1
|
Forehand C, Keats K, Amerine LB, Sikora A. Rethinking justifications for critical care pharmacist positions: Translating bedside evidence to the C-suite. Am J Health Syst Pharm 2023; 80:1275-1279. [PMID: 37254868 DOI: 10.1093/ajhp/zxad122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Indexed: 06/01/2023] Open
Affiliation(s)
- Christy Forehand
- Department of Pharmacy, Augusta University Medical Center, Augusta, GA, and Department of Clinical and Administrative Pharmacy, University of Georgia College of Pharmacy, Augusta, GA, USA
| | - Kelli Keats
- Department of Pharmacy, Augusta University Medical Center, Augusta, GA, USA
| | - Lindsey B Amerine
- Department of Pharmacy, University of North Carolina Medical Center, Morrisville, NC, USA
| | - Andrea Sikora
- Department of Pharmacy, Augusta University Medical Center, Augusta, GA, and Department of Clinical and Administrative Pharmacy, University of Georgia College of Pharmacy, Augusta, GA, USA
| |
Collapse
|
2
|
Pluenneke JC, Semler MW, Casey JD, Qian ET, Rice TW, Stollings JL. Quantifying Critical Care Pharmacist Interventions in COVID-19. J Intensive Care Med 2023; 38:651-656. [PMID: 36755415 PMCID: PMC9912037 DOI: 10.1177/08850666231156551] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Revised: 01/24/2023] [Accepted: 01/26/2023] [Indexed: 02/10/2023]
Abstract
Purpose/Background: Pharmacists have been shown to play an important role in the medication management of critically ill patients. Pharmacist interventions in the care of critically ill patients with coronavirus disease 2019 (COVID-19) have not been quantitatively described. Methodology: A single center, retrospective, observational study was conducted at Vanderbilt University Medical Center in Nashville, Tennessee. All adult patients admitted to the COVID-19 intensive care unit (ICU) or Medical ICU with a COVID-19 diagnosis between March 1, 2020, and June 30, 2021, were included. All interventions made by pharmacists were documented electronically, collected, categorized, and analyzed. The primary outcome of this study was the median number of interventions by pharmacists per patient. The secondary outcome was the number of different types of interventions performed. Results: A total of 768 patients were included in the analysis. The median age was 63 years old; 63% of patients were male and 71% were Caucasian. Median hospital length of stay (LOS) was 12 days (interquartile range (IQR) 7-21) and ICU LOS was 5 days (IQR 1-11). The median Sequential Organ Failure Assessment score was 4 (IQR 2-7) and Charlson Comorbidity Index was 3 (IQR 2-5). Mortality at 60 days occurred in 352 patients (46%). Pharmacists performed a total of 7027 interventions for 655 patients with a median number of pharmacist interventions per patient of 6 (IQR 3-14). The most common pharmacist interventions were medication discontinuation (24%), completion of components of the ICU liberation bundle (19%), medication dose adjustment (18%), therapeutic drug monitoring (15%), and medication initiation (10%). Conclusions: Pharmacists made multiple interventions related to medication use and management in critically ill patients with COVID-19. This study adds important information of the evolving role clinical pharmacists play in the care of critical illness, specifically during the COVID-19 pandemic.
Collapse
Affiliation(s)
- Jack C. Pluenneke
- Department of Pharmaceutical Services, Vanderbilt University Medical Center, Nashville, TN, USA
- Vanderbilt University Medical Center, Nashville, TN, USA
| | - Matthew W. Semler
- Vanderbilt University Medical Center, Nashville, TN, USA
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jonathan D. Casey
- Vanderbilt University Medical Center, Nashville, TN, USA
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Edward T. Qian
- Vanderbilt University Medical Center, Nashville, TN, USA
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Todd W. Rice
- Vanderbilt University Medical Center, Nashville, TN, USA
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Joanna L. Stollings
- Department of Pharmaceutical Services, Vanderbilt University Medical Center, Nashville, TN, USA
- Vanderbilt University Medical Center, Nashville, TN, USA
- Critical Illness Brain Dysfunction Survivorship Center, Nashville, TN, USA
| |
Collapse
|
3
|
Schmidt LE, Patel S, Stollings JL. The pharmacist's role in implementation of the ABCDEF bundle into clinical practice. Am J Health Syst Pharm 2021; 77:1751-1762. [PMID: 32789461 DOI: 10.1093/ajhp/zxaa247] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
PURPOSE To summarize published data regarding implementation of the ABCDEF bundle, a multicomponent process for avoidance of oversedation and prolonged ventilation in intensive care unit (ICU) patients; discuss pertinent literature to support each bundle element; and discuss the role of the pharmacist in coordinating bundle elements and implementation of the ABCDEF bundle into clinical practice. SUMMARY Neuromuscular weakness and ICU-acquired weakness are common among critically ill patients and associated with significant cost and societal burdens. Recent literature supporting early liberation from mechanical ventilation and early mobilization has demonstrated improved short- and long-term outcomes. With expanded use of pharmacy services in the ICU setting, pharmacists are well positioned to advocate for best care practices in ICUs. A dedicated, interprofessional team is necessary for the implementation of the ABCDEF bundle in inpatient clinical practice settings. As evidenced by a number of studies, successful implementation of the ABCDEF bundle derives from involvement by motivated and highly trained individuals, timely completion of individual patient care tasks, and effective leadership to ensure proper implementation and ongoing support. Factors commonly identified by clinicians as barriers to bundle implementation in clinical practice include patient instability and safety concerns, lack of knowledge, staff concerns, unclear protocol criteria, and lack of interprofessional team care coordination. This narrative review discusses research on bundle elements and recommendations for application by pharmacists in clinical practice. CONCLUSIONS Despite the benefits associated with implementation of the ABCDEF bundle, evidence suggests that the recommended interventions may not be routinely used within the ICU. The pharmacist provides the expertise and knowledge for adoption of the bundle into everyday clinical practice.
Collapse
Affiliation(s)
- Lauren E Schmidt
- Department of Pharmacy, Penn Presbyterian Medical Center, Philadelphia, PA
| | - Sneha Patel
- Department of Pharmaceutical Services, Vanderbilt University Medical Center, Nashville, TN
| | - Joanna L Stollings
- Department of Pharmaceutical Services, Vanderbilt University Medical Center, Nashville, TN.,Critical Illness, Brain Dysfunction and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, TN
| |
Collapse
|
4
|
Sanz Perl Y, Bocaccio H, Pallavicini C, Pérez-Ipiña I, Laureys S, Laufs H, Kringelbach M, Deco G, Tagliazucchi E. Nonequilibrium brain dynamics as a signature of consciousness. Phys Rev E 2021; 104:014411. [PMID: 34412335 DOI: 10.1103/physreve.104.014411] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Accepted: 06/29/2021] [Indexed: 12/15/2022]
Abstract
The cognitive functions of human and nonhuman primates rely on the dynamic interplay of distributed neural assemblies. As such, it seems unlikely that cognition can be supported by macroscopic brain dynamics at the proximity of equilibrium. We confirmed this hypothesis by investigating electrocorticography data from nonhuman primates undergoing different states of unconsciousness (sleep, and anesthesia with propofol, ketamine, and ketamine plus medetomidine), and functional magnetic resonance imaging data from humans, both during deep sleep and under propofol anesthesia. Systematically, all states of reduced consciousness unfolded at higher proximity to equilibrium compared to conscious wakefulness, as demonstrated by the computation of entropy production and the curl of probability flux in phase space. Our results establish nonequilibrium macroscopic brain dynamics as a robust signature of consciousness, opening the way for the characterization of cognition and awareness using tools from statistical mechanics.
Collapse
Affiliation(s)
- Yonatan Sanz Perl
- Universidad de San Andrés, Buenos Aires, B1644BID, Argentina.,Physics Department, University of Buenos Aires, and Buenos Aires Physics Institute, Buenos Aires 1428, Argentina.,Center for Brain and Cognition, Computational Neuroscience Group, Universitat Pompeu Fabra, Barcelona 08002, Spain
| | - Hernán Bocaccio
- Physics Department, University of Buenos Aires, and Buenos Aires Physics Institute, Buenos Aires 1428, Argentina
| | - Carla Pallavicini
- Physics Department, University of Buenos Aires, and Buenos Aires Physics Institute, Buenos Aires 1428, Argentina
| | - Ignacio Pérez-Ipiña
- Physics Department, University of Buenos Aires, and Buenos Aires Physics Institute, Buenos Aires 1428, Argentina
| | - Steven Laureys
- Coma Science Group, GIGA Consciousness, University of Liège, 4000 Liège, Belgium
| | - Helmut Laufs
- Department of Neurology, Christian Albrechts University Kiel, 24118 Kiel, Germany
| | - Morten Kringelbach
- Department of Psychiatry, University of Oxford, Oxford OX12JD, United Kingdom
| | - Gustavo Deco
- Center for Brain and Cognition, Computational Neuroscience Group, Universitat Pompeu Fabra, Barcelona 08002, Spain
| | - Enzo Tagliazucchi
- Physics Department, University of Buenos Aires, and Buenos Aires Physics Institute, Buenos Aires 1428, Argentina.,Latin American Brain Health Institute (BrainLat), Universidad Adolfo Ibañez, Santiago 7910000, Chile
| |
Collapse
|
5
|
Sanz Perl Y, Pallavicini C, Pérez Ipiña I, Demertzi A, Bonhomme V, Martial C, Panda R, Annen J, Ibañez A, Kringelbach M, Deco G, Laufs H, Sitt J, Laureys S, Tagliazucchi E. Perturbations in dynamical models of whole-brain activity dissociate between the level and stability of consciousness. PLoS Comput Biol 2021; 17:e1009139. [PMID: 34314430 PMCID: PMC8315553 DOI: 10.1371/journal.pcbi.1009139] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2020] [Accepted: 06/01/2021] [Indexed: 01/07/2023] Open
Abstract
Consciousness transiently fades away during deep sleep, more stably under anesthesia, and sometimes permanently due to brain injury. The development of an index to quantify the level of consciousness across these different states is regarded as a key problem both in basic and clinical neuroscience. We argue that this problem is ill-defined since such an index would not exhaust all the relevant information about a given state of consciousness. While the level of consciousness can be taken to describe the actual brain state, a complete characterization should also include its potential behavior against external perturbations. We developed and analyzed whole-brain computational models to show that the stability of conscious states provides information complementary to their similarity to conscious wakefulness. Our work leads to a novel methodological framework to sort out different brain states by their stability and reversibility, and illustrates its usefulness to dissociate between physiological (sleep), pathological (brain-injured patients), and pharmacologically-induced (anesthesia) loss of consciousness.
