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Sterr F, Bauernfeind L, Knop M, Rester C, Metzing S, Palm R. Weaning-associated interventions for ventilated intensive care patients: A scoping review. Nurs Crit Care 2024. [PMID: 39155350 DOI: 10.1111/nicc.13143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2024] [Revised: 07/22/2024] [Accepted: 07/25/2024] [Indexed: 08/20/2024]
Abstract
BACKGROUND Mechanical ventilation is a core intervention in critical care, but may also lead to negative consequences. Therefore, ventilator weaning is crucial for patient recovery. Numerous weaning interventions have been investigated, but an overview of interventions to evaluate different foci on weaning research is still missing. AIM To provide an overview of interventions associated with ventilator weaning. STUDY DESIGN We conducted a scoping review. A systematic search of the Medline, CINAHL and Cochrane Library databases was carried out in May 2023. Interventions from studies or reviews that aimed to extubate or decannulate mechanically ventilated patients in intensive care units were included. Studies concerning children, outpatients or non-invasive ventilation were excluded. Screening and data extraction were conducted independently by three reviewers. Identified interventions were thematically analysed and clustered. RESULTS Of the 7175 records identified, 193 studies were included. A total of six clusters were formed: entitled enteral nutrition (three studies), tracheostomy (17 studies), physical treatment (13 studies), ventilation modes and settings (47 studies), intervention bundles (42 studies), and pharmacological interventions including analgesic agents (8 studies), sedative agents (53 studies) and other agents (15 studies). CONCLUSIONS Ventilator weaning is widely researched with a special focus on ventilation modes and pharmacological agents. Some aspects remain poorly researched or unaddressed (e.g. nutrition, delirium treatment, sleep promotion). RELEVANCE TO CLINICAL PRACTICE This review compiles studies on ventilator weaning interventions in thematic clusters, highlighting the need for multidisciplinary care and consideration of various interventions. Future research should combine different interventions and investigate their interconnection.
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Affiliation(s)
- Fritz Sterr
- Faculty of Health, School of Nursing Sciences, Witten/Herdecke University, Witten, Germany
- Faculty of Applied Healthcare Sciences, Deggendorf Institute of Technology, Deggendorf, Germany
| | - Lydia Bauernfeind
- Faculty of Applied Healthcare Sciences, Deggendorf Institute of Technology, Deggendorf, Germany
- Institute of Nursing Science and Practice, Paracelsus Medical University Salzburg, Salzburg, Austria
| | - Michael Knop
- Faculty of Applied Healthcare Sciences, Deggendorf Institute of Technology, Deggendorf, Germany
| | - Christian Rester
- Faculty of Applied Healthcare Sciences, Deggendorf Institute of Technology, Deggendorf, Germany
| | - Sabine Metzing
- Faculty of Health, School of Nursing Sciences, Witten/Herdecke University, Witten, Germany
| | - Rebecca Palm
- Faculty of Health, School of Nursing Sciences, Witten/Herdecke University, Witten, Germany
- School VI Medicine and Health Sciences, Department of Health Services Research, Carl von Ossietzky Universität Oldenburg, Oldenburg, Germany
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Maamar A, Liard C, Doucet W, Reizine F, Painvin B, Delamaire F, Coirier V, Quelven Q, Guillot P, Lesouhaitier M, Tadié JM, Gacouin A. Acquired agitation in acute respiratory distress syndrome with COVID-19 compared to influenza patients: a propensity score matching observational study. Virol J 2022; 19:145. [PMID: 36085163 PMCID: PMC9463051 DOI: 10.1186/s12985-022-01868-1] [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: 06/14/2022] [Accepted: 08/16/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND A growing body of evidence reports that agitation and encephalopathy are frequent in critically ill Covid-19 patients. We aimed to assess agitation's incidence and risk factors in critically ill ARDS patients with Covid-19. For that purpose, we compared SARS-CoV-2 acute respiratory distress syndrome (ARDS) patients with a population of influenza ARDS patients, given that the influenza virus is also known for its neurotropism and ability to induce encephalopathy. METHODS We included all the patients with laboratory-confirmed Covid-19 infection and ARDS admitted to our medical intensive care unit (ICU) between March 10th, 2020 and April 16th, 2021, and all the patients with laboratory-confirmed influenza infection and ARDS admitted to our ICU between April 10th, 2006 and February 8th, 2020. Clinical and biological data were prospectively collected and retrospectively analyzed. We also recorded previously known factors associated with agitation (ICU length of stay, length of invasive ventilation, SOFA score and SAPS II at admission, sedative and opioids consumption, time to defecation). Agitation was defined as a day with Richmond Agitation Sedation Scale greater than 0 after exclusion of other causes of delirium and pain. We compared the prevalence of agitation among Covid-19 patients during their ICU stay and in those with influenza patients. RESULTS We included 241 patients (median age 62 years [53-70], 158 males (65.5%)), including 146 patients with Covid-19 and 95 patients with Influenza. One hundred eleven (46.1%) patients had agitation during their ICU stay. Patients with Covid-19 had significantly more agitation than patients with influenza (respectively 80 patients (54.8%) and 31 patients (32.6%), p < 0.01). After matching with a propensity score, Covid-19 patients remained more agitated than influenza patients (49 (51.6% vs 32 (33.7%), p = 0.006). Agitation remained independently associated with mortality after adjustment for other factors (HR = 1.85, 95% CI 1.37-2.49, p < 0.001). CONCLUSION Agitation in ARDS Covid-19 patients was more frequent than in ARDS influenza patients and was not associated with common risk factors, such as severity of illness or sedation. Systemic hyperinflammation might be responsible for these neurological manifestations, but there is no specific management to our knowledge.
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Affiliation(s)
- Adel Maamar
- CHU Rennes, Service de Maladies Infectieuses et Réanimation Médicale, Hôpital Pontchaillou, Université de Rennes 1, 2, rue Henri Le Guilloux, 35033, Rennes Cedex 9, France.
| | - Clémence Liard
- CHU Rennes, Service de Maladies Infectieuses et Réanimation Médicale, Hôpital Pontchaillou, Université de Rennes 1, 2, rue Henri Le Guilloux, 35033, Rennes Cedex 9, France
| | - Willelm Doucet
- CHU Rennes, Service de Maladies Infectieuses et Réanimation Médicale, Hôpital Pontchaillou, Université de Rennes 1, 2, rue Henri Le Guilloux, 35033, Rennes Cedex 9, France
| | - Florian Reizine
- CHU Rennes, Service de Maladies Infectieuses et Réanimation Médicale, Hôpital Pontchaillou, Université de Rennes 1, 2, rue Henri Le Guilloux, 35033, Rennes Cedex 9, France
| | - Benoit Painvin
- CHU Rennes, Service de Maladies Infectieuses et Réanimation Médicale, Hôpital Pontchaillou, Université de Rennes 1, 2, rue Henri Le Guilloux, 35033, Rennes Cedex 9, France
| | - Flora Delamaire
- CHU Rennes, Service de Maladies Infectieuses et Réanimation Médicale, Hôpital Pontchaillou, Université de Rennes 1, 2, rue Henri Le Guilloux, 35033, Rennes Cedex 9, France
| | - Valentin Coirier
- CHU Rennes, Service de Maladies Infectieuses et Réanimation Médicale, Hôpital Pontchaillou, Université de Rennes 1, 2, rue Henri Le Guilloux, 35033, Rennes Cedex 9, France
| | - Quentin Quelven
- CHU Rennes, Service de Maladies Infectieuses et Réanimation Médicale, Hôpital Pontchaillou, Université de Rennes 1, 2, rue Henri Le Guilloux, 35033, Rennes Cedex 9, France
| | - Pauline Guillot
- CHU Rennes, Service de Maladies Infectieuses et Réanimation Médicale, Hôpital Pontchaillou, Université de Rennes 1, 2, rue Henri Le Guilloux, 35033, Rennes Cedex 9, France
| | - Mathieu Lesouhaitier
- CHU Rennes, Service de Maladies Infectieuses et Réanimation Médicale, Hôpital Pontchaillou, Université de Rennes 1, 2, rue Henri Le Guilloux, 35033, Rennes Cedex 9, France
| | - Jean Marc Tadié
- CHU Rennes, Service de Maladies Infectieuses et Réanimation Médicale, Hôpital Pontchaillou, Université de Rennes 1, 2, rue Henri Le Guilloux, 35033, Rennes Cedex 9, France.,Faculté de Médecine, Université de Rennes 1, Unité INSERM CIC 1414, IFR 140, Rennes, France
| | - Arnaud Gacouin
- CHU Rennes, Service de Maladies Infectieuses et Réanimation Médicale, Hôpital Pontchaillou, Université de Rennes 1, 2, rue Henri Le Guilloux, 35033, Rennes Cedex 9, France.,Faculté de Médecine, Université de Rennes 1, Unité INSERM CIC 1414, IFR 140, Rennes, France
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The Application of the Nurse-Led Sedation and Analgesia Management in ICU after Heart Surgeries. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2022; 2022:7706172. [PMID: 35836831 PMCID: PMC9276485 DOI: 10.1155/2022/7706172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 04/25/2022] [Accepted: 04/28/2022] [Indexed: 11/28/2022]
Abstract
Aim Traditional sedation management consists of doctors adjusting the dosage of sedative drugs or adding other drugs in combination according to the evaluation of nurses; the nurses then execute the orders. The nurses' passive execution in the process is not the ideal model for continuous evaluation and observation of sedation. This study aims to investigate the application and effects of nurse-provided procedural sedation and analgesia for patients in intensive care unit. Methods The experimental group consisted of 354 heart surgery patients who received procedural sedation and analgesia from nurses from November 2020 to August 2021. The control group consisted of 301 patients who had had heart surgery and received the traditional sedation management program from January to October 2020. The differences in levels of the sedative effect, delirium, and unplanned extubation of patients between these two groups were compared. Results There were no significant differences in baseline characteristics between the two groups (P > 0.05). It was found that both insufficient sedation and excessive sedation decreased in the experimental group when compared to the control group, while the appropriate proportion of sedation increased (72.41% versus 37.98%); the difference was statistically significant (P < 0.05). The incidence of delirium was lower for patients in the experimental group than for patients in the control group (37.01% versus 66.45%); the difference was statistically significant (P < 0.05). The incidence of unplanned extubation caused by patient factors was lower for the experimental group than for the control group, but the difference was not statistically significant (P > 0.05). Conclusion The programmed sedation scheme led by nurses can improve the sedation effect and reduce the incidence of delirium. Implications for Practice. The management team gives the sedative goal and establishes the standard flowchart. The sedation management led by the nurse according to the goal and flowchart is better than the traditional sedation management.
