison analysis of hepatic and renal function and severe adverse reactions all showed no significant difference between the three groups.

CONCLUSIONS

Electroacupuncture appears to reduce markedly the dose of sedative drug required in critically ill patients with mechanical ventilation monitored by BIS, without any obvious severe adverse action, and larger studies to confirm the effect are justified.

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

Introduction

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

Methods

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

Results

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

Conclusions

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

Randomized trial of light versus deep sedation on mental health after critical illness

OBJECTIVES

: To investigate if light sedation favorably affects subsequent patient mental health compared with deep sedation. Symptoms of posttraumatic stress disorder are common in patients after they have undergone prolonged mechanical ventilation and are associated with sedation depth.

DESIGN

: Randomized, open-label, controlled trial.

SETTING

: Single tertiary care center.

PATIENTS

: Adult patients requiring mechanical ventilation.

INTERVENTIONS

: Patients were randomized to receive either light (patient awake and cooperative) or deep sedation (patient asleep, awakening upon physical stimulation).

MEASUREMENTS AND MAIN RESULTS

: Self-reported measures of posttraumatic stress disorder, anxiety, and depression were collected at intensive care unit discharge and 4 wks later. The primary outcomes were symptoms of posttraumatic stress disorder, anxiety, and depression 4 wks after intensive care unit discharge.A total of 137 patients were assigned to either the light (n = 69) or the deep sedation (n = 68) group. Seven patients withdrew consent and one patient was randomized in error, leaving 129 patients (n = 65 in light sedation and n = 64 in deep sedation) available for analysis. At the 4-wk follow-up, patients in the deep sedation group tended to have more posttraumatic stress disorder symptoms (p = .07); the deep sedation group had more trouble remembering the event (37% vs. 14%; p = .02) and more disturbing memories of the intensive care unit (18% vs. 4%; p = .05). Patients in the light sedation group had an average one day less being ventilated and 1.5 fewer days in the intensive care unit. There were no differences between the two groups in the occurrence of anxiety and depression, and also no difference in mortality or in the incidence of adverse events.

CONCLUSIONS

: These data suggest that a strategy of light sedation affords benefits with regard to reduction of intensive care unit stay and duration of ventilation without negatively affecting subsequent patient mental health or patient safety.