Collapse
Affiliation(s)
- Yonatan Sanz Perl
- Department of Physics, University of Buenos Aires, Intendente Güiraldes 2160—Ciudad Universitaria—Buenos Aires, Argentina
- National Scientific and Technical Research Council (CONICET), CABA, Buenos Aires, Argentina
- Cognitive Neuroscience Center (CNC), Universidad de San Andrés, Buenos Aires, Argentina
- Center for Brain and Cognition, Computational Neuroscience Group, Universitat Pompeu Fabra, Barcelona, Spain
- * E-mail: (YSP); (ET)
| | - Carla Pallavicini
- Department of Physics, University of Buenos Aires, Intendente Güiraldes 2160—Ciudad Universitaria—Buenos Aires, Argentina
- National Scientific and Technical Research Council (CONICET), CABA, Buenos Aires, Argentina
- Fundación para la Lucha contra las Enfermedades Neurológicas de la Infancia (FLENI), Buenos Aires, Argentina
| | - Ignacio Pérez Ipiña
- Department of Physics, University of Buenos Aires, Intendente Güiraldes 2160—Ciudad Universitaria—Buenos Aires, Argentina
- Fundación para la Lucha contra las Enfermedades Neurológicas de la Infancia (FLENI), Buenos Aires, Argentina
| | - Athena Demertzi
- Physiology of Cognition Research Lab, GIGA-Consciousness, GIGA Institute, University of Liège, Liège, Belgium
| | - Vincent Bonhomme
- Anesthesia and Intensive Care Laboratory, GIGA-Consciousness, GIGA Institute, University of Liège, Liège, Belgium
- University Department of Anesthesia and Intensive Care Medicine, Centre Hospitalier Régional de la Citadelle (CHR Citadelle), Liège, Belgium
- Department of Anesthesia and Intensive Care Medicine, Centre Hospitalier Universitaire de Liège (CHU Liège), Liège, Belgium
| | - Charlotte Martial
- Coma Science Group, GIGA Consciousness, University of Liège, Liège, Belgium
- Centre du Cerveau², Centre Hospitalier Universitaire de Liège (CHU Liège), Liège, Belgium
| | - Rajanikant Panda
- Coma Science Group, GIGA Consciousness, University of Liège, Liège, Belgium
- Centre du Cerveau², Centre Hospitalier Universitaire de Liège (CHU Liège), Liège, Belgium
| | - Jitka Annen
- Coma Science Group, GIGA Consciousness, University of Liège, Liège, Belgium
- Centre du Cerveau², Centre Hospitalier Universitaire de Liège (CHU Liège), Liège, Belgium
| | - Agustin Ibañez
- National Scientific and Technical Research Council (CONICET), CABA, Buenos Aires, Argentina
- Cognitive Neuroscience Center (CNC), Universidad de San Andrés, Buenos Aires, Argentina
- Latin American Brain Health Institute (BrainLat), Universidad Adolfo Ibáñez, Santiago, Chile
- Global Brain Health Institute (GBHI), University of California-San Francisco (UCSF), San Francisco, California, United States and Trinity College Dublin, Ireland
| | - Morten Kringelbach
- Department of Psychiatry, University of Oxford, Oxford, United Kingdom
- Center for Music in the Brain, Department of Clinical Medicine, Aarhus University, Århus, Denmark
- Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga, Portugal
- Centre for Eudaimonia and Human Flourishing, University of Oxford, Oxford, United Kingdom
| | - Gustavo Deco
- Center for Brain and Cognition, Computational Neuroscience Group, Universitat Pompeu Fabra, Barcelona, Spain
- Department of Information and Communication Technologies, Universitat Pompeu Fabra, Barcelona, Spain
- Institució Catalana de la Recerca i Estudis Avançats (ICREA), Barcelona, Spain
- Department of Neuropsychology, Max Planck Institute for Human Cognitive and Brain Sciences, Leipzig, Germany
- School of Psychological Sciences, Monash University, Melbourne, Australia
| | - Helmut Laufs
- Department of Neurology and Brain Imaging Center, Goethe University, Frankfurt am Main, Germany
- Department of Neurology, Christian Albrechts University, Kiel, Germany
| | - Jacobo Sitt
- Institut du Cerveau et de la Moelle épinière, ICM, Paris, France
- Inserm U 1127, Paris, France
- CNRS UMR 7225, Paris, France
| | - Steven Laureys
- Coma Science Group, GIGA Consciousness, University of Liège, Liège, Belgium
- Centre du Cerveau², Centre Hospitalier Universitaire de Liège (CHU Liège), Liège, Belgium
| | - Enzo Tagliazucchi
- Department of Physics, University of Buenos Aires, Intendente Güiraldes 2160—Ciudad Universitaria—Buenos Aires, Argentina
- National Scientific and Technical Research Council (CONICET), CABA, Buenos Aires, Argentina
- Latin American Brain Health Institute (BrainLat), Universidad Adolfo Ibáñez, Santiago, Chile
- Department of Neurology, Christian Albrechts University, Kiel, Germany
- * E-mail: (YSP); (ET)
| |
Collapse
|
6
|
Abstract
OBJECTIVES To provide a multiorganizational statement to update recommendations for critical care pharmacy practice and make recommendations for future practice. A position paper outlining critical care pharmacist activities was last published in 2000. Since that time, significant changes in healthcare and critical care have occurred. DESIGN The Society of Critical Care Medicine, American College of Clinical Pharmacy Critical Care Practice and Research Network, and the American Society of Health-Systems Pharmacists convened a joint task force of 15 pharmacists representing a broad cross-section of critical care pharmacy practice and pharmacy administration, inclusive of geography, critical care practice setting, and roles. The Task Force chairs reviewed and organized primary literature, outlined topic domains, and prepared the methodology for group review and consensus. A modified Delphi method was used until consensus (> 66% agreement) was reached for each practice recommendation. Previous position statement recommendations were reviewed and voted to either retain, revise, or retire. Recommendations were categorized by level of ICU service to be applicable by setting and grouped into five domains: patient care, quality improvement, research and scholarship, training and education, and professional development. MAIN RESULTS There are 82 recommendation statements: 44 original recommendations and 38 new recommendation statements. Thirty-four recommendations represent the domain of patient care, primarily relating to critical care pharmacist duties and pharmacy services. In the quality improvement domain, 21 recommendations address the role of the critical care pharmacist in patient and medication safety, clinical quality programs, and analytics. Nine recommendations were made in the domain of research and scholarship. Ten recommendations were made in the domain of training and education and eight recommendations regarding professional development. CONCLUSIONS Critical care pharmacists are essential members of the multiprofessional critical care team. The statements recommended by this taskforce delineate the activities of a critical care pharmacist and the scope of pharmacy services within the ICU. Effort should be made from all stakeholders to implement the recommendations provided, with continuous effort toward improving the delivery of care for critically ill patients.