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Kabra R, Patel M, Bhansali PJ, Kumar S, Acharya S. Intermediate Syndrome and Marchiafava-Bignami Syndrome: Double Trouble in Weaning Off. Cureus 2022; 14:e26694. [PMID: 35949784 PMCID: PMC9358054 DOI: 10.7759/cureus.26694] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/09/2022] [Indexed: 11/24/2022] Open
Abstract
Intermediate syndrome affects 10-40% of those with severe organophosphorus poisoning, causing delayed weakness in the proximal parts of the body, neck flexors, and breathing muscles. We present the case of organophosphorus poisoning that advanced to intermediate syndrome and subsequently worsened, with imaging later revealing the Marchiafava-Bignami condition, which aggravated the intermediate syndrome.
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Mart MF, Pun BT, Pandharipande P, Jackson JC, Ely EW. ICU Survivorship-The Relationship of Delirium, Sedation, Dementia, and Acquired Weakness. Crit Care Med 2021; 49:1227-1240. [PMID: 34115639 PMCID: PMC8282752 DOI: 10.1097/ccm.0000000000005125] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The advent of modern critical care medicine has revolutionized care of the critically ill patient in the last 50 years. The Society of Critical Care Medicine (was formed in recognition of the challenges and need for specialized treatment for these fragile patients. As the specialty has grown, it has achieved impressive scientific advances that have reduced mortality and saved lives. With those advances, however, came growing recognition that the burden of critical illness did not end at the doorstep of the hospital. Delirium, once thought to be a mere by-product of critical illness, was found to be an independent predictor of mortality, prolonged mechanical ventilation, and long-lasting cognitive impairment. Similarly, deep sedation and immobility, so often used to keep patients "comfortable" and to facilitate mechanical ventilation and recovery, worsen mortality and lead to the development of ICU-acquired weakness. The realization that these outcomes are inextricably linked to one another and how we manage our patients has helped us recognize the need for culture change. We, as a specialty, now understand that although celebrating the successes of survival, we now also have a duty to focus on those who survive their diseases. Led by initiatives such as the ICU Liberation Campaign of the Society of Critical Care Medicine, the natural progression of the field is now focused on getting patients back to their homes and lives unencumbered by disability and impairment. Much work remains to be done, but the futures of our most critically ill patients will continue to benefit if we leverage and build on the history of our first 50 years.
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Affiliation(s)
- Matthew F Mart
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Nashville, TN
| | - Brenda T Pun
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Nashville, TN
| | - Pratik Pandharipande
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Nashville, TN
- Department of Anesthesiology, Division of Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - James C Jackson
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Nashville, TN
| | - E Wesley Ely
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Nashville, TN
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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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Abstract
PURPOSES OF REVIEW Critically ill patients frequently require mechanical ventilation as part of their care. Administration of analgesia and sedation to ensure patient comfort and facilitate mechanical ventilation must be balanced against the known negative consequences of excessive sedation. The present review focuses on the current evidence for sedation management during mechanical ventilation, including choice of sedatives, sedation strategies, and special considerations for acute respiratory distress syndrome (ARDS). RECENT FINDINGS The Society of Critical Care Medicine recently published their updated clinical practice guidelines for analgesia, agitation, sedation, delirium, immobility, and sleep in adult patients in the ICU. Deep sedation, especially early in the course of mechanical ventilation, is associated with prolonged time to liberation from mechanical ventilation, longer ICU stays, longer hospital stays, and increased mortality. Dexmedetomidine may prevent ICU delirium when administered nocturnally at low doses; however, it was not shown to improve mortality when used as the primary sedative early in the course of mechanical ventilation, though the majority of patients in the informing study failed to achieve the prescribed light level of sedation. In a follow up to the ACURASYS trial, deep sedation with neuromuscular blockade did not result in improved mortality compared to light sedation in patients with severe ARDS. SUMMARY Light sedation should be targeted early in the course of mechanical ventilation utilizing daily interruptions of sedation and/or nursing protocol-based algorithms, even in severe ARDS.
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Neuschwander A, Chhor V, Yavchitz A, Resche-Rigon M, Pirracchio R. Automated weaning from mechanical ventilation: Results of a Bayesian network meta-analysis. J Crit Care 2020; 61:191-198. [PMID: 33181416 DOI: 10.1016/j.jcrc.2020.10.025] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2020] [Revised: 10/20/2020] [Accepted: 10/23/2020] [Indexed: 12/29/2022]
Abstract
PURPOSE Mechanical ventilation (MV) weaning is a crucial step. Automated weaning modes reduce MV duration but the question of the best automated mode remains unanswered. Our objective was to compare the major automated modes for MV weaning in critically ill and post-operative adult patients. MATERIAL AND METHODS We conducted a network Bayesian meta-analysis to compare different automated modes. We searched MEDLINE, EMBASE and Cochrane central registry for randomized control trials comparing automated weaning modes either to another automated mode or to standard-of-care. The primary outcome was the duration of MV weaning extracted from the original trials. RESULTS 663 articles were screened and 26 trials (2097patients) were included in the final analysis. All automated modes included in the study (ASV°, Intellivent ASV, Smartcare, Automode°, PAV° and MRV°) outperformed standard-of-care but no automated mode reduced the duration of mechanical ventilation weaning as compared to others in the network meta-analysis. CONCLUSION Compared to standard weaning practice, all automated modes significantly reduced the duration of MV weaning in critically ill and post-operative adult patients. When cross-compared using a network meta-analysis, no specific mode was different in reducing the duration of MV weaning. The study was registered in PROSPERO (CRD42015024742).
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Affiliation(s)
- Arthur Neuschwander
- Service d'Anesthésie Réanimation, Hôpital Européen Georges Pompidou, Université Paris Descartes, Sorbonne Paris Cité, Paris, France
| | - Vibol Chhor
- Service d'Anesthésie Réanimation, Hôpital Européen Georges Pompidou, Université Paris Descartes, Sorbonne Paris Cité, Paris, France
| | - Amélie Yavchitz
- Service d'Anesthésie Réanimation, Hôpital Européen Georges Pompidou, Université Paris Descartes, Sorbonne Paris Cité, Paris, France
| | - Matthieu Resche-Rigon
- Service de Biostatistiques et Information Médicale, Hôpital Saint Louis, Unité INSERM UMR-1153, Université Paris Diderot, Sorbonne Paris Cité, Paris, France
| | - Romain Pirracchio
- Service d'Anesthésie Réanimation, Hôpital Européen Georges Pompidou, Université Paris Descartes, Sorbonne Paris Cité, Paris, France; Department of Anesthesia and Perioperative Medicine, San Francisco General Hospital and Trauma Center, University of California, San Francisco, CA, USA.
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Sedighie L, Bolourchifard F, Rassouli M, Zayeri F. Effect of Comprehensive Pain Management Training Program on Awareness and Attitude of ICU Nurses. Anesth Pain Med 2020; 10:e98679. [PMID: 32754429 PMCID: PMC7341110 DOI: 10.5812/aapm.98679] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2019] [Revised: 02/03/2020] [Accepted: 02/25/2020] [Indexed: 01/08/2023] Open
Abstract
Background Pain is one of the main complaints of many patients in intensive care units. However, most nurses and physicians are unable to properly monitor and relieve pain in these patients. Factors such as patients' inability to describe their pain and insufficient knowledge of nurses and physicians have made pain management difficult. Given that the knowledge and attitude of nurses play an important role in the effective implementation of the pain management process, this study aimed to investigate the effect of comprehensive pain management training program on the awareness and attitude of intensive care unit nurses. Methods This quasi-experimental single-group study was conducted in two phases (pre and post-intervention) to investigate the awareness and attitude of all nurses employed in the intensive care unit of Tehran Modarres Hospital, based on the determined inclusion and exclusion criteria. In the pre-intervention phase, the awareness and attitudes of the nurses were assessed using a questionnaire. After conducting the pain management training course, an executive program and algorithm were implemented for pain management in ICUs. Then, the nurses’ awareness and attitude toward pain management were assessed again. Finally, changes in the scores of the nurses’ awareness and attitude were analyzed by SPSS V. 22 software in two phases before and after applying the interventions using the Wilcoxon test. The relationship between some demographic variables and the level of awareness and attitude of nurses was also investigated using the Kruskal-Wallis and Mann-Whitney tests. Results The results of this study indicated that the mean score of the nurses’ awareness was significantly different in pre- and post-intervention phases (P < 0.05). Despite an increase in the post-intervention mean score of the nurses’ attitude (71.03), no statistically significant change was observed. Additionally, among the demographic variables, there was only a significant relationship between the nurses' job experience in ICUs and their attitudes. Conclusions Based on the results of this study, teaching and implementing a comprehensive program for pain management can play an effective role in promoting the nurses’ awareness. Therefore, it is proposed to use pain management models to improve the nurses' knowledge and attitude toward pain management in ICU patients.
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Affiliation(s)
- Ladan Sedighie
- Department of Nursing, Student Research Committee, School of Nursing & Midwifery, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Fariba Bolourchifard
- Department of Nursing, School of Nursing & Midwifery, Shahid Beheshti University of Medical Sciences, Tehran, Iran
- Corresponding Author: Ph.D. in Nursing, Assistant Professor, School of Nursing & Midwifery, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
| | - Maryam Rassouli
- Cancer Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Farid Zayeri
- Department of Biostatistics, Proteomics Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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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: 1808] [Impact Index Per Article: 361.6] [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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Karikari S, Rausa J, Flores S, Loomba RS. Neurally adjusted ventilatory assist versus conventional ventilation in the pediatric population: Are there benefits? Pediatr Pulmonol 2019; 54:1374-1381. [PMID: 31231985 DOI: 10.1002/ppul.24413] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2019] [Accepted: 05/09/2019] [Indexed: 11/09/2022]
Abstract
INTRODUCTION Neurally-adjusted ventilator assist (NAVA) is a relatively new form of ventilation in which the electrical activity of the diaphragm is sensed by a catheter. The amplitude of this electrical signal is then used to deliver an appropriately proportioned pressure supported breath to the patient. Due to the synchronous nature of the breaths and the patient-adjusted nature of the support, NAVA has been shown to have benefits over conventional ventilation. Meta-analyses were conducted of published pediatric studies to compare ventilatory endpoints between NAVA and conventional ventilation. METHODS Studies comparing ventilatory parameters between NAVA and conventional ventilation in pediatric patients were identified. These studies were reviewed for appropriateness for inclusion and studies of only pediatric patients with data for similar endpoints between both arms were then pooled. RESULTS Statistically significant differences were noted in asynchrony, peak inspiratory pressure (PIP), and oxygen saturation by pulse oximetry. Asynchrony was 17% lower with NAVA, PIP was 1.74 cmH2 0 lower with NAVA, and oxygen saturation was 1.1% greater with NAVA. There was no statistically significant difference in peak expiratory pressure, mean airway pressure, electrical diaphragmatic activity, respiratory rate, hydrogen ion concentration, partial pressure of oxygen, or partial pressure of carbon dioxide. CONCLUSION Statistically significant differences were noted in percent asynchrony, PIP, and oxygen saturation when comparing NAVA to conventional ventilation. These all tended to favor NAVA. Other than percent asynchrony, however, the other statistically significant findings were not clinically significant.
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Affiliation(s)
- Serwaa Karikari
- Division of Cardiology, Advocate Children's Hospital, Chicago Medical School/ Rosalind Franklin University of Medicine and Science, Chicago, Illinois
| | - Jacqueline Rausa
- Division of Cardiology, Advocate Children's Hospital, Chicago Medical School/ Rosalind Franklin University of Medicine and Science, Chicago, Illinois
| | - Saul Flores
- Division of Critical Care, Texas Children's Hospital, Houston, Texas
| | - Rohit S Loomba
- Division of Cardiology, Advocate Children's Hospital, Chicago Medical School/ Rosalind Franklin University of Medicine and Science, Chicago, Illinois
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Ferraioli D, Ferguson L, Carberry M. Quality improvement project aimed at improving the reliability of spontaneous awakening trials in a district general intensive care unit. BMJ Open Qual 2019; 8:e000518. [PMID: 31206059 PMCID: PMC6542449 DOI: 10.1136/bmjoq-2018-000518] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Revised: 12/21/2018] [Accepted: 04/24/2019] [Indexed: 01/02/2023] Open
Abstract
Traditionally regarded as good practice, continuous infusions of sedation and analgesic medications are used to reduce anxiety and distress and facilitate care of mechanically ventilated patients in the intensive care unit (ICU). Growing evidence has demonstrated that use of such infusions prolongs days spent invasively ventilated, increases the incidence of ICU acquired weakness and delirium and subsequently increasing the duration of their ICU and hospital stay. Several critical care guidelines recommend titrating to light sedation ±a daily sedation hold or spontaneous awakening trial (SAT). Given the known beneficial effects of sedation holds, we aimed to increase their use within our ICU, a 10-bedded unit with mixed ICU and high-ependency unit facilities in National Health Service Scotland. A retrospective case note review was performed to obtain baseline data of SAT eligible patients who received a sedation hold. The model for improvement 1 was used to implement an ICU protocol based on the 'Wake up and breath' guidelines 2 and measure the improvements made. The median percentage of SAT eligible patients that received a sedation hold increased from 47% to 96% during the project period. No significant adverse events were reported during this period and a reduction in ventilation and unit stay was observed. Quality improvement methods have facilitated successful and safe integration of a daily sedation hold protocol in our ICU.
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Bluhmki T, Dobler D, Beyersmann J, Pauly M. The wild bootstrap for multivariate Nelson-Aalen estimators. LIFETIME DATA ANALYSIS 2019; 25:97-127. [PMID: 29512005 PMCID: PMC6323102 DOI: 10.1007/s10985-018-9423-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/12/2017] [Accepted: 02/05/2018] [Indexed: 06/08/2023]
Abstract
We rigorously extend the widely used wild bootstrap resampling technique to the multivariate Nelson-Aalen estimator under Aalen's multiplicative intensity model. Aalen's model covers general Markovian multistate models including competing risks subject to independent left-truncation and right-censoring. This leads to various statistical applications such as asymptotically valid confidence bands or tests for equivalence and proportional hazards. This is exemplified in a data analysis examining the impact of ventilation on the duration of intensive care unit stay. The finite sample properties of the new procedures are investigated in a simulation study.
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Affiliation(s)
- Tobias Bluhmki
- Institute of Statistics, Ulm University, Helmholtzstrasse 20, 89081, Ulm, Germany
| | - Dennis Dobler
- Department of Mathematics, Vrije Universiteit Amsterdam, De Boelelaan 1081a, 1081 HV, Amsterdam, The Netherlands.
| | - Jan Beyersmann
- Institute of Statistics, Ulm University, Helmholtzstrasse 20, 89081, Ulm, Germany
| | - Markus Pauly
- Institute of Statistics, Ulm University, Helmholtzstrasse 20, 89081, Ulm, Germany
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Cruickshank M, Henderson L, MacLennan G, Fraser C, Campbell M, Blackwood B, Gordon A, Brazzelli M. Alpha-2 agonists for sedation of mechanically ventilated adults in intensive care units: a systematic review. Health Technol Assess 2017; 20:v-xx, 1-117. [PMID: 27035758 DOI: 10.3310/hta20250] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Care of critically ill patients in intensive care units (ICUs) often requires potentially invasive or uncomfortable procedures, such as mechanical ventilation (MV). Sedation can alleviate pain and discomfort, provide protection from stressful or harmful events, prevent anxiety and promote sleep. Various sedative agents are available for use in ICUs. In the UK, the most commonly used sedatives are propofol (Diprivan(®), AstraZeneca), benzodiazepines [e.g. midazolam (Hypnovel(®), Roche) and lorazepam (Ativan(®), Pfizer)] and alpha-2 adrenergic receptor agonists [e.g. dexmedetomidine (Dexdor(®), Orion Corporation) and clonidine (Catapres(®), Boehringer Ingelheim)]. Sedative agents vary in onset/duration of effects and in their side effects. The pattern of sedation of alpha-2 agonists is quite different from that of other sedatives in that patients can be aroused readily and their cognitive performance on psychometric tests is usually preserved. Moreover, respiratory depression is less frequent after alpha-2 agonists than after other sedative agents. OBJECTIVES To conduct a systematic review to evaluate the comparative effects of alpha-2 agonists (dexmedetomidine and clonidine) and propofol or benzodiazepines (midazolam and lorazepam) in mechanically ventilated adults admitted to ICUs. DATA SOURCES We searched major electronic databases (e.g. MEDLINE without revisions, MEDLINE In-Process & Other Non-Indexed Citations, EMBASE and Cochrane Central Register of Controlled Trials) from 1999 to 2014. METHODS Evidence was considered from randomised controlled trials (RCTs) comparing dexmedetomidine with clonidine or dexmedetomidine or clonidine with propofol or benzodiazepines such as midazolam, lorazepam and diazepam (Diazemuls(®), Actavis UK Limited). Primary outcomes included mortality, duration of MV, length of ICU stay and adverse events. One reviewer extracted data and assessed the risk of bias of included trials. A second reviewer cross-checked all the data extracted. Random-effects meta-analyses were used for data synthesis. RESULTS Eighteen RCTs (2489 adult patients) were included. One trial at unclear risk of bias compared dexmedetomidine with clonidine and found that target sedation was achieved in a higher number of patients treated with dexmedetomidine with lesser need for additional sedation. The remaining 17 trials compared dexmedetomidine with propofol or benzodiazepines (midazolam or lorazepam). Trials varied considerably with regard to clinical population, type of comparators, dose of sedative agents, outcome measures and length of follow-up. Overall, risk of bias was generally high or unclear. In particular, few trials blinded outcome assessors. Compared with propofol or benzodiazepines (midazolam or lorazepam), dexmedetomidine had no significant effects on mortality [risk ratio (RR) 1.03, 95% confidence interval (CI) 0.85 to 1.24, I (2) = 0%; p = 0.78]. Length of ICU stay (mean difference -1.26 days, 95% CI -1.96 to -0.55 days, I (2) = 31%; p = 0.0004) and time to extubation (mean difference -1.85 days, 95% CI -2.61 to -1.09 days, I (2) = 0%; p < 0.00001) were significantly shorter among patients who received dexmedetomidine. No difference in time to target sedation range was observed between sedative interventions (I (2) = 0%; p = 0.14). Dexmedetomidine was associated with a higher risk of bradycardia (RR 1.88, 95% CI 1.28 to 2.77, I (2) = 46%; p = 0.001). LIMITATIONS Trials varied considerably with regard to participants, type of comparators, dose of sedative agents, outcome measures and length of follow-up. Overall, risk of bias was generally high or unclear. In particular, few trials blinded assessors. CONCLUSIONS Evidence on the use of clonidine in ICUs is very limited. Dexmedetomidine may be effective in reducing ICU length of stay and time to extubation in critically ill ICU patients. Risk of bradycardia but not of overall mortality is higher among patients treated with dexmedetomidine. Well-designed RCTs are needed to assess the use of clonidine in ICUs and identify subgroups of patients that are more likely to benefit from the use of dexmedetomidine. STUDY REGISTRATION This study is registered as PROSPERO CRD42014014101. FUNDING The National Institute for Health Research Health Technology Assessment programme. The Health Services Research Unit is core funded by the Chief Scientist Office of the Scottish Government Health and Social Care Directorates.
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Affiliation(s)
| | - Lorna Henderson
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Graeme MacLennan
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Cynthia Fraser
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Marion Campbell
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Bronagh Blackwood
- Centre for Infection and Immunity, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, UK
| | - Anthony Gordon
- Faculty of Medicine, Department of Surgery and Cancer, Charing Cross Hospital, Imperial College London, London, UK
| | - Miriam Brazzelli
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
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15
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Sutton LJ, Jarden RJ. Improving the quality of nurse-influenced patient care in the intensive care unit. Nurs Crit Care 2016; 22:339-347. [PMID: 27976489 DOI: 10.1111/nicc.12266] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2016] [Revised: 08/10/2016] [Accepted: 09/19/2016] [Indexed: 11/29/2022]
Abstract
BACKGROUND Quality of care is a major focus in the intensive care unit (ICU). AIM To describe a nurse-initiated quality improvement (QI) project that improved the care of critically ill patients in a New Zealand tertiary ICU. DESIGN A framework for QI was developed and implemented as part of a practice change initiative. METHODS Audit data were collected, analysed and reported across seven nurse-influenced patient care standards. The seven standards were enteral nutrition delivered within 24 h of admission, timely administration of antibiotics, sedation holds for eligible patients, early mobilization and three pressure ulcer prevention strategies. RESULTS Comparison of audit data collected in 2014 and 2015 demonstrated improvements in five of the seven standards. Those standards with the largest practice improvements were related to the following standards: all eligible patients have enteral nutrition commenced within the first 24 h of ICU admission (3% increase); all eligible patients receive antibiotics within 30 min of prescription time (6% increase); all eligible patients have a daily sedation interruption (DSI; 24% increase); and all eligible patients are mobilized daily in their ICU stay (11% increase in percentage of patients mobilized daily). CONCLUSIONS The nursing-initiated QI project demonstrated improved ICU patient care in relation to early enteral nutrition commencement, DSIs and early and daily mobilizing. RELEVANCE TO CLINICAL PRACTICE The use of a nursing QI framework incorporating audit and feedback is one method of evaluating and enhancing the quality of care and improving patient outcomes. This initiative demonstrated the improved quality of nursing care for ICU patients, particularly in relation to early enteral nutrition commencement, timely antibiotics, DSIs and daily mobilizing. It is thus highly relevant to critical care nursing teams, particularly those working to create a culture where change is safe, achievable and valued.