Collapse
|
7
|
Temesgen N, Chekol B, Tamirie T, Eshetie D, Simeneh N, Feleke A. Adult sedation and analgesia in a resource limited intensive care unit - A Systematic Review and evidence based guideline. Ann Med Surg (Lond) 2021; 66:102356. [PMID: 34035907 PMCID: PMC8138481 DOI: 10.1016/j.amsu.2021.102356] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 04/15/2021] [Accepted: 04/25/2021] [Indexed: 12/04/2022] Open
Abstract
Background Sedation and analgesia are essential in the intensive care unit in order to promote control of pain, anxiety, prevent loss of materials, accidental extubation and improve the synchrony of patients with ventilator. However, excess of these medications leads to an increased morbidity and mortality, and thus demands protocol. Methods Preferred Reporting Items for Systematic Reviews and the Meta-Analysis Protocol have been used to undertake this review. Pub Med, Cochrane Library, and Google Scholar search engines were used to find up-to-date evidence that helps to draw recommendations and conclusions. Results In this Guideline and Systematic Review, we have used 16 Systemic Review and Meta-Analysis, 3 Evidence-Based Guidelines and 10 RCT Meta-Analysis, 6 Systemic Reviews of Non-randomized Studies, 8 Randomized Clinical Trials, 11 Cohort Studies, 5 Cross-Sectional Studies and 1 Case Report with their respective study descriptions. Discussion Analgesia, which as a sedation basement can reduce sedative use, is key aspect of treatment in ICU patients, and we can also conclude that an analgesic sedation regimen can reduce the occurrence of delirium by reducing sedatives. The aim of this guideline and the systematic review is to write up and formulate analgesia-based sedation for limited resource settings. Conclusions Analgesia and sedation are effective in critically ill patients; however, too much sedation is associated with longer periods of mechanical ventilation and longer duration of ICU stay. Poorly managed ICU patients have a delirium rate of up to 80%, increased mortality, longer hospital stays, higher hospital costs and bad long-term outcomes. Critically ill patients shall be awake, alert without pain, anxiety and delirium. Analgesia and sedation in the ICU shall be given as per needed after determined they are in need of. Sedation breaks are paramount important as equal as spontaneous breathing trials. Unnecessary deep sedations will increase hospital and personnel costs by increasing length of ICU stay.
Collapse
Affiliation(s)
- Netsanet Temesgen
- Debre Tabor University, College of Health Sciences, School of Medicine, Department of Anesthesia, Ethiopia
| | - Bsazinew Chekol
- Debre Tabor University, College of Health Sciences, School of Medicine, Department of Anesthesia, Ethiopia
| | - Tadesse Tamirie
- Debre Tabor University, College of Health Sciences, School of Medicine, Department of Anesthesia, Ethiopia
| | - Denberu Eshetie
- Debre Tabor University, College of Health Sciences, School of Medicine, Department of Anesthesia, Ethiopia
| | - Nigussie Simeneh
- University of Gondar, College of Medicine and Health Sciences, Department of Anesthesia and Critical Care, Ethiopia
| | - Abatneh Feleke
- University of Gondar, College of Medicine and Health Sciences, Department of Anesthesia and Critical Care, Ethiopia
| |
Collapse
|
8
|
Perl YS, Bocaccio H, Pérez-Ipiña I, Zamberlán F, Piccinini J, Laufs H, Kringelbach M, Deco G, Tagliazucchi E. Generative Embeddings of Brain Collective Dynamics Using Variational Autoencoders. PHYSICAL REVIEW LETTERS 2020; 125:238101. [PMID: 33337222 DOI: 10.1103/physrevlett.125.238101] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Revised: 09/29/2020] [Accepted: 10/26/2020] [Indexed: 06/12/2023]
Abstract
We consider the problem of encoding pairwise correlations between coupled dynamical systems in a low-dimensional latent space based on few distinct observations. We use variational autoencoders (VAEs) to embed temporal correlations between coupled nonlinear oscillators that model brain states in the wake-sleep cycle into a two-dimensional manifold. Training a VAE with samples generated using two different parameter combinations results in an embedding that encodes the repertoire of collective dynamics, as well as the topology of the underlying connectivity network. We first follow this approach to infer the trajectory of brain states measured from wakefulness to deep sleep from the two end points of this trajectory; then, we show that the same architecture was capable of representing the pairwise correlations of generic Landau-Stuart oscillators coupled by complex network topology.
Collapse
Affiliation(s)
- Yonatan Sanz Perl
- Universidad de San Andrés, Buenos Aires 1644, Argentina
- Physics Department, University of Buenos Aires and Buenos Aires Physics Institute, Buenos Aires 1428, Argentina
- Center for Brain and Cognition, Computational Neuroscience Group, Universitat Pompeu Fabra, Barcelona 08002, Spain
| | - Hernán Bocaccio
- Physics Department, University of Buenos Aires and Buenos Aires Physics Institute, Buenos Aires 1428, Argentina
| | - Ignacio Pérez-Ipiña
- Physics Department, University of Buenos Aires and Buenos Aires Physics Institute, Buenos Aires 1428, Argentina
| | - Federico Zamberlán
- Physics Department, University of Buenos Aires and Buenos Aires Physics Institute, Buenos Aires 1428, Argentina
| | - Juan Piccinini
- Physics Department, University of Buenos Aires and Buenos Aires Physics Institute, Buenos Aires 1428, Argentina
| | - Helmut Laufs
- Department of Neurology, Christian-Albrechts-University Kiel, Kiel 24118, Germany
| | - Morten Kringelbach
- Department of Psychiatry, University of Oxford, Oxford 2JD, United Kingdom
| | - Gustavo Deco
- Center for Brain and Cognition, Computational Neuroscience Group, Universitat Pompeu Fabra, Barcelona 08002, Spain
| | - Enzo Tagliazucchi
- Physics Department, University of Buenos Aires and Buenos Aires Physics Institute, Buenos Aires 1428, Argentina
| |
Collapse
|
9
|
Mohammad RA, Betthauser KD, Korona RB, Coe AB, Kolpek JH, Fritschle AC, Jagow B, Kenes M, MacTavish P, Slampak‐Cindric AA, Whitten JA, Jones C, Simonelli R, Rowlands I, Stollings JL. Clinical pharmacist services within intensive care unit recovery clinics: An opinion of the critical care practice and research network of the American College of Clinical Pharmacy. JOURNAL OF THE AMERICAN COLLEGE OF CLINICAL PHARMACY 2020. [DOI: 10.1002/jac5.1311] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- Rima A. Mohammad
- Department of Clinical Pharmacy University of Michigan College of Pharmacy Ann Arbor Michigan USA
| | - Kevin D. Betthauser
- Department of Pharmacy Services Barnes‐Jewish Hospital Saint Louis Missouri USA
| | | | - Antoinette B. Coe
- Department of Clinical Pharmacy University of Michigan College of Pharmacy Ann Arbor Michigan USA
| | | | | | - Benjamin Jagow
- Department of Pharmacy MercyOne Des Moines Medical Center Des Moines Iowa USA
| | - Michael Kenes
- Department of Clinical Pharmacy University of Michigan College of Pharmacy Ann Arbor Michigan USA
| | | | | | | | - Carol Jones
- Department of Pharmacy Guy's and St. Thomas' NHS Foundation Trust London UK
| | | | - Ian Rowlands
- Department of Pharmacy Barts Health NHS Trust London UK
| | - Joanna L. Stollings
- Department of Pharmacy and Critical Illness Brain Dysfunction, Survivorship (CIBS) Center, Vanderbilt University Medical Center Nashville Tennessee USA
| |
Collapse
|
10
|
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.
Collapse
|
11
|
|
12
|
Brophy A, Cardinale M, Andrews LB, Kaplan JB, Adams C, Opsha Y, Brandt KA, Dixit D, Nerenberg SF, Saleh JA. Prospective Observational Evaluation of Sedation and Pain Management Guideline Adherence Across New Jersey Intensive Care Units. J Pharm Pract 2018; 32:529-533. [PMID: 29685062 DOI: 10.1177/0897190018770549] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND The practice guidelines for the management of pain, agitation, and delirium (PAD) from the Society of Critical Care Medicine shifted from primarily focusing on the treatment of anxiety in 2002 to the treatment of pain in 2013. OBJECTIVE This prospective, observational, multicenter study aimed to assess the degree of practice adherence to the PAD guidelines for ventilated patients in New Jersey intensive care units (ICUs). METHODS Pharmacist investigators at 8 centers designated 4 days at least 10 days apart to evaluate all patients on mechanical ventilation. The primary outcomes included adherence to 4 guideline recommendations: treatment of pain before sedation, use of nonnarcotic analgesic medications, use of nonbenzodiazepine sedative medications, and use of goal-directed sedation. RESULTS Of 138 patients evaluated, 50% had a primary medical diagnosis (as opposed to surgical, cardiac, or neurological diagnosis), and the median Sequential Organ Failure Assessment (SOFA) score was 7. Pain was treated prior to administration of sedatives in 55.4% of subjects, with fentanyl being the primary analgesic used. In addition, 19% received no analgesia, and 11.5% received nonopioid analgesia. Sedative agents were administered to 87 subjects (48 nonbenzodiazepine and 39 benzodiazepine). Of those receiving benzodiazepines, 22 received intermittent bolus regimens and 16 received continuous infusions, of which 5 were for another indication besides sedation. Validated scales measuring the degree of sedation were completed at least once in 56 (81.6%) patients receiving sedatives. CONCLUSIONS Current sedation practices suggest that integration of evidence-based PAD guidelines across New Jersey adult ICUs is inconsistent despite pharmacist involvement.