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Affiliation(s)
- Lynsey J Sutton
- Wellington Regional Hospital, Intensive Care Unit, Intensive Care Services, Wellington Regional Hospital, Wellington, New Zealand.,Graduate School of Nursing Midwifery & Health (GSNMH), Victoria University of Wellington, New Zealand
| | - Rebecca J Jarden
- Department of Nursing, School of Clinical Sciences, Auckland University of Technology (AUT), Auckland, New Zealand
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16
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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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17
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Hutton B, Burry LD, Kanji S, Mehta S, Guenette M, Martin CM, Fergusson DA, Adhikari NK, Egerod I, Williamson D, Straus S, Moher D, Ely EW, Rose L. Comparison of sedation strategies for critically ill patients: a protocol for a systematic review incorporating network meta-analyses. Syst Rev 2016; 5:157. [PMID: 27646881 PMCID: PMC5029074 DOI: 10.1186/s13643-016-0338-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2016] [Accepted: 09/13/2016] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Sedatives and analgesics are administered to provide sedation and manage agitation and pain in most critically ill mechanically ventilated patients. Various sedation administration strategies including protocolized sedation and daily sedation interruption are used to mitigate drug pharmacokinetic limitations and minimize oversedation, thereby shortening the duration of mechanical ventilation. At present, it is unclear which strategy is most effective, as few have been directly compared. Our review will use network meta-analysis (NMA) to compare and rank sedation strategies to determine their efficacy and safety for mechanically ventilated patients. METHODS We will search the following from 1980 to March 2016: Ovid MEDLINE, CINAHL, Embase, PsycINFO, and Web of Science. We will also search the Cochrane Library, gray literature, and the International Clinical Trials Registry Platform. We will use a validated randomized control trial search filter to identify studies evaluating any strategy to optimize sedation in mechanically ventilated adult patients. Authors will independently extract data from eligible studies in duplicate and complete the Cochrane Risk of Bias tool. Our outcomes of interest include duration of mechanical ventilation, time to first extubation, ICU and hospital length of stay, re-intubation, tracheostomy, mortality, total sedative and opioid exposure, health-related quality of life, and adverse events. To inform our NMA, we will first conduct conventional pair-wise meta-analyses using random-effects models. Where appropriate, we will perform Bayesian NMA using WinBUGS software. DISCUSSION There are multiple strategies to optimize sedation for mechanically ventilated patients. Current ICU guidelines recommend protocolized sedation or daily sedation interruption. Our systematic review incorporating NMA will provide a unified analysis of all sedation strategies to determine the relative efficacy and safety of interventions that may not have been compared directly. We will provide knowledge users, decision makers, and professional societies with ranking of multiple sedation strategies to inform future sedation guidelines. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42016037480.
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Affiliation(s)
- Brian Hutton
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, The Ottawa Hospital, General Campus, 501 Smyth Rd, Ottawa, ON, K1H8L6, Canada. .,School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa, Ottawa, ON, Canada.
| | - Lisa D Burry
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada.,Department of Pharmacy, Mount Sinai Hospital, 600 University Avenue, Toronto, ON, M5G1X5, Canada
| | - Salmaan Kanji
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, The Ottawa Hospital, General Campus, 501 Smyth Rd, Ottawa, ON, K1H8L6, Canada.,Department of Pharmacy, The Ottawa Hospital, Ottawa, ON, Canada
| | - Sangeeta Mehta
- Department of Medicine, Interdepartmental Division of Critical Care, University of Toronto, Toronto, ON, Canada.,Department of Medicine, Division of Critical Care, Mount Sinai Hospital, Toronto, ON, Canada
| | - Melanie Guenette
- Department of Pharmacy, Mount Sinai Hospital, 600 University Avenue, Toronto, ON, M5G1X5, Canada
| | - Claudio M Martin
- Department of Medicine, Division of Critical Care, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada.,Lawson Health Research Institute, London Health Sciences Centre, London, ON, Canada
| | - Dean A Fergusson
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, The Ottawa Hospital, General Campus, 501 Smyth Rd, Ottawa, ON, K1H8L6, Canada.,Department of Medicine, University of Ottawa, Ottawa, ON, Canada.,Centre for Practice-Changing Research, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Neill K Adhikari
- Department of Medicine, Interdepartmental Division of Critical Care, University of Toronto, Toronto, ON, Canada.,Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.,Evaluative Clinical Sciences, Trauma, Emergency and Critical Care Research Program, Sunnybrook Research Institute, Toronto, ON, Canada
| | - Ingrid Egerod
- University of Copenhagen, Rigshospitalet, Neurointensive Intensive Care, Copenhagen O, Denmark
| | - David Williamson
- Faculté de Pharmacie, Université de Montréal, Montreal, QC, Canada.,Département de Pharmacie, Hôpital du Sacré-Coeur, Montreal, QC, Canada
| | - Sharon Straus
- Knowledge Translation Program, Li Ka Shing Knowledge Institute, Saint Michael's Hospital, Toronto, ON, Canada
| | - David Moher
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, The Ottawa Hospital, General Campus, 501 Smyth Rd, Ottawa, ON, K1H8L6, Canada.,School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa, Ottawa, ON, Canada.,Centre for Practice-Changing Research, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - E Wesley Ely
- Department of Medicine, Vanderbilt University Medical Center, Health Services Research Center, Nashville, TN, USA
| | - Louise Rose
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.,Evaluative Clinical Sciences, Trauma, Emergency and Critical Care Research Program, Sunnybrook Research Institute, Toronto, ON, Canada.,Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, ON, Canada.,Institute for Clinical Evaluative Sciences, Toronto, ON, Canada.,Provincial Centre of Weaning Excellence, Toronto East General Hospital, Toronto, ON, Canada
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18
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L’entraînement des muscles inspirateurs : une stratégie efficace dans le sevrage de la ventilation mécanique. MEDECINE INTENSIVE REANIMATION 2016. [DOI: 10.1007/s13546-015-1129-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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19
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Hjelmgren J, Bruce Wirta S, Huetson P, Myrén KJ, Göthberg S. Health economic modeling of the potential cost saving effects of Neurally Adjusted Ventilator Assist. Ther Adv Respir Dis 2016; 10:3-17. [PMID: 26424363 PMCID: PMC5933658 DOI: 10.1177/1753465815603659] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVES Asynchrony between patient and ventilator breaths is associated with increased duration of mechanical ventilation (MV). Neurally Adjusted Ventilatory Assist (NAVA) controls MV through an esophageal reading of diaphragm electrical activity via a nasogastric tube mounted with electrode rings. NAVA has been shown to decrease asynchrony in comparison to pressure support ventilation (PSV). The objective of this study was to conduct a health economic evaluation of NAVA compared with PSV. METHODS We developed a model based on an indirect link between improved synchrony with NAVA versus PSV and fewer days spent on MV in synchronous patients. Unit costs for MV were obtained from the Swedish intensive care unit register, and used in the model along with NAVA-specific costs. The importance of each parameter (proportion of asynchronous patients, costs, and average MV duration) for the overall results was evaluated through sensitivity analyses. RESULTS Base case results showed that 21% of patients ventilated with NAVA were asynchronous versus 52% of patients receiving PSV. This equals an absolute difference of 31% and an average of 1.7 days less on MV and a total cost saving of US$7886 (including NAVA catheter costs). A breakeven analysis suggested that NAVA was cost effective compared with PSV given an absolute difference in the proportion of asynchronous patients greater than 2.5% (49.5% versus 52% asynchronous patients with NAVA and PSV, respectively). The base case results were stable to changes in parameters, such as difference in asynchrony, duration of ventilation and daily intensive care unit costs. CONCLUSION This study showed economically favorable results for NAVA versus PSV. Our results show that only a minor decrease in the proportion of asynchronous patients with NAVA is needed for investments to pay off and generate savings. Future studies need to confirm this result by directly relating improved synchrony to the number of days on MV.
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Affiliation(s)
- Jonas Hjelmgren
- IMS Health HEOR, Sveavägen 155, Stockholm, Sweden Amgen (Europe) GmbH, Dammstrasse 23, Zug, Switzerland
| | | | | | - Karl-Johan Myrén
- IMS Health HEOR, Sveavägen 155, Stockholm, Sweden SOBI, Tomtebodavägen 23A, Solna, Sweden
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20
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Frade-Mera MJ, Regueiro-Díaz N, Díaz-Castellano L, Torres-Valverde L, Alonso-Pérez L, Landívar-Redondo MM, Muñoz-Pasín R, Terceros-Almanza LJ, Temprano-Vázquez S, Sánchez-Izquierdo-Riera JÁ. [A first step towards safer sedation and analgesia: A systematic evaluation of outcomes and level of sedation and analgesia in the mechanically ventilated critically ill patient]. ENFERMERIA INTENSIVA 2016; 27:155-167. [PMID: 26803376 DOI: 10.1016/j.enfi.2015.10.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2015] [Accepted: 10/19/2015] [Indexed: 10/22/2022]
Abstract
INTRODUCTION Safe analgesia and sedation strategies are necessary in order to avoid under or over sedation, as well as improving the comfort and safety of critical care patients. OBJECTIVES To compare and contrast a multidisciplinary protocol of systematic evaluation and management of analgesia and sedation in a group of critical care patients on mechanical ventilation with the usual procedures. MATERIALS AND METHODS A cohort study with contemporary series was conducted in a tertiary care medical-surgical ICU February to November during 2013 and 2014. The inclusion criteria were mechanical ventilation ≥ 24h and use of sedation by continuous infusion. Sedation was monitored using the Richmond agitation-sedation scale or bispectral index, and analgesia were measured using the numeric rating scale, or behavioural indicators of pain scale. The study variables included; mechanical ventilation time, weaning time, ventilation support time, artificial airway time, continuous sedative infusion time, daily dose and frequency of analgesic and sedative drug use, hospital stay, and ICU and hospital mortality, Richmond agitation-sedation scale, bispectral index, numeric rating scale, and behavioural indicators of pain scale measurements. Kruskal Wallis and Chi2, and a significance of p<.05 were used. RESULTS The study included 153 admissions, 75 pre-intervention and 78 post-intervention, with a mean age of 55.7±13 years old, and 67% men. Both groups showed similarities in age, reason for admission, and APACHE. There were non-significant decreases in mechanical ventilation time 4 (1.4-9.2) and 3.2 (1.4-8.1) days, respectively; p= 0.7, continuous sedative infusion time 6 (3-11) and 5 (3-11) days; p= 0.9, length of hospital stay 29 (18-52); 25 (14-41) days; p= 0.1, ICU mortality (8 vs. 5%; p= 0.4), and hospital mortality (10.6 vs. 9.4%: p= 0.8). Daily doses of midazolam and remifentanil decreased 347 (227-479) mg/day; 261 (159-358) mg/day; p= 0.02 and 2175 (1427-3285) mcg/day; 1500 (715-2740) mcg/day; p= 0.02, respectively. There were increases in the use of remifentanil (32% vs. 51%; p= 0.01), dexmedetomidine (0 vs.6%; p= 0.02), dexketoprofen (60 vs. 76%; p= 0.03), and haloperidol (15 vs.28%; p= 0.04). The use of morphine decreased (71 vs. 54%; p= 0.03). There was an increase in the number of measurements and Richmond agitation-sedation scale scores 6 (3-17); 21 (9-39); p< 0.0001, behavioural indicators of pain scale 6 (3-18); 19(8-33); p< 0.001 and numeric rating scale 4 (2-6); 8 (6-17); p< 0.0001. CONCLUSIONS The implementation of a multidisciplinary protocol of systematic evaluation of analgesia and sedation management achieved an improvement in monitoring and adequacy of dose to patient needs, leading to improved outcomes.
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Affiliation(s)
- M J Frade-Mera
- UCI Polivalente, Hospital Universitario 12 de Octubre, Madrid, España.
| | - N Regueiro-Díaz
- UCI Polivalente, Hospital Universitario 12 de Octubre, Madrid, España
| | - L Díaz-Castellano
- UCI Polivalente, Hospital Universitario 12 de Octubre, Madrid, España
| | - L Torres-Valverde
- UCI Polivalente, Hospital Universitario 12 de Octubre, Madrid, España
| | - L Alonso-Pérez
- UCI Polivalente, Hospital Universitario 12 de Octubre, Madrid, España
| | | | - R Muñoz-Pasín
- UCI Polivalente, Hospital Universitario 12 de Octubre, Madrid, España
| | - L J Terceros-Almanza
- Servicio de Medicina Intensiva, Hospital Universitario 12 de Octubre, Madrid, España
| | - S Temprano-Vázquez
- Servicio de Medicina Intensiva, Hospital Universitario 12 de Octubre, Madrid, España
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Sutherasan Y, Peñuelas O, Muriel A, Vargas M, Frutos-Vivar F, Brunetti I, Raymondos K, D'Antini D, Nielsen N, Ferguson ND, Böttiger BW, Thille AW, Davies AR, Hurtado J, Rios F, Apezteguía C, Violi DA, Cakar N, González M, Du B, Kuiper MA, Soares MA, Koh Y, Moreno RP, Amin P, Tomicic V, Soto L, Bülow HH, Anzueto A, Esteban A, Pelosi P. Management and outcome of mechanically ventilated patients after cardiac arrest. Crit Care 2015; 19:215. [PMID: 25953483 PMCID: PMC4457998 DOI: 10.1186/s13054-015-0922-9] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2015] [Accepted: 04/13/2015] [Indexed: 11/13/2022] Open
Abstract
Introduction The aim of this study was to describe and compare the changes in ventilator management and complications over time, as well as variables associated with 28-day hospital mortality in patients receiving mechanical ventilation (MV) after cardiac arrest. Methods We performed a secondary analysis of three prospective, observational multicenter studies conducted in 1998, 2004 and 2010 in 927 ICUs from 40 countries. We screened 18,302 patients receiving MV for more than 12 hours during a one-month-period. We included 812 patients receiving MV after cardiac arrest. We collected data on demographics, daily ventilator settings, complications during ventilation and outcomes. Multivariate logistic regression analysis was performed to calculate odds ratios, determining which variables within 24 hours of hospital admission were associated with 28-day hospital mortality and occurrence of acute respiratory distress syndrome (ARDS) and pneumonia acquired during ICU stay at 48 hours after admission. Results Among 812 patients, 100 were included from 1998, 239 from 2004 and 473 from 2010. Ventilatory management changed over time, with decreased tidal volumes (VT) (1998: mean 8.9 (standard deviation (SD) 2) ml/kg actual body weight (ABW), 2010: 6.7 (SD 2) ml/kg ABW; 2004: 9 (SD 2.3) ml/kg predicted body weight (PBW), 2010: 7.95 (SD 1.7) ml/kg PBW) and increased positive end-expiratory pressure (PEEP) (1998: mean 3.5 (SD 3), 2010: 6.5 (SD 3); P <0.001). Patients included from 2010 had more sepsis, cardiovascular dysfunction and neurological failure, but 28-day hospital mortality was similar over time (52% in 1998, 57% in 2004 and 52% in 2010). Variables independently associated with 28-day hospital mortality were: older age, PaO2 <60 mmHg, cardiovascular dysfunction and less use of sedative agents. Higher VT, and plateau pressure with lower PEEP were associated with occurrence of ARDS and pneumonia acquired during ICU stay. Conclusions Protective mechanical ventilation with lower VT and higher PEEP is more commonly used after cardiac arrest. The incidence of pulmonary complications decreased, while other non-respiratory organ failures increased with time. The application of protective mechanical ventilation and the prevention of single and multiple organ failure may be considered to improve outcome in patients after cardiac arrest. Electronic supplementary material The online version of this article (doi:10.1186/s13054-015-0922-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Yuda Sutherasan
- Department of Medicine, Ramathibodi Hospital, Mahidol University, RAMA VI road, Bangkok, 10400, Thailand. .,Department of Surgical Sciences and Integrated Diagnostics IRCCS AOU San Martino-IST, Largo Rosanna Benzi 8, Genoa, 16131, Italy.
| | - Oscar Peñuelas
- Hospital Universitario Infanta Cristina and CIBER Enfermedades Respiratorias, Avenida 9 de junio, 2, 28981, Parla, Madrid, Spain.
| | - Alfonso Muriel
- Biostatistics Unit, Ramón y Cajal Institute and Research Health, IRYCIS, CIBERESP, Hospital Ramón y Cajal Ctra., Colmenar Km 9.100, 28034, Madrid, Spain.
| | - Maria Vargas
- Department of Neurosciences, Odonthostomatological and Reproductive Sciences, University of Naples, "Federico II", Naples, 80100, Italy.
| | - Fernando Frutos-Vivar
- Hospital Universitario de Getafe and CIBER Enfermedades Respiratorias, Carretera de Toledo Km 12.500, 28905, Madrid, Spain.
| | - Iole Brunetti
- Department of Surgical Sciences and Integrated Diagnostics IRCCS AOU San Martino-IST, Largo Rosanna Benzi 8, Genoa, 16131, Italy.
| | - Konstantinos Raymondos
- Anaesthesiology and Intensive Care Medicine, Medical School Hanover, 544 Carl-Neuberg-Strasse 1, D-30625, Hanover, Germany.
| | - Davide D'Antini
- Dipartimento di Anestesia, Rianimazione e Terapia Intensiva, Universita' degli Studi di Foggia, Viale Pinto, 1, 71100, Foggia, Italy.
| | - Niklas Nielsen
- Department of Anesthesia and Intensive Care, Intensive Care Unit, Helsingborg Hospital, S Vallgatan 5, 251 87, Helsingborg, Sweden.
| | - Niall D Ferguson
- Interdepartmental Division of Critical Care Medicine, Department of Medicine, University of Toronto, University Health Network and Mount Sinai Hospital, 585 University Avenue, Toronto, M5G 2N2, ON, Canada.
| | - Bernd W Böttiger
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital of Cologne, Kerpener Straße 62, 50937, Köln, Germany.
| | - Arnaud W Thille
- Cenre Hospitalier Universitaire de Poitiers, Réanimation Médicale, INSERM CIC 1402, Université de Poitiers, Poitiers, 86000, France.
| | - Andrew R Davies
- Department of Epidemiology and Preventive Medicine, ANZIC-RC, Monash University, Commercial Road, Melbourne, 3004, Australia.
| | - Javier Hurtado
- Dept. Pathophysiology, Hospital de Clínicas, Av. Italia s/n. Universidad de la Republica, Montevideo, 11600, Uruguay.
| | - Fernando Rios
- Department of Intensive Care, Hospital Nacional Prof. Alejandro Posadas El Palomar, Buenos Aires, CP, 1684, Argentina.
| | - Carlos Apezteguía
- Department of Intensive Care, Hospital Nacional Prof. Alejandro Posadas El Palomar, Buenos Aires, CP, 1684, Argentina.
| | - Damian A Violi
- Medical Staff-Critical Care, Hospital Prof. Dr. Luis Guemes, Buenos Aires, Argentina.
| | - Nahit Cakar
- Anesthesiology and Intensive Care, Istanbul University, Istanbul Medical Faculty, Millet cad., 34093, Istanbul, Turkey.
| | - Marco González
- Clínica Medellín & Universidad Pontificia Bolivariana, Medellín, Colombia.
| | - Bin Du
- Medical ICU, Peking Union Medical College Hospital, 1 Shuai Fu Yuan, Beijing, 100730, People's Republic of China.
| | - Michael A Kuiper
- Department of Intensive Care, Medical Center Leeuwarden Henri Dunantweg 2, 8934, AD, Leeuwarden, The Netherlands.
| | | | - Younsuck Koh
- Department of Pulmonary and Critical Care Medicine Asan Medical Center, Univ. of Ulsan College of Medicine, 388-1 Pungnap Dong Songpa Ku Seoul, 138-736, Seoul, Republic of Korea.
| | - Rui P Moreno
- Unidade de Cuidados Intensivos Neurocríticos Hospital de São José Centro Hospitalarde Lisboa Central, E.P.E. R. José António Serrano, 1150-199, Lisbon, Portugal.
| | - Pravin Amin
- Bombay Hospital Institute of Medical Sciences, 12 New Marine Lines, Mumbai, 400020, India.
| | | | - Luis Soto
- Instituto Nacional del Tórax de Santiago, Santiago, Chile.
| | - Hans-Henrik Bülow
- Anaesthesiology and Intensive Care, Holbaek Hospitall, Region Zealand University of Copenhagen, Smedelundsgade, 60 4300, Holbaek, Denmark.
| | - Antonio Anzueto
- South Texas Veterans Health Care System and University of Texas Health Science Center, 111 E 7400 Merton Minter blvd, 78229, San Antonio, TX, USA.
| | - Andrés Esteban
- Hospital Universitario de Getafe and CIBER Enfermedades Respiratorias, Carretera de Toledo Km 12.500, 28905, Madrid, Spain.
| | - Paolo Pelosi
- Department of Surgical Sciences and Integrated Diagnostics IRCCS AOU San Martino-IST, Largo Rosanna Benzi 8, Genoa, 16131, Italy.