Collapse
Affiliation(s)
- Alison Brophy
- Saint Barnabas Medical Center, RWJBarnabas Health, Livingston, NJ, USA
| | - Maria Cardinale
- Department of Pharmacy Practice and Administration, Ernest Mario School of Pharmacy Rutgers, The State University of New Jersey, Piscataway, NJ, USA.,Saint Peter's University Hospital, New Brunswick, NJ, USA
| | - Liza B Andrews
- Department of Pharmacy Practice and Administration, Ernest Mario School of Pharmacy Rutgers, The State University of New Jersey, Piscataway, NJ, USA.,Robert Wood Johnson University Hospital Hamilton, RWJBarnabas Health, Hamilton, NJ, USA
| | - Justin B Kaplan
- Department of Pharmacy, Hackensack University Medical Center, Hackensack, NJ, USA
| | - Christopher Adams
- Department of Pharmacy Practice and Administration, Ernest Mario School of Pharmacy Rutgers, The State University of New Jersey, Piscataway, NJ, USA.,Robert Wood Johnson University Hospital Somerset, RWJBarnabas Health, Somerset, NJ, USA
| | - Yekaterina Opsha
- Saint Barnabas Medical Center, RWJBarnabas Health, Livingston, NJ, USA.,Department of Pharmacy Practice and Administration, Ernest Mario School of Pharmacy Rutgers, The State University of New Jersey, Piscataway, NJ, USA
| | - Kimberly A Brandt
- Department of Pharmacy, Novant Health Huntersville Medical Center, Huntersville, NC, USA
| | - Deepali Dixit
- Department of Pharmacy Practice and Administration, Ernest Mario School of Pharmacy Rutgers, The State University of New Jersey, Piscataway, NJ, USA.,Robert Wood Johnson University Hospital, RWJBarnabas Health, New Brunswick, NJ, USA
| | - Steven F Nerenberg
- Department of Pharmacy Practice and Administration, Ernest Mario School of Pharmacy Rutgers, The State University of New Jersey, Piscataway, NJ, USA.,Department of Pharmacy, St. Joseph's Regional Medical Center, Paterson, NJ, USA
| | - Julie A Saleh
- Department of Pharmacy Practice and Administration, Ernest Mario School of Pharmacy Rutgers, The State University of New Jersey, Piscataway, NJ, USA.,Monmouth Medical Center, RWJBarnabasHealth, Long Branch, NJ, USA
| |
Collapse
|
13
|
Stollings JL, Bloom SL, Wang L, Ely EW, Jackson JC, Sevin CM. Critical Care Pharmacists and Medication Management in an ICU Recovery Center. Ann Pharmacother 2018; 52:713-723. [PMID: 29457491 DOI: 10.1177/1060028018759343] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Many patients experience complications following critical illness; these are now widely referred to as post-intensive care syndrome (PICS). An interprofessional intensive care unit (ICU) recovery center (ICU-RC), also known as a PICS clinic, is one potential approach to promoting patient and family recovery following critical illness. OBJECTIVES To describe the role of an ICU-RC critical care pharmacist in identifying and treating medication-related problems among ICU survivors. METHODS A prospective, observational cohort study was conducted of all outpatient appointments of a tertiary care hospital's ICU-RC between July 2012 and December 2015. The pharmacist completed a full medication review, including medication reconciliation, interview, counseling, and resultant interventions, during the ICU-RC appointment. RESULTS Data from all completed ICU-RC visits were analyzed (n = 62). A full medication review was performed in 56 (90%) of these patients by the pharmacist. The median number of pharmacy interventions per patient was 4 (interquartile range = 2, 5). All 56 patients had at least 1 pharmacy intervention; 22 (39%) patients had medication(s) stopped at the clinic appointment, and 18 (32%) patients had new medication(s) started. The pharmacist identified 9 (16%) patients who had an adverse drug event (ADE); 18 (32%) patients had ADE preventive measures instituted. An influenza vaccination was administered to 13 (23%) patients despite an inpatient protocol to ensure influenza vaccination prior to discharge. A pneumococcal vaccination was administered to 2 (4%) patients. CONCLUSIONS Use of a critical care pharmacist resulted in the identification and treatment of multiple medication-related problems in an ICU-RC as well as implementation of preventive measures.
Collapse
Affiliation(s)
| | - Sarah L Bloom
- 1 Vanderbilt University Medical Center, Nashville, TN, USA
| | - Li Wang
- 1 Vanderbilt University Medical Center, Nashville, TN, USA
| | - E Wesley Ely
- 1 Vanderbilt University Medical Center, Nashville, TN, USA.,2 Department of Veterans Affairs Medical Center Tennessee Valley Healthcare System, Nashville, TN, USA
| | - James C Jackson
- 2 Department of Veterans Affairs Medical Center Tennessee Valley Healthcare System, Nashville, TN, USA.,3 Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Carla M Sevin
- 1 Vanderbilt University Medical Center, Nashville, TN, USA
| |
Collapse
|
14
|
Altawalbeh SM, Saul MI, Seybert AL, Thorpe JM, Kane-Gill SL. Intensive care unit drug costs in the context of total hospital drug expenditures with suggestions for targeted cost containment efforts. J Crit Care 2017; 44:77-81. [PMID: 29073536 DOI: 10.1016/j.jcrc.2017.10.029] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2017] [Revised: 10/13/2017] [Accepted: 10/18/2017] [Indexed: 10/18/2022]
Abstract
PURPOSE To assess costs of intensive care unit (ICU) related pharmacotherapy relative to hospital drug expenditures, and to identify potential targets for cost-effectiveness investigations. We offer the unique advantage of comparing ICU drug costs with previously published data a decade earlier to describe changes over time. MATERIALS AND METHODS Financial transactions for all ICU patients during fiscal years (FY) 2009-2012 were retrieved from the hospital's data repository. ICU drug costs were evaluated for each FY. ICU departments' charges were also retrieved and calculated as percentages of total ICU charges. RESULTS Albumin, prismasate (dialysate), voriconazole, factor VII and alteplase denoted the highest percentages of ICU drug costs. ICU drug costs contributed to an average of 31% (SD 1.0%) of the hospital's total drug costs. ICU drug costs per patient day increased by 5.8% yearly versus 7.8% yearly for non-ICU drugs. This rate was higher for ICU drugs costs at 12% a decade previous. Pharmacy charges contributed to 17.7% of the total ICU charges. CONCLUSIONS Growth rates of costs per year have declined but still drug expenditures in the ICU are consistently a significant driver in this resource intensive environment with a high impact on hospital drug expenditures.
Collapse
Affiliation(s)
- Shoroq M Altawalbeh
- Department of Pharmacy and Therapeutics, School of Pharmacy, University of Pittsburgh, Pittsburgh, PA, United States; Department of Clinical Pharmacy, School of Pharmacy, Jordan University of Science and Technology, Irbid, Jordan
| | - Melissa I Saul
- School of Medicine, University of Pittsburgh, Pittsburgh, PA, United States
| | - Amy L Seybert
- Department of Pharmacy and Therapeutics, School of Pharmacy, University of Pittsburgh, Pittsburgh, PA, United States; UPMC, Department of Pharmacy, Pittsburgh, PA, United States
| | - Joshua M Thorpe
- Department of Pharmacy and Therapeutics, School of Pharmacy, University of Pittsburgh, Pittsburgh, PA, United States
| | - Sandra L Kane-Gill
- Department of Pharmacy and Therapeutics, School of Pharmacy, University of Pittsburgh, Pittsburgh, PA, United States; UPMC, Department of Pharmacy, Pittsburgh, PA, United States.
| |
Collapse
|
15
|
Schneider R, Puetz A, Vassiliou T, Wiesmann T, Lewan U, Wulf H, Bartsch DK, Rolfes C. The Benefit of Benzodiazepine Reduction: Improving Sedation in Surgical Intensive Care. Indian J Crit Care Med 2017; 21:274-280. [PMID: 28584430 PMCID: PMC5455020 DOI: 10.4103/ijccm.ijccm_67_17] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Aims: Sedation, as it is often required in critical care, is associated with immobilization, prolonged ventilation, and increased morbidity. Most sedation protocols are based on benzodiazepines. The presented study analyzes the benefit of benzodiazepine-free sedation. Methods: In 2008, 134 patients were treated according to a protocol using benzodiazepine and propofol (Group 1). In 2009, we introduced a new sedation strategy based on sufentanil, nonsteroidal anti-inflammatory drugs, neuroleptics, and antidepressants, which was applied in 140 consecutive patients (Group 2). Depth of sedation, duration of mechanical ventilation, duration of Intensive Care Unit, and hospital stay were analyzed. Results: Group 1 had both a longer duration of deep sedation (18.7 ± 2.5 days vs. 12.6 ± 1.85 days, P = 0.031) and a longer duration of controlled ventilation (311, 35 ± 32.69 vs. 143, 96 ± 20.76 h, P < 0.0001) than Group 2. Ventilator days were more frequent in Group 1 (653, 66 ± 98.37 h vs. 478, 89 ± 68.92 h, P = 0.128). Conclusions: The benzodiazepine-free sedation protocol has been shown to significantly reduce depth of sedation and controlled ventilation. Additional evidence is needed to ascertain reduction of ventilator days which would not only be of benefit for the patient but also for the hospital Management.
Collapse
Affiliation(s)
- Ralph Schneider
- Department of Visceral, Thoracic and Vascular Surgery, Philipps University Marburg, Germany
| | - Andreas Puetz
- Department of Anaesthesiology and Intensive Care Therapy, Philipps University Marburg, Germany
| | - Timon Vassiliou
- Department of Anaesthesiology and Intensive Care Therapy, Philipps University Marburg, Germany
| | - Thomas Wiesmann
- Department of Anaesthesiology and Intensive Care Therapy, Philipps University Marburg, Germany
| | - Ulrike Lewan
- Department of Anaesthesiology and Intensive Care Therapy, Philipps University Marburg, Germany
| | - Hinnerk Wulf
- Department of Anaesthesiology and Intensive Care Therapy, Philipps University Marburg, Germany
| | - Detlef K Bartsch
- Department of Visceral, Thoracic and Vascular Surgery, Philipps University Marburg, Germany
| | - Caroline Rolfes
- Department of Anaesthesiology and Intensive Care Therapy, Philipps University Marburg, Germany.,Clinic of Anesthesiology and Intensive Care Medicine, University of Cologne, Germany
| |
Collapse
|
16
|
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.