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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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Abstract
OBJECTIVE Delirium is common during critical illness and associated with adverse outcomes. We compared characteristics and outcomes of delirious and nondelirious patients enrolled in a multicenter trial comparing protocolized sedation with protocolized sedation plus daily sedation interruption. DESIGN Randomized trial. SETTING Sixteen North American medical and surgical ICUs. PATIENTS Four hundred thirty critically ill, mechanically ventilated adults. INTERVENTIONS All patients had hourly titration of opioid and benzodiazepine infusions using a validated sedation scale. For patients in the interruption group, infusions were resumed, if indicated, at half of previous doses. Delirium screening occurred daily; positive screening was defined as an Intensive Care Delirium Screening Checklist score of 4 or more at any time. MEASUREMENTS AND MAIN RESULTS Delirium was diagnosed in 226 of 420 assessed patients (53.8%). Coma was identified in 32.7% of delirious compared with 22.7% of nondelirious patients (p = 0.03). The median time to onset of delirium was 3.5 days (interquartile range, 2-7), and the median duration of delirium was 2 days (interquartile range, 1-4). Delirious patients were more likely to be male (61.1% vs 46.6%; p = 0.005), have a surgical/trauma diagnosis (21.2% vs 11.0%; p = 0.030), and history of tobacco (31.5% vs 16.2%; p = 0.002) or alcohol use (34.6% vs 20.9%; p = 0.009). Patients with positive delirium screening had longer duration of ventilation (13 vs 7 d; p < 0.001), ICU stay (12 vs 8 d; p < 0.0001), and hospital stay (24 vs 15 d; p < 0.0001). Delirious patients were more likely to be physically restrained (86.3% vs 76.7%; p = 0.014) and undergo tracheostomy (34.6% vs 15.5%; p < 0.0001). Antecedent factors independently associated with delirium onset were restraint use (hazard ratio, 1.87; 95% CI, 1.33-2.63; p = 0.0003), antipsychotic administration (hazard ratio, 1.67; 95% CI, 1.005-2.767; p = 0.047), and midazolam dose (hazard ratio, 0.998; 95% CI, 0.997-1.0; p = 0.049). There was no difference in delirium prevalence or duration between the interruption and control groups. CONCLUSION In mechanically ventilated adults, delirium was common and associated with longer duration of ventilation and hospitalization. Physical restraint was most strongly associated with delirium.
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Current practices and barriers impairing physicians' and nurses' adherence to analgo-sedation recommendations in the intensive care unit--a national survey. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2014; 18:655. [PMID: 25475212 PMCID: PMC4324789 DOI: 10.1186/s13054-014-0655-1] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/27/2014] [Accepted: 11/10/2014] [Indexed: 02/07/2023]
Abstract
Introduction Appropriate management of analgo-sedation in the intensive care unit (ICU) is associated with improved patient outcomes. Our objectives were: a) to describe utilization of analgo-sedation regimens and strategies (assessment using scales, protocolized analgo-sedation and daily sedation interruption (DSI)) and b) to describe and compare perceptions challenging utilization of these strategies, amongst physicians and nurses. Methods In the 101 adult ICUs in Belgium, we surveyed all physicians and a sample of seven nurses per ICU. A multidisciplinary team designed a survey tool based on a previous qualitative study and a literature review. The latter was available in paper (for nurses essentially) and web based (for physicians). Topics addressed included: practices, perceptions regarding recommended strategies and demographics. Pre-testing involved respondents’ debriefings and test re-test reliability. Four reminders were sent. Results Response rate was 60% (898/1,491 participants) representing 94% (95/101) of all hospitals. Protocols were available to 31% of respondents. Validated scales to monitor pain in patients unable to self-report and to monitor sedation were available to 11% and 75% of respondents, respectively. Frequency of use of sedation scales varied (never to hourly). More physicians than nurses agreed with statements reporting benefits of sedation scales, including: increased autonomy for nurses (82% versus 68%, P <0.001), enhancement of their role (84% versus 66%, P <0.001), aid in monitoring administration of sedatives (83% versus 68%, P <0.001), and cost control (54% versus 29%, P <0.001). DSI was used in less than 25% of patients for 75% of respondents. More nurses than physicians indicated DSI is contra-indicated in hemodynamic instability (66% versus 53%, P <0.001) and complicated weaning from mechanical ventilation (47% versus 29%, P <0.001). Conversely, more physicians than nurses indicated contra-indications including: seizures (56% versus 40%, P <0.001) and refractory intracranial hypertension (90% versus 83%, P <0.001). More nurses than physicians agreed with statements reporting DSI impairs patient comfort (60% versus 37%, P <0.001) and increases complications such as self-extubation (82% versus 69%, P <0.001). Conclusions Current analgo-sedation practices leave room for improvement. Physicians and nurses meet different challenges in using appropriate analgo-sedation strategies. Implementational interventions must be tailored according to profession. Electronic supplementary material The online version of this article (doi:10.1186/s13054-014-0655-1) contains supplementary material, which is available to authorized users.
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Chen HB, Liu J, Chen LQ, Wang GC. Effectiveness of daily interruption of sedation in sedated patients with mechanical ventilation in ICU: A systematic review. Int J Nurs Sci 2014. [DOI: 10.1016/j.ijnss.2014.10.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
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Flynn Makic MB. Daily sedation interruption: current state of the science. J Perianesth Nurs 2014; 29:501-3. [PMID: 25458630 DOI: 10.1016/j.jopan.2014.09.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2014] [Accepted: 09/25/2014] [Indexed: 10/24/2022]
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Halpern SD, Becker D, Curtis JR, Fowler R, Hyzy R, Kaplan LJ, Rawat N, Sessler CN, Wunsch H, Kahn JM. An Official American Thoracic Society/American Association of Critical-Care Nurses/American College of Chest Physicians/Society of Critical Care Medicine Policy Statement: The Choosing Wisely® Top 5 List in Critical Care Medicine. Am J Respir Crit Care Med 2014; 190:818-26. [DOI: 10.1164/rccm.201407-1317st] [Citation(s) in RCA: 104] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
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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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Optimizing the approach to pain, agitation, and delirium in critical care. Can J Anaesth 2014; 61:605-10. [PMID: 24798256 DOI: 10.1007/s12630-014-0175-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2014] [Accepted: 04/17/2014] [Indexed: 10/25/2022] Open
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Daily sedative interruption versus intermittent sedation in mechanically ventilated critically ill patients: a randomized trial. Ann Intensive Care 2014; 4:14. [PMID: 24900938 PMCID: PMC4026117 DOI: 10.1186/2110-5820-4-14] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2013] [Accepted: 04/17/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Daily sedative interruption and intermittent sedation are effective in abbreviating the time on mechanical ventilation. Whether one is superior to the other has not yet been determined. Our aim was to compare daily interruption and intermittent sedation during the mechanical ventilation period in a low nurse staffing ICU. METHODS Adult patients expected to need mechanical ventilation for more than 24 hours were randomly assigned, in a single center, either to daily interruption of continuous sedative and opioid infusion or to intermittent sedation. In both cases, our goal was to maintain a Sedation Agitation Scale (SAS) level of 3 or 4; that is patients should be calm, easily arousable or awakened with verbal stimuli or gentle shaking. Primary outcome was ventilator-free days in 28 days. Secondary outcomes were ICU and hospital mortality, incidence of delirium, nurse workload, self-extubation and psychological distress six months after ICU discharge. RESULTS A total of 60 patients were included. There were no differences in the ventilator-free days in 28 days between daily interruption and intermittent sedation (median: 24 versus 25 days, P = 0.160). There were also no differences in ICU mortality (40 versus 23.3%, P = 0.165), hospital mortality (43.3 versus 30%, P = 0.284), incidence of delirium (30 versus 40%, P = 0.472), self-extubation (3.3 versus 6.7%, P = 0.514), and psychological stress six months after ICU discharge. Also, the nurse workload was not different between groups, but it was reduced on day 5 compared to day 1 in both groups (Nurse Activity Score (NAS) in the intermittent sedation group was 54 on day 1 versus 39 on day 5, P < 0.001; NAS in daily interruption group was 53 on day 1 versus 38 on day 5, P < 0.001). Fentanyl and midazolam total dosages per patient were higher in the daily interruption group. The tidal volume was higher in the intermittent sedation group during the first five days of ICU stay. CONCLUSIONS There was no difference in the number of ventilator-free days in 28 days between both groups. Intermittent sedation was associated with lower sedative and opioid doses. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT00824239.
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Jagan P, Hariharan S, Chen D, Kumar AY. Do Sedation and Neuromuscular Blockade Influence the Outcome of Adult Intensive Care Patients? A Prospective Observational Study. J Intensive Care Soc 2014. [DOI: 10.1177/175114371401500208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
A prospective observational study was conducted on patients admitted to an adult intensive care unit (ICU) to investigate the pattern of sedation, analgesia and neuromuscular blockade and to determine their relationship to patient outcomes. Data including age, gender, diagnoses, dosage of sedatives, analgesics and neuromuscular blocking agents (NMBA), duration of mechanical ventilation, admission and weaning sedation scores, ICU length of stay and outcomes were recorded; 1550 patient-days were studied from 140 mechanically ventilated patients, of which 52 (37%) received NMBA. The mean length of stay in patients receiving NMBA was 15.6 days compared to 11.7 in patients who did not receive them (p=0.08). Mean duration of mechanical ventilation was 12.5 days in patients receiving NMBA, while it was 10.2 days in patients who did not receive NMBA (p=0.21). Neuromuscular blockade did not significantly influence the duration of mechanical ventilation, length of stay and survival of ICU patients.
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Affiliation(s)
- Pavani Jagan
- Consultant Anaesthetist, Port-of-Spain General Hospital, Trinidad
| | - Seetharaman Hariharan
- Professor, Anaesthesia and Critical Care Medicine Anaesthesia and Intensive Care Unit, Department of Clinical Surgical Sciences, The University of the West Indies, St. Augustine, Trinidad and Tobago
| | - Deryk Chen
- Associate Lecturer in Anaesthesia, Anaesthesia and Intensive Care Unit, Department of Clinical Surgical Sciences, The University of the West Indies, St. Augustine, Trinidad and Tobago
| | - Areti Y Kumar
- Professor of Anaesthesia and Intensive Care, Anaesthesia and Intensive Care Unit, Department of Clinical Surgical Sciences, The University of the West Indies, St. Augustine, Trinidad and Tobago
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Keough J, Nee PA. Daily Interruption of Sedation in Mechanically Ventilated Adults without Tracheostomy. J Intensive Care Soc 2014. [DOI: 10.1177/175114371401500213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
The use of sedative and analgesic dugs is essential in intensive care. The lowest effective doses should be used for the shortest period of time in order to limit the risk of serious complications. Daily interruption of sedation (DIS) is one strategy that has been shown to reduce overall sedative drug use and to promote earlier liberation from mechanical ventilation. However, uptake has been limited because of concerns over accidental removal of devices, the additional human resources required to accomplish the sedation break and the large numbers of patients who may be ineligible for the intervention. Some recent studies have challenged the usefulness of DIS and have promoted instead, nurse-controlled protocols and the use of sedation scoring tools. This review examines the evidence for and against DIS in the adult ICU setting.
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Affiliation(s)
- Jamie Keough
- Core Trainee, Year 1, Anaesthesia, Mersey Deanery
| | - Patrick A Nee
- Consultant in Emergency and Critical Care Medicine, Whiston Hospital, Merseyside; Visiting Professor of Emergency Medicine, Liverpool John Moores University
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Nilsen ML, Sereika SM, Hoffman LA, Barnato A, Donovan H, Happ MB. Nurse and patient interaction behaviors' effects on nursing care quality for mechanically ventilated older adults in the ICU. Res Gerontol Nurs 2014; 7:113-25. [PMID: 24496114 DOI: 10.3928/19404921-20140127-02] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2013] [Accepted: 12/05/2013] [Indexed: 01/26/2023]
Abstract
The study purposes were to (a) describe interaction behaviors and factors that may effect communication and (b) explore associations between interaction behaviors and nursing care quality indicators among 38 mechanically ventilated patients (age ≥60 years) and their intensive care unit nurses (n = 24). Behaviors were measured by rating videorecorded observations from the Study of Patient-Nurse Effectiveness with Communication Strategies (SPEACS). Characteristics and quality indicators were obtained from the SPEACS dataset and medical chart abstraction. All positive behaviors occurred at least once. Significant (p < 0.05) associations were observed between (a) positive nurse and positive patient behaviors, (b) patient unaided augmentative and alternative communication (AAC) strategies and positive nurse behaviors, (c) individual patient unaided AAC strategies and individual nurse positive behaviors, (d) positive nurse behaviors and pain management, and (e) positive patient behaviors and sedation level. Findings provide evidence that nurse and patient behaviors effect communication and may be associated with nursing care quality.
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Grant MJC, Balas MC, Curley MAQ. Defining sedation-related adverse events in the pediatric intensive care unit. Heart Lung 2014; 42:171-6. [PMID: 23643411 DOI: 10.1016/j.hrtlng.2013.02.004] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2012] [Revised: 02/25/2013] [Accepted: 02/27/2013] [Indexed: 11/16/2022]
Abstract
BACKGROUND Clinical trials exploring optimal sedation management in critically ill pediatric patients are urgently needed to improve both short- and long-term outcomes. Concise operational definitions that define and provide best-available estimates of sedation-related adverse events (AE) in the pediatric population are fundamental to this line of inquiry. OBJECTIVES To perform a multiphase systematic review of the literature to identify, define, and provide estimates of sedation-related AEs in the pediatric ICU setting for use in a multicenter clinical trial. METHODS In Phase One, we identified and operationally defined the AE. OVID-MEDLINE and CINAHL databases were searched from January 1998 to January 2012. Key terms included sedation, intensive and critical care. We limited our search to data-based clinical trials from neonatal to adult age. In Phase Two, we replicated the search strategy for all AEs and identified pediatric-specific AE rates. RESULTS We reviewed 20 articles identifying sedation-related adverse events and 64 articles on the pediatric-specific sedation-related AE. A total of eleven sedation-related AEs were identified, operationally defined and estimated pediatric event rates were derived. AEs included: inadequate sedation management, inadequate pain management, clinically significant iatrogenic withdrawal, unplanned endotracheal tube extubation, post-extubation stridor with chest-wall retractions at rest, extubation failure, unplanned removal of invasive tubes, ventilator-associated pneumonia, catheter-associated bloodstream infection, Stage II+ pressure ulcers and new tracheostomy. CONCLUSIONS Concise operational definitions that defined and provided best-available event rates of sedation-related AEs in the pediatric population are presented. Uniform reporting of adverse events will improve subject and patient safety.
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Affiliation(s)
- Mary Jo C Grant
- Pediatric Critical Care, Primary Children's Medical Center, 100 North Mario Capecchi Drive, Salt Lake City, UT 84113, USA.
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Clinical practice guidelines for evidence-based management of sedoanalgesia in critically ill adult patients. ACTA ACUST UNITED AC 2013. [DOI: 10.1016/j.medine.2013.04.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
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Abstract
OBJECTIVE The updated clinical practice guidelines for the management of pain, agitation, and delirium recommend either daily sedation interruption or maintaining light levels of sedation as methods to improve outcomes for patients who are sedated in the ICU. We review the evidence supporting both methods and discuss whether one method is preferable or if they should be used concurrently. DATA SOURCE Original research articles identified using the electronic PubMed database. STUDY SELECTION AND DATA EXTRACTION Randomized controlled trials and large prospective cohort studies of mechanically ventilated ICU patients requiring sedation were selected. DATA SYNTHESIS The methods of daily sedation interruption and targeting light sedation levels (including avoidance of deep sedation) are safe in critically ill patients with no increase, and a potential decrease, in long-term psychiatric disturbances. Randomized trials comparing these methods with standard care, which has traditionally involved moderate to heavy sedation, found that both methods reduced duration of mechanical ventilation and ICU length of stay. Additionally, one trial noted that daily sedation interruption paired with spontaneous breathing trials improved 1-year survival, whereas a large observational study found that deep sedation was associated with decreased 180-day survival. Two common characteristics of these interventions in trials showing benefits were avoidance of deep levels of sedation and significant reductions in sedative doses, especially benzodiazepines. Thus, combining targeted light sedation with daily sedation interruption may be more beneficial than either method alone if sedative doses are reduced and arousal and mobility are facilitated during the ICU stay. CONCLUSION Daily sedation interruption and targeting light sedation levels are safe and proven to improve outcomes for sedated ICU patients when these approaches result in reduced sedative exposure and facilitate arousal. It remains unclear as to whether one approach is superior, and further studies are needed to evaluate which patients benefit most from either or both techniques.
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Celis-Rodríguez E, Birchenall C, de la Cal M, Castorena Arellano G, Hernández A, Ceraso D, Díaz Cortés J, Dueñas Castell C, Jimenez E, Meza J, Muñoz Martínez T, Sosa García J, Pacheco Tovar C, Pálizas F, Pardo Oviedo J, Pinilla DI, Raffán-Sanabria F, Raimondi N, Righy Shinotsuka C, Suárez M, Ugarte S, Rubiano S. Guía de práctica clínica basada en la evidencia para el manejo de la sedoanalgesia en el paciente adulto críticamente enfermo. Med Intensiva 2013; 37:519-74. [DOI: 10.1016/j.medin.2013.04.001] [Citation(s) in RCA: 73] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2013] [Accepted: 04/16/2013] [Indexed: 01/18/2023]
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Prävention der nosokomialen beatmungsassoziierten Pneumonie. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2013. [DOI: 10.1007/s00103-013-1846-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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Aday AW, Dell'orfano H, Hirning BA, Matta L, O'Brien MH, Scirica BM, Avery KR, Morrow DA. Evaluation of a clinical pathway for sedation and analgesia of mechanically ventilated patients in a cardiac intensive care unit (CICU): The Brigham and Women's Hospital Levine CICU sedation pathways. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2013; 2:299-305. [PMID: 24338288 DOI: 10.1177/2048872613501986] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Intravenous sedation and analgesia are important therapies during mechanical ventilation (MV). However, daily interruption of these medications is associated with improved outcomes in mechanically ventilated patients. We tested a clinical pathway for the use of sedation and analgesia during MV in a cardiac intensive care unit (CICU). METHODS AND RESULTS We evaluated all mechanically ventilated patients in a CICU during two phases: phase 1 prior to pathway implementation (PRE) and phase 2 post-pathway implementation (POST). A total of 198 patients (98 PRE and 100 POST) and 1012 days of intubation (574 PRE and 434 POST) were included in this analysis. We found an increase in the frequency of daily interruptions of sedation post-implementation (49.3% PRE and 58.4% POST, p=0.0041). There was a significant decrease in the mean duration of MV in the POST vs PRE periods (5.0±2.3 vs 6.1±2.8 days, p=0.015). There was also a significant decrease in total neuroimaging studies (9 vs 49, p=0.001) and a trend toward a decrease in tracheostomies (3.0% vs 6.1%, p=0.33). Mean CICU length of stay (LOS) and hospital LOS respectively were 10.4 days and 16.8 days PRE and 10.4 days and 17.9 days POST (p=0.99 and p=0.55). Mortality did not differ (PRE 36.7% vs POST 32.0% p=0.55). CONCLUSIONS Implementation of a pragmatic pathway for sedation and analgesia in a CICU was associated with an increase in the daily interruption of sedation and a corresponding decrease in the duration of MV days and the need for neuroimaging.
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Affiliation(s)
- Aaron W Aday
- Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, USA
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Early Goal-Directed Sedation Versus Standard Sedation in Mechanically Ventilated Critically Ill Patients. Crit Care Med 2013; 41:1983-91. [DOI: 10.1097/ccm.0b013e31828a437d] [Citation(s) in RCA: 110] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Shehabi Y, Bellomo R, Mehta S, Riker R, Takala J. Intensive care sedation: the past, present and the future. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2013; 17:322. [PMID: 23758942 PMCID: PMC3706847 DOI: 10.1186/cc12679] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Despite the universal prescription of sedative drugs in the intensive care unit (ICU), current practice is not guided by high-level evidence. Landmark sedation trials have made significant contributions to our understanding of the problems associated with ICU sedation and have promoted changes to current practice. We identified challenges and limitations of clinical trials which reduced the generalizability and the universal adoption of key interventions. We present an international perspective regarding current sedation practice and a blueprint for future research, which seeks to avoid known limitations and generate much-needed high-level evidence to better guide clinicians' management and therapeutic choices of sedative agents.