Collapse
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
| |
Collapse
|
17
|
Benedict N, Hess MM. History and future of critical care pharmacy practice. Am J Health Syst Pharm 2016; 72:2101-5. [PMID: 26581938 DOI: 10.2146/ajhp150638] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Affiliation(s)
- Neal Benedict
- Neal Benedict, Pharm.D., is Associate Professor, Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, and Critical Care Pharmacist, UPMC Presbyterian-Shadyside, Pittsburgh, PA. Mary M. Hess, Pharm.D., FASHP, FCCM, FCCP, is Associate Dean, Student Affairs, and Professor of Pharmacy Practice, Jefferson College of Pharmacy, Thomas Jefferson University, Philadelphia, PA
| | - Mary M Hess
- Neal Benedict, Pharm.D., is Associate Professor, Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, and Critical Care Pharmacist, UPMC Presbyterian-Shadyside, Pittsburgh, PA. Mary M. Hess, Pharm.D., FASHP, FCCM, FCCP, is Associate Dean, Student Affairs, and Professor of Pharmacy Practice, Jefferson College of Pharmacy, Thomas Jefferson University, Philadelphia, PA.
| |
Collapse
|
18
|
MacLaren R, Toombs LK, Plamondon JM, Rocker GM, Patrick WD, Hall RI. Implementing Protocol-Based Therapy of Continuous Neuromuscular Blockade Provides Cost Minimization. J Pharm Technol 2016. [DOI: 10.1177/875512250101700204] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Objective: To compare empiric and protocol-based therapies of neuromuscular blockade in terms of cost and control of paralysis. Methods: Data were prospectively collected for nine months before and five months after a protocol was implemented in the 24-bed medical/surgical/neurologic intensive care unit as a physician-initiated, doublesided medication order form. Pancuronium was the preferred agent and vecuronium was an alternative for patients with renal dysfunction, hepatic dysfunction, or hemodynamic instability. Results: Twenty-nine empiric-therapy patients and 17 protocol-based therapy patients were comparatively evaluated. Length of stay in the intensive care unit and duration of neuromuscular blockade were similar between groups. Protocol adherence rate was 76.5%. Protocol-based therapy increased the hourly dose of pancuronium (0.29 ± 0.37 mg vs. 0.02 ± 0.10 mg; p < 0.005) and reduced the mean hourly cost of neuromuscular blockade compared with empiric therapy ($5.11 ± 4.76 Canadian [CDN] vs. $9.03 ± 7.03 CDN; p < 0.05). Vecuronium use did not change, but rocuronium and atracurium were not given after protocol implementation. The proportion of recorded train-of-four measurements representing adequate neuromuscular blockade increased (52.3% vs. 32.7%; p < 0.05) with protocol-based therapy. Conclusions: Compliance with a neuromuscular blocking protocol reduces drug costs and improves control of neuromuscular blockade.
Collapse
Affiliation(s)
- Robert MacLaren
- ROBERT MacLAREN PharmD, Assistant Professor, School of Pharmacy, University of Colorado Health Sciences Center, Denver, CO
| | - L Kent Toombs
- L KENT TOOMBS BSC (Pharm), Staff Pharmacist, Department of Pharmacy, Queen Elizabeth II Health Sciences Centre, Halifax, Nova Scotia, Canada
| | - Johanna M Plamondon
- JOHANNA M PLAMONDON BSc (Pharm), Staff Pharmacist, Department of Pharmacy, Queen Elizabeth II Health Sciences Centre
| | - Graeme M Rocker
- GRAEME M ROCKER MA DM FRCP FRCPC, Respirologist, Department of Respirology, Queen Elizabeth II Health Sciences Centre
| | - Ward D Patrick
- WARD D PATRICK MD FRCPC, Internist, Department of Medicine, Queen Elizabeth II Health Sciences Centre
| | - Richard I Hall
- RICHARD I HALL MD FRCPC FCCP, Director, Department of Intensive Care Services, Queen Elizabeth II Health Sciences Centre
| |
Collapse
|
19
|
Improved analgesia, sedation, and delirium protocol associated with decreased duration of delirium and mechanical ventilation. Ann Am Thorac Soc 2014; 11:367-74. [PMID: 24597599 DOI: 10.1513/annalsats.201306-210oc] [Citation(s) in RCA: 74] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
RATIONALE Introduction of sedation protocols has been associated with improved patient outcomes. It is not known if an update to an existing high-quality sedation protocol, featuring increased patient assessment and reduced benzodiazepine exposure, is associated with improved patient process and outcome quality metrics. METHODS This was an observational before (n = 703) and after (n = 780) cohort study of mechanically ventilated patients in a 24-bed trauma-surgical intensive care unit (ICU) from 2009 to 2011. The three main protocol updates were: (1) requirement to document Richmond Agitation Sedation Scale (RASS) scores every 4 hours, (2) requirement to document Confusion Assessment Method-ICU (CAM ICU) twice daily, and (3) systematic, protocolized deescalation of excess sedation. Multivariable linear regression was used for the primary analysis. The primary outcome was the duration of mechanical ventilation. Prespecified secondary endpoints included days of delirium; the frequency of patient assessment with the RASS and CAM-ICU instruments; benzodiazepine dosing; durations of mechanical ventilation, ICU stay, and hospitalization; and hospital mortality and ventilator associated pneumonia rate. RESULTS Patients in the updated protocol cohort had 1.22 more RASS assessments per day (5.38 vs. 4.16; 95% confidence interval [CI], 1.05-1.39; P < 0.01) and 1.15 more CAM-ICU assessments per day (1.49 vs. 0.35; 95% CI, 1.08-1.21; P < 0.01) than the baseline cohort. The mean hourly benzodiazepine dose decreased by 34.8% (0.08 mg lorazepam equivalents/h; 0.15 vs. 0.23; P < 0.01). In the multivariable model, the median duration of mechanical ventilation decreased by 17.6% (95% CI, 0.6-31.7%; P = 0.04). The overall odds ratio of delirium was 0.67 (95% CI, 0.49-0.91; P = 0.01) comparing updated versus baseline cohort. A 12.4% reduction in median duration of ICU stay (95% CI, 0.5-22.8%; P = 0.04) and a 14.0% reduction in median duration of hospitalization (95% CI, 2.0-24.5%; P = 0.02) were also seen. No significant association with mortality (odds ratio, 1.18; 95% CI, 0.80-1.76; P = 0.40) was seen. CONCLUSIONS Implementation of an updated ICU analgesia, sedation, and delirium protocol was associated with an increase in RASS and CAM-ICU assessment and documentation; reduced hourly benzodiazepine dose; and decreased delirium and median durations of mechanical ventilation, ICU stay, and hospitalization.
Collapse
|
20
|
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
|
21
|
Chawla R, Myatra SN, Ramakrishnan N, Todi S, Kansal S, Dash SK. Current practices of mobilization, analgesia, relaxants and sedation in Indian ICUs: A survey conducted by the Indian Society of Critical Care Medicine. Indian J Crit Care Med 2014; 18:575-84. [PMID: 25249742 PMCID: PMC4166873 DOI: 10.4103/0972-5229.140146] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Background and Aim: Use of sedation, analgesia and neuromuscular blocking agents is widely practiced in Intensive Care Units (ICUs). Our aim is to study the current practice patterns related to mobilization, analgesia, relaxants and sedation (MARS) to help in standardizing best practices in these areas in the ICU. Materials and Methods: A web-based nationwide survey involving physicians of the Indian Society of Critical Care Medicine (ISCCM) and the Indian Society of Anesthesiologists (ISA) was carried out. A questionnaire included questions on demographics, assessment scales for delirium, sedation and pain, as also the pharmacological agents and the practice methods. Results: Most ICUs function in a semi-closed model. Midazolam (94.99%) and Fentanyl (47.04%) were the most common sedative and analgesic agents used, respectively. Vecuronium was the preferred neuromuscular agent. Monitoring of sedation, analgesia and delirium in the ICU. Ramsay's Sedation Scale (56.1%) and Visual Analogue Scale (48.07%) were the preferred sedation and pain scales, respectively. CAM (Confusion Assessment Method)-ICU was the most preferred method of delirium assessment. Haloperidol was the most commonly used agent for delirium. Majority of the respondents were aware of the benefit of early mobilization, but lack of support staff and safety concerns were the main obstacles to its implementation. Conclusion: The results of the survey suggest that compliance with existing guidelines is low. Benzodiazepines still remain the predominant ICU sedative. The recommended practice of giving analgesia before sedation is almost non-existent. Delirium remains an underrecognized entity. Monitoring of sedation levels, analgesia and delirium is low and validated and recommended scales for the same are rarely used. Although awareness of the benefits of early mobilization are high, the implementation is low.