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Porhomayon J, Nader ND, El-Solh AA, Hite M, Scott J, Silinskie K. Pre- and post-intervention study to assess the impact of a sedation protocol in critically ill surgical patients. J Surg Res 2013; 184:966-72.e4. [PMID: 23622725 DOI: 10.1016/j.jss.2013.03.065] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2012] [Revised: 02/08/2013] [Accepted: 03/20/2013] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Sedation and pain management for mechanically ventilated critically ill surgical patients pose many challenges for the intensivist. Even though daily interruption of sedatives and opioids is appropriate in medical intensive care unit (ICU) patients, it may not be feasible in the surgical patients with pain from surgical incision or trauma. Therefore we developed an analgesia/sedation based protocol for the surgical ICU population. METHODS We performed a two-phase prospective observational control study. We evaluated a prescriber driven analgesia/sedation protocol (ASP) in a 12-bed surgical ICU. The pre-ASP group was sedated as usual (n = 100) and the post-ASP group was managed with the new ASP (n = 100). Each phase of the study lasted for 5 mo. Comparisons between the two groups were performed by χ(2) or Fisher's exact test for categorical variables and the Mann-Whitney test for nonparametric variables. A P value <0.05 was statistically significant. RESULTS We found a significant reduction in the use of fentanyl (P < 0.001) and midazolam (P = 0.001). We achieved sedation goals of 86.8% in the post-ASP group compared to 74.4% in the pre-ASP (P < 0.001). Mean mechanical ventilations days in pre- and post-ASP group were 5.9 versus 3.8 (P = 0.033). CONCLUSION In our cohort of critically ill surgery patients implementation of an ASP resulted in reduced use of continuously infused benzodiazepines and opioids, a decline in cumulative benzodiazepine and analgesic dosages, and a greater percentage of Richmond Agitation Sedation Scale scores at goal. We also showed reduced mechanical ventilation days.
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Affiliation(s)
- Jahan Porhomayon
- VA Western New York Healthcare System & Rochester General Hospital, Division of Critical Care Medicine, Department of Anesthesiology & Surgery, State University of New York at Buffalo School of Medicine and Biomedical Sciences, Buffalo, New York.
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Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit. Crit Care Med 2013; 41:263-306. [PMID: 23269131 DOI: 10.1097/ccm.0b013e3182783b72] [Citation(s) in RCA: 2284] [Impact Index Per Article: 207.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVE To revise the "Clinical Practice Guidelines for the Sustained Use of Sedatives and Analgesics in the Critically Ill Adult" published in Critical Care Medicine in 2002. METHODS The American College of Critical Care Medicine assembled a 20-person, multidisciplinary, multi-institutional task force with expertise in guideline development, pain, agitation and sedation, delirium management, and associated outcomes in adult critically ill patients. The task force, divided into four subcommittees, collaborated over 6 yr in person, via teleconferences, and via electronic communication. Subcommittees were responsible for developing relevant clinical questions, using the Grading of Recommendations Assessment, Development and Evaluation method (http://www.gradeworkinggroup.org) to review, evaluate, and summarize the literature, and to develop clinical statements (descriptive) and recommendations (actionable). With the help of a professional librarian and Refworks database software, they developed a Web-based electronic database of over 19,000 references extracted from eight clinical search engines, related to pain and analgesia, agitation and sedation, delirium, and related clinical outcomes in adult ICU patients. The group also used psychometric analyses to evaluate and compare pain, agitation/sedation, and delirium assessment tools. All task force members were allowed to review the literature supporting each statement and recommendation and provided feedback to the subcommittees. Group consensus was achieved for all statements and recommendations using the nominal group technique and the modified Delphi method, with anonymous voting by all task force members using E-Survey (http://www.esurvey.com). All voting was completed in December 2010. Relevant studies published after this date and prior to publication of these guidelines were referenced in the text. The quality of evidence for each statement and recommendation was ranked as high (A), moderate (B), or low/very low (C). The strength of recommendations was ranked as strong (1) or weak (2), and either in favor of (+) or against (-) an intervention. A strong recommendation (either for or against) indicated that the intervention's desirable effects either clearly outweighed its undesirable effects (risks, burdens, and costs) or it did not. For all strong recommendations, the phrase "We recommend …" is used throughout. A weak recommendation, either for or against an intervention, indicated that the trade-off between desirable and undesirable effects was less clear. For all weak recommendations, the phrase "We suggest …" is used throughout. In the absence of sufficient evidence, or when group consensus could not be achieved, no recommendation (0) was made. Consensus based on expert opinion was not used as a substitute for a lack of evidence. A consistent method for addressing potential conflict of interest was followed if task force members were coauthors of related research. The development of this guideline was independent of any industry funding. CONCLUSION These guidelines provide a roadmap for developing integrated, evidence-based, and patient-centered protocols for preventing and treating pain, agitation, and delirium in critically ill patients.
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Riessen R. Tägliche Sedierungspausen bei maschinell beatmeten Intensivpatienten zusätzlich zu einer Protokoll-basierten Sedierung. Med Klin Intensivmed Notfmed 2013; 108:153-5. [DOI: 10.1007/s00063-012-0210-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2013] [Accepted: 01/28/2013] [Indexed: 10/27/2022]
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Affiliation(s)
- John P Kress
- Department of Medicine, Section of Pulmonary and Critical Care, University of Chicago, Chicago, IL.
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Sedation depth and long-term mortality in mechanically ventilated critically ill adults: a prospective longitudinal multicentre cohort study. Intensive Care Med 2013; 39:910-8. [PMID: 23344834 PMCID: PMC3625407 DOI: 10.1007/s00134-013-2830-2] [Citation(s) in RCA: 225] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2012] [Accepted: 12/22/2012] [Indexed: 11/29/2022]
Abstract
Purpose To ascertain the relationship among early (first 48 h) deep sedation, time to extubation, delirium and long-term mortality. Methods We conducted a multicentre prospective longitudinal cohort study in 11 Malaysian hospitals including medical/surgical patients (n = 259) who were sedated and ventilated ≥24 h. Patients were followed from ICU admission up to 28 days in ICU with 4-hourly sedation and daily delirium assessments and 180-day mortality. Deep sedation was defined as Richmond Agitation Sedation Score (RASS) ≤−3. Results The cohort had a mean (SD) age of 53.1 (15.9) years and APACHE II score of 21.3 (8.2) with hospital and 180-day mortality of 82 (31.7 %) and 110/237 (46.4 %). Patients were followed for 2,657 ICU days and underwent 13,836 RASS assessments. Midazolam prescription was predominant compared to propofol, given to 241 (93 %) versus 72 (28 %) patients (P < 0.0001) for 966 (39.6 %) versus 183 (7.5 %) study days respectively. Deep sedation occurred in (182/257) 71 % patients at first assessment and in 159 (61 %) patients and 1,658 (59 %) of all RASS assessments at 48 h. Multivariable Cox proportional hazard regression analysis adjusting for a priori assigned covariates including sedative agents, diagnosis, age, APACHE II score, operative, elective, vasopressors and dialysis showed that early deep sedation was independently associated with longer time to extubation [hazard ratio (HR) 0.93, 95 % confidence interval (CI) 0.89–0.97, P = 0.003], hospital death (HR 1.11, 95 % CI 1.05–1.18, P < 0.001) and 180-day mortality (HR 1.09, 95 % CI 1.04–1.15, P = 0.002), but not time to delirium (HR 0.98, P = 0.23). Delirium occurred in 114 (44 %) of patients. Conclusion Irrespective of sedative choice, early deep sedation was independently associated with delayed extubation and higher mortality, and thus was a potentially modifiable risk in interventional trials.
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Roberts DJ, Haroon B, Hall RI. Sedation for critically ill or injured adults in the intensive care unit: a shifting paradigm. Drugs 2012; 72:1881-916. [PMID: 22950534 DOI: 10.2165/11636220-000000000-00000] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
As most critically ill or injured patients will require some degree of sedation, the goal of this paper was to comprehensively review the literature associated with use of sedative agents in the intensive care unit (ICU). The first and selected latter portions of this article present a narrative overview of the shifting paradigm in ICU sedation practices, indications for uninterrupted or prolonged ICU sedation, and the pharmacology of sedative agents. In the second portion, we conducted a structured, although not entirely systematic, review of the available evidence associated with use of alternative sedative agents in critically ill or injured adults. Data sources for this review were derived by searching OVID MEDLINE and PubMed from their first available date until May 2012 for relevant randomized controlled trials (RCTs), systematic reviews and/or meta-analyses and economic evaluations. Advances in the technology of mechanical ventilation have permitted clinicians to limit the use of sedation among the critically ill through daily sedative interruptions or other means. These practices have been reported to result in improved mortality, a decreased length of ICU and hospital stay and a lower risk of drug-associated delirium. However, in some cases, prolonged or uninterrupted sedation may still be indicated, such as when patients develop intracranial hypertension following traumatic brain injury. The pharmacokinetics of sedative agents have clinical importance and may be altered by critical illness or injury, co-morbid conditions and/or drug-drug interactions. Although use of validated sedation scales to monitor depth of sedation is likely to reduce adverse events, they have no utility for patients receiving neuromuscular receptor blocking agents. Depth of sedation monitoring devices such as the Bispectral Index (BIS©) also have limitations. Among existing RCTs, no sedative agent has been reported to improve the risk of mortality among the critically ill or injured. Moreover, although propofol may be associated with a shorter time to tracheal extubation and recovery from sedation than midazolam, the risk of hypertriglyceridaemia and hypotension is higher with propofol. Despite dexmedetomidine being linked with a lower risk of drug-associated delirium than alternative sedative agents, this drug increases risk of bradycardia and hypotension. Among adults with severe traumatic brain injury, there are insufficient data to suggest that any single sedative agent decreases the risk of subsequent poor neurological outcomes or mortality. The lack of examination of confounders, including the type of healthcare system in which the investigation was conducted, is a major limitation of existing pharmacoeconomic analyses, which likely limits generalizability of their results.
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Affiliation(s)
- Derek J Roberts
- Departments of Surgery, Community Health Sciences (Division of Epidemiology) and Critical Care Medicine, University of Calgary and the Foothills Medical Centre, Calgary, AB, Canada
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Vinayak AG. Rebuttal From Dr Vinayak. Chest 2012. [DOI: 10.1378/chest.12-1998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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Shehabi Y, Bellomo R, Reade MC, Bailey M, Bass F, Howe B, McArthur C, Seppelt IM, Webb S, Weisbrodt L. Early Intensive Care Sedation Predicts Long-Term Mortality in Ventilated Critically Ill Patients. Am J Respir Crit Care Med 2012; 186:724-31. [DOI: 10.1164/rccm.201203-0522oc] [Citation(s) in RCA: 344] [Impact Index Per Article: 28.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Chanques G, Conseil M, Coisel Y, Carr J, Jung B, Jaber S. Sédation-analgésie en réanimation : arrêt quotidien par les médecins ou gestion continue par les infirmières. MEDECINE INTENSIVE REANIMATION 2012. [DOI: 10.1007/s13546-012-0511-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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