Collapse
Affiliation(s)
- Rajesh Chawla
- Department of Critical Care Medicine, Indraprastha Apollo Hospital, New Delhi, India
| | - Sheila Nainan Myatra
- Department of Anaesthesia, Critical Care and Pain, Tata Memorial Hospital, Mumbai, India
| | | | - Subhash Todi
- Department of Critical Care Medicine, Vision Care Hospital, Mukundpur, Kolkata, India
| | - Sudha Kansal
- Department of Critical Care Medicine, Indraprastha Apollo Hospital, New Delhi, India
| | - Sananta Kumar Dash
- Department of Anaesthesia and Critical Care Medicine, Citizens Hospitals and American Oncology Hospitals, Hyderabad, India
| |
Collapse
|
22
|
Amico E, Gomez F, Di Perri C, Vanhaudenhuyse A, Lesenfants D, Boveroux P, Bonhomme V, Brichant JF, Marinazzo D, Laureys S. Posterior cingulate cortex-related co-activation patterns: a resting state FMRI study in propofol-induced loss of consciousness. PLoS One 2014; 9:e100012. [PMID: 24979748 PMCID: PMC4076184 DOI: 10.1371/journal.pone.0100012] [Citation(s) in RCA: 80] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2014] [Accepted: 05/21/2014] [Indexed: 11/25/2022] Open
Abstract
Background Recent studies have been shown that functional connectivity of cerebral areas is not a static phenomenon, but exhibits spontaneous fluctuations over time. There is evidence that fluctuating connectivity is an intrinsic phenomenon of brain dynamics that persists during anesthesia. Lately, point process analysis applied on functional data has revealed that much of the information regarding brain connectivity is contained in a fraction of critical time points of a resting state dataset. In the present study we want to extend this methodology for the investigation of resting state fMRI spatial pattern changes during propofol-induced modulation of consciousness, with the aim of extracting new insights on brain networks consciousness-dependent fluctuations. Methods Resting-state fMRI volumes on 18 healthy subjects were acquired in four clinical states during propofol injection: wakefulness, sedation, unconsciousness, and recovery. The dataset was reduced to a spatio-temporal point process by selecting time points in the Posterior Cingulate Cortex (PCC) at which the signal is higher than a given threshold (i.e., BOLD intensity above 1 standard deviation). Spatial clustering on the PCC time frames extracted was then performed (number of clusters = 8), to obtain 8 different PCC co-activation patterns (CAPs) for each level of consciousness. Results The current analysis shows that the core of the PCC-CAPs throughout consciousness modulation seems to be preserved. Nonetheless, this methodology enables to differentiate region-specific propofol-induced reductions in PCC-CAPs, some of them already present in the functional connectivity literature (e.g., disconnections of the prefrontal cortex, thalamus, auditory cortex), some others new (e.g., reduced co-activation in motor cortex and visual area). Conclusion In conclusion, our results indicate that the employed methodology can help in improving and refining the characterization of local functional changes in the brain associated to propofol-induced modulation of consciousness.
Collapse
Affiliation(s)
- Enrico Amico
- Coma Science Group, Cyclotron Research Centre, University of Liège, Liège, Belgium
- Faculty of Psychology and Educational Sciences, Department of Data Analysis, Ghent University, Ghent, Belgium
- * E-mail:
| | - Francisco Gomez
- Coma Science Group, Cyclotron Research Centre, University of Liège, Liège, Belgium
| | - Carol Di Perri
- Department of Neuroradiology, National Neurological Institute C. Mondino, Pavia, Italy
| | - Audrey Vanhaudenhuyse
- Coma Science Group, Cyclotron Research Centre, University of Liège, Liège, Belgium
- Department of Algology and Palliative Care, CHU Sart Tilman Hospital, University of Liège, Liège, Belgium
| | - Damien Lesenfants
- Coma Science Group, Cyclotron Research Centre, University of Liège, Liège, Belgium
| | - Pierre Boveroux
- Coma Science Group, Cyclotron Research Centre, University of Liège, Liège, Belgium
- Department of Anesthesia and Intensive Care Medicine, CHU Sart Tilman Hospital, University of Liège, Liège, Belgium
| | - Vincent Bonhomme
- Coma Science Group, Cyclotron Research Centre, University of Liège, Liège, Belgium
- Department of Anesthesia and Intensive Care Medicine, CHU Sart Tilman Hospital, University of Liège, Liège, Belgium
- Department of Anesthesia and Intensive Care Medicine, CHR Citadelle, University of Liège, Liège, Belgium
| | - Jean-François Brichant
- Department of Anesthesia and Intensive Care Medicine, CHU Sart Tilman Hospital, University of Liège, Liège, Belgium
| | - Daniele Marinazzo
- Faculty of Psychology and Educational Sciences, Department of Data Analysis, Ghent University, Ghent, Belgium
| | - Steven Laureys
- Coma Science Group, Cyclotron Research Centre, University of Liège, Liège, Belgium
- Department of Neurology, University of Liège, Liège, Belgium
| |
Collapse
|
23
|
Preslaski CR, Lat I, MacLaren R, Poston J. Pharmacist contributions as members of the multidisciplinary ICU team. Chest 2014; 144:1687-1695. [PMID: 24189862 DOI: 10.1378/chest.12-1615] [Citation(s) in RCA: 88] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
Critical care pharmacy services in the ICU have expanded from traditional dispensing responsibilities to being recognized as an essential component of multidisciplinary care for critically ill patients. Augmented by technology and resource utilization, this shift in roles has allowed pharmacists to provide valuable services in the form of assisting physicians and clinicians with pharmacotherapy decision-making, reducing medication errors, and improving medication safety systems to optimize patient outcomes. Documented improvements in the management of infections, anticoagulation therapy, sedation, and analgesia for patients receiving mechanical ventilation and in emergency response help to justify the need for clinical pharmacy services for critically ill patients. Contributions to quality improvement initiatives, scholarly and research activities, and the education and training of interdisciplinary personnel are also valued services offered by clinical pharmacists. Partnering with physician and nursing champions can garner support from hospital administrators for the addition of clinical pharmacy critical care services. The addition of a pharmacist to an interprofessional critical care team should be encouraged as health-care systems focus on improving the quality and efficiency of care delivered to improve patient outcomes.
Collapse
Affiliation(s)
| | - Ishaq Lat
- Department of Pharmacy, The University of Chicago Medical Center, Chicago, IL.
| | - Robert MacLaren
- Department of Clinical Pharmacy, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado, Aurora, CO
| | - Jason Poston
- Department of Medicine, Section of Pulmonary/Critical Care Medicine, Pritzker School of Medicine, The University of Chicago, Chicago, IL
| |
Collapse
|
24
|
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.
Collapse
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.
| | | | | | | |
Collapse
|
25
|
Abstract
OBJECTIVE We systematically reviewed ICU-based knowledge translation studies to assess the impact of knowledge translation interventions on processes and outcomes of care. DATA SOURCES We searched electronic databases (to July, 2010) without language restrictions and hand-searched reference lists of relevant studies and reviews. STUDY SELECTION Two reviewers independently identified randomized controlled trials and observational studies comparing any ICU-based knowledge translation intervention (e.g., protocols, guidelines, and audit and feedback) to management without a knowledge translation intervention. We focused on clinical topics that were addressed in greater than or equal to five studies. DATA EXTRACTION Pairs of reviewers abstracted data on the clinical topic, knowledge translation intervention(s), process of care measures, and patient outcomes. For each individual or combination of knowledge translation intervention(s) addressed in greater than or equal to three studies, we summarized each study using median risk ratio for dichotomous and standardized mean difference for continuous process measures. We used random-effects models. Anticipating a small number of randomized controlled trials, our primary meta-analyses included randomized controlled trials and observational studies. In separate sensitivity analyses, we excluded randomized controlled trials and collapsed protocols, guidelines, and bundles into one category of intervention. We conducted meta-analyses for clinical outcomes (ICU and hospital mortality, ventilator-associated pneumonia, duration of mechanical ventilation, and ICU length of stay) related to interventions that were associated with improvements in processes of care. DATA SYNTHESIS From 11,742 publications, we included 119 investigations (seven randomized controlled trials, 112 observational studies) on nine clinical topics. Interventions that included protocols with or without education improved continuous process measures (seven observational studies and one randomized controlled trial; standardized mean difference [95% CI]: 0.26 [0.1, 0.42]; p = 0.001 and four observational studies and one randomized controlled trial; 0.83 [0.37, 1.29]; p = 0.0004, respectively). Heterogeneity among studies within topics ranged from low to extreme. The exclusion of randomized controlled trials did not change our results. Single-intervention and lower-quality studies had higher standardized mean differences compared to multiple-intervention and higher-quality studies (p = 0.013 and 0.016, respectively). There were no associated improvements in clinical outcomes. CONCLUSIONS Knowledge translation interventions in the ICU that include protocols with or without education are associated with the greatest improvements in processes of critical care.
Collapse
|
26
|
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.
Collapse
|
27
|
|
28
|
Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock: 2012. Crit Care Med 2013; 41:580-637. [PMID: 23353941 DOI: 10.1097/ccm.0b013e31827e83af] [Citation(s) in RCA: 3898] [Impact Index Per Article: 354.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To provide an update to the "Surviving Sepsis Campaign Guidelines for Management of Severe Sepsis and Septic Shock," last published in 2008. DESIGN A consensus committee of 68 international experts representing 30 international organizations was convened. Nominal groups were assembled at key international meetings (for those committee members attending the conference). A formal conflict of interest policy was developed at the onset of the process and enforced throughout. The entire guidelines process was conducted independent of any industry funding. A stand-alone meeting was held for all subgroup heads, co- and vice-chairs, and selected individuals. Teleconferences and electronic-based discussion among subgroups and among the entire committee served as an integral part of the development. METHODS The authors were advised to follow the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to guide assessment of quality of evidence from high (A) to very low (D) and to determine the strength of recommendations as strong (1) or weak (2). The potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasized. Some recommendations were ungraded (UG). Recommendations were classified into three groups: 1) those directly targeting severe sepsis; 2) those targeting general care of the critically ill patient and considered high priority in severe sepsis; and 3) pediatric considerations. RESULTS Key recommendations and suggestions, listed by category, include: early quantitative resuscitation of the septic patient during the first 6 hrs after recognition (1C); blood cultures before antibiotic therapy (1C); imaging studies performed promptly to confirm a potential source of infection (UG); administration of broad-spectrum antimicrobials therapy within 1 hr of recognition of septic shock (1B) and severe sepsis without septic shock (1C) as the goal of therapy; reassessment of antimicrobial therapy daily for de-escalation, when appropriate (1B); infection source control with attention to the balance of risks and benefits of the chosen method within 12 hrs of diagnosis (1C); initial fluid resuscitation with crystalloid (1B) and consideration of the addition of albumin in patients who continue to require substantial amounts of crystalloid to maintain adequate mean arterial pressure (2C) and the avoidance of hetastarch formulations (1C); initial fluid challenge in patients with sepsis-induced tissue hypoperfusion and suspicion of hypovolemia to achieve a minimum of 30 mL/kg of crystalloids (more rapid administration and greater amounts of fluid may be needed in some patients) (1C); fluid challenge technique continued as long as hemodynamic improvement, as based on either dynamic or static variables (UG); norepinephrine as the first-choice vasopressor to maintain mean arterial pressure ≥ 65 mm Hg (1B); epinephrine when an additional agent is needed to maintain adequate blood pressure (2B); vasopressin (0.03 U/min) can be added to norepinephrine to either raise mean arterial pressure to target or to decrease norepinephrine dose but should not be used as the initial vasopressor (UG); dopamine is not recommended except in highly selected circumstances (2C); dobutamine infusion administered or added to vasopressor in the presence of a) myocardial dysfunction as suggested by elevated cardiac filling pressures and low cardiac output, or b) ongoing signs of hypoperfusion despite achieving adequate intravascular volume and adequate mean arterial pressure (1C); avoiding use of intravenous hydrocortisone in adult septic shock patients if adequate fluid resuscitation and vasopressor therapy are able to restore hemodynamic stability (2C); hemoglobin target of 7-9 g/dL in the absence of tissue hypoperfusion, ischemic coronary artery disease, or acute hemorrhage (1B); low tidal volume (1A) and limitation of inspiratory plateau pressure (1B) for acute respiratory distress syndrome (ARDS); application of at least a minimal amount of positive end-expiratory pressure (PEEP) in ARDS (1B); higher rather than lower level of PEEP for patients with sepsis-induced moderate or severe ARDS (2C); recruitment maneuvers in sepsis patients with severe refractory hypoxemia due to ARDS (2C); prone positioning in sepsis-induced ARDS patients with a PaO2/FIO2 ratio of ≤ 100 mm Hg in facilities that have experience with such practices (2C); head-of-bed elevation in mechanically ventilated patients unless contraindicated (1B); a conservative fluid strategy for patients with established ARDS who do not have evidence of tissue hypoperfusion (1C); protocols for weaning and sedation (1A); minimizing use of either intermittent bolus sedation or continuous infusion sedation targeting specific titration endpoints (1B); avoidance of neuromuscular blockers if possible in the septic patient without ARDS (1C); a short course of neuromuscular blocker (no longer than 48 hrs) for patients with early ARDS and a Pao2/Fio2 < 150 mm Hg (2C); a protocolized approach to blood glucose management commencing insulin dosing when two consecutive blood glucose levels are > 180 mg/dL, targeting an upper blood glucose ≤ 180 mg/dL (1A); equivalency of continuous veno-venous hemofiltration or intermittent hemodialysis (2B); prophylaxis for deep vein thrombosis (1B); use of stress ulcer prophylaxis to prevent upper gastrointestinal bleeding in patients with bleeding risk factors (1B); oral or enteral (if necessary) feedings, as tolerated, rather than either complete fasting or provision of only intravenous glucose within the first 48 hrs after a diagnosis of severe sepsis/septic shock (2C); and addressing goals of care, including treatment plans and end-of-life planning (as appropriate) (1B), as early as feasible, but within 72 hrs of intensive care unit admission (2C). Recommendations specific to pediatric severe sepsis include: therapy with face mask oxygen, high flow nasal cannula oxygen, or nasopharyngeal continuous PEEP in the presence of respiratory distress and hypoxemia (2C), use of physical examination therapeutic endpoints such as capillary refill (2C); for septic shock associated with hypovolemia, the use of crystalloids or albumin to deliver a bolus of 20 mL/kg of crystalloids (or albumin equivalent) over 5 to 10 mins (2C); more common use of inotropes and vasodilators for low cardiac output septic shock associated with elevated systemic vascular resistance (2C); and use of hydrocortisone only in children with suspected or proven "absolute"' adrenal insufficiency (2C). CONCLUSIONS Strong agreement existed among a large cohort of international experts regarding many level 1 recommendations for the best care of patients with severe sepsis. Although a significant number of aspects of care have relatively weak support, evidence-based recommendations regarding the acute management of sepsis and septic shock are the foundation of improved outcomes for this important group of critically ill patients.
Collapse
|
29
|
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.
Collapse
|
30
|
Dellinger RP, Levy MM, Rhodes A, Annane D, Gerlach H, Opal SM, Sevransky JE, Sprung CL, Douglas IS, Jaeschke R, Osborn TM, Nunnally ME, Townsend SR, Reinhart K, Kleinpell RM, Angus DC, Deutschman CS, Machado FR, Rubenfeld GD, Webb S, Beale RJ, Vincent JL, Moreno R. Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock, 2012. Intensive Care Med 2013; 39:165-228. [PMID: 23361625 PMCID: PMC7095153 DOI: 10.1007/s00134-012-2769-8] [Citation(s) in RCA: 3088] [Impact Index Per Article: 280.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2012] [Accepted: 11/12/2012] [Indexed: 12/02/2022]
Abstract
OBJECTIVE To provide an update to the "Surviving Sepsis Campaign Guidelines for Management of Severe Sepsis and Septic Shock," last published in 2008. DESIGN A consensus committee of 68 international experts representing 30 international organizations was convened. Nominal groups were assembled at key international meetings (for those committee members attending the conference). A formal conflict of interest policy was developed at the onset of the process and enforced throughout. The entire guidelines process was conducted independent of any industry funding. A stand-alone meeting was held for all subgroup heads, co- and vice-chairs, and selected individuals. Teleconferences and electronic-based discussion among subgroups and among the entire committee served as an integral part of the development. METHODS The authors were advised to follow the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to guide assessment of quality of evidence from high (A) to very low (D) and to determine the strength of recommendations as strong (1) or weak (2). The potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasized. Recommendations were classified into three groups: (1) those directly targeting severe sepsis; (2) those targeting general care of the critically ill patient and considered high priority in severe sepsis; and (3) pediatric considerations. RESULTS Key recommendations and suggestions, listed by category, include: early quantitative resuscitation of the septic patient during the first 6 h after recognition (1C); blood cultures before antibiotic therapy (1C); imaging studies performed promptly to confirm a potential source of infection (UG); administration of broad-spectrum antimicrobials therapy within 1 h of the recognition of septic shock (1B) and severe sepsis without septic shock (1C) as the goal of therapy; reassessment of antimicrobial therapy daily for de-escalation, when appropriate (1B); infection source control with attention to the balance of risks and benefits of the chosen method within 12 h of diagnosis (1C); initial fluid resuscitation with crystalloid (1B) and consideration of the addition of albumin in patients who continue to require substantial amounts of crystalloid to maintain adequate mean arterial pressure (2C) and the avoidance of hetastarch formulations (1B); initial fluid challenge in patients with sepsis-induced tissue hypoperfusion and suspicion of hypovolemia to achieve a minimum of 30 mL/kg of crystalloids (more rapid administration and greater amounts of fluid may be needed in some patients (1C); fluid challenge technique continued as long as hemodynamic improvement is based on either dynamic or static variables (UG); norepinephrine as the first-choice vasopressor to maintain mean arterial pressure ≥65 mmHg (1B); epinephrine when an additional agent is needed to maintain adequate blood pressure (2B); vasopressin (0.03 U/min) can be added to norepinephrine to either raise mean arterial pressure to target or to decrease norepinephrine dose but should not be used as the initial vasopressor (UG); dopamine is not recommended except in highly selected circumstances (2C); dobutamine infusion administered or added to vasopressor in the presence of (a) myocardial dysfunction as suggested by elevated cardiac filling pressures and low cardiac output, or (b) ongoing signs of hypoperfusion despite achieving adequate intravascular volume and adequate mean arterial pressure (1C); avoiding use of intravenous hydrocortisone in adult septic shock patients if adequate fluid resuscitation and vasopressor therapy are able to restore hemodynamic stability (2C); hemoglobin target of 7-9 g/dL in the absence of tissue hypoperfusion, ischemic coronary artery disease, or acute hemorrhage (1B); low tidal volume (1A) and limitation of inspiratory plateau pressure (1B) for acute respiratory distress syndrome (ARDS); application of at least a minimal amount of positive end-expiratory pressure (PEEP) in ARDS (1B); higher rather than lower level of PEEP for patients with sepsis-induced moderate or severe ARDS (2C); recruitment maneuvers in sepsis patients with severe refractory hypoxemia due to ARDS (2C); prone positioning in sepsis-induced ARDS patients with a PaO (2)/FiO (2) ratio of ≤100 mm Hg in facilities that have experience with such practices (2C); head-of-bed elevation in mechanically ventilated patients unless contraindicated (1B); a conservative fluid strategy for patients with established ARDS who do not have evidence of tissue hypoperfusion (1C); protocols for weaning and sedation (1A); minimizing use of either intermittent bolus sedation or continuous infusion sedation targeting specific titration endpoints (1B); avoidance of neuromuscular blockers if possible in the septic patient without ARDS (1C); a short course of neuromuscular blocker (no longer than 48 h) for patients with early ARDS and a PaO (2)/FI O (2) <150 mm Hg (2C); a protocolized approach to blood glucose management commencing insulin dosing when two consecutive blood glucose levels are >180 mg/dL, targeting an upper blood glucose ≤180 mg/dL (1A); equivalency of continuous veno-venous hemofiltration or intermittent hemodialysis (2B); prophylaxis for deep vein thrombosis (1B); use of stress ulcer prophylaxis to prevent upper gastrointestinal bleeding in patients with bleeding risk factors (1B); oral or enteral (if necessary) feedings, as tolerated, rather than either complete fasting or provision of only intravenous glucose within the first 48 h after a diagnosis of severe sepsis/septic shock (2C); and addressing goals of care, including treatment plans and end-of-life planning (as appropriate) (1B), as early as feasible, but within 72 h of intensive care unit admission (2C). Recommendations specific to pediatric severe sepsis include: therapy with face mask oxygen, high flow nasal cannula oxygen, or nasopharyngeal continuous PEEP in the presence of respiratory distress and hypoxemia (2C), use of physical examination therapeutic endpoints such as capillary refill (2C); for septic shock associated with hypovolemia, the use of crystalloids or albumin to deliver a bolus of 20 mL/kg of crystalloids (or albumin equivalent) over 5-10 min (2C); more common use of inotropes and vasodilators for low cardiac output septic shock associated with elevated systemic vascular resistance (2C); and use of hydrocortisone only in children with suspected or proven "absolute"' adrenal insufficiency (2C). CONCLUSIONS Strong agreement existed among a large cohort of international experts regarding many level 1 recommendations for the best care of patients with severe sepsis. Although a significant number of aspects of care have relatively weak support, evidence-based recommendations regarding the acute management of sepsis and septic shock are the foundation of improved outcomes for this important group of critically ill patients.
Collapse
|
31
|
McConnell KW, Coopersmith CM. Organ failure avoidance and mitigation strategies in surgery. Surg Clin North Am 2012; 92:307-19, ix. [PMID: 22414415 DOI: 10.1016/j.suc.2012.01.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
Postoperative organ failure is a challenging disease process that is better prevented than treated. Providers should use close observation and clinical judgment, and checklists of best practices to minimize the risk of organ failure in their patients. The treatment of multiorgan dysfunction syndrome (MODS) generally remains supportive, outside of rapid initiation of source control (when appropriate) and targeted antibiotic therapy. More specific treatments may be developed as the complex pathophysiology of MODS is better understood and more homogenous patient populations are selected for study.
Collapse
Affiliation(s)
- Kevin W McConnell
- Acute and Critical Care Surgery, Emory University School of Medicine, Atlanta, GA 30322, USA
| | | |
Collapse
|
32
|
Abstract
Pain is abundant in the intensive care unit (ICU). Successful analgesia demands a comprehensive appreciation for the etiologies of pain, vigilant clinical assessment, and personalized treatments. For the critically ill, frequent threats to mental and bodily integrity magnify the experience of pain, challenging clinicians to respond swiftly and thoughtfully. Because pain is difficult to predict and physiologic correlates are not specific, self-report remains the gold standard assessment. When communication is limited by intubation or cognitive deficits, behavioral pain scales prove useful. Patient-tailored analgesia aspires to mitigate suffering while optimizing alertness and cognitive capacity. Mindfulness of the neuropsychiatric features of pain helps the ICU clinician to clarify limits of traditional analgesia and identify alternative approaches to care. Armed with empirical data and clinical practice recommendations to better conceptualize, identify, and treat pain and its neuropsychiatric comorbidities, the authors (psychiatric consultants, by trade) reinforce holistic approaches to pain management in the ICU. After all, without attempts to understand and relieve suffering on all fronts, pain will remain undertreated.
Collapse
Affiliation(s)
- Pierre N Azzam
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
| | | |
Collapse
|
33
|
Awissi DK, Bégin C, Moisan J, Lachaine J, Skrobik Y. I-SAVE Study: Impact of Sedation, Analgesia, and Delirium Protocols Evaluated in the Intensive Care Unit: An Economic Evaluation. Ann Pharmacother 2012; 46:21-8. [DOI: 10.1345/aph.1q284] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND: Intensive care units (ICUs) account for considerable health care costs. Adequate pain and sedation management is important to clinical care. OBJECTIVE: To determine whether implementing a protocol for management of analgesia, sedation, and delirium in the ICU would save costs. METHODS: With data from the I-SAVE (Impact of Sedation, Analgesia and Delirium Protocols Evaluated in the Intensive Care Unit: an Economic Evaluation) study, a prospective pre- and postprotocol design was used. Between the 2 periods, protocols for systematic management of sedation, analgesia, and delirium were implemented. Cost-effectiveness was calculated by associating the variation of cost and effectiveness measures (proportion of patients within targeted pain, sedation, and delirium goals). Total costs (in 2004 Canadian dollars), by patient, consisted of the sum of sedation, analgesia, and delirium drug acquisition costs during the ICU stay and the cost of the ICU stay. RESULTS: A total of 1214 patients, 604 in the preprotocol group and 610 in the postprotocol group, were included. The mean (SD) ICU length of stay and the duration of mechanical ventilation were shorter among patients of the postprotocol group compared with those of the preprotocol group (5.43 [6.43] and 6.39 [8.05] days, respectively; p = 0.004 and 5.95 [6.80] and 7.27 [9.09] days, respectively; p < 0.009). The incidence of delirium remained the same. The proportion of patients with Richmond Agitation and Sedation (RASS) scores between −1 and +1 increased from 57.0% to 66.2% (p = 0.001), whereas the proportion of patients with a numeric rating scale (NRS) score of 1 or less increased from 56.3% to 66.6% (p < 0.001). The mean total cost of ICU hospitalization decreased from $6212.64 (7846.86) in the preprotocol group to $5279.90 (6263.91) in the postprotocol group (p = 0.022). The cost analyses for pain and agitation management improved; the proportion of patients with RASS scores between −1 and +1 or NRS scores of 1 or less increased significantly in the postprotocol group while costing, on average, $932.74 less per hospitalization. CONCLUSIONS: Establishing protocols for patient-driven management of sedation, analgesia, and delirium is a cost-effective practice and allows savings of nearly $1000 per hospitalization.
Collapse
Affiliation(s)
- Don-Kelena Awissi
- Don-Kelena Awissi MSc Pharm BCPS, Clinical Pharmacist, Pharmacy Department, Maisonneuve-Rosemont Hospital, Montreal, Quebec, Canada
| | - Cindy Bégin
- Cindy Bégin MSc Pharm, Clinical Pharmacist, Pharmacy Department, Maisonneuve-Rosemont Hospital
| | - Julie Moisan
- Julie Moisan MSc Pharm, Clinical Pharmacist, Pharmacy Department, Hopital du Sacré-Cœur de Montreal, Montreal
| | - Jean Lachaine
- Jean Lachaine PhD, Associate Professor, Faculty of Pharmacy, Université de Montréal, Montreal
| | - Yoanna Skrobik
- Yoanna Skrobik MD FRCP, Professor of Medicine, Intensive Care Unit, Maisonneuve-Rosemont Hospital
| |
Collapse
|
34
|
Abstract
Protocolized target-based sedation and analgesia is central to effective management of sedation. Important components include identifying goals and specific targets,using valid and reliable tools to measure pain, agitation, and sedation, and titrating a logically selected combination of sedatives and analgesics to defined end-points.A variety of approaches to structured management have been tested in controlled trials with major categories of (1) sedation algorithms and protocols and (2) daily interruption of sedation. Although not all studies that compare new interventions to “usual care” document dramatic improvements, many studies show that by reducing oversedation, using a structured approach, faster recovery from respiratory failure may ensue. The somewhat discrepant results illustrate, however, that various approaches,such as DIS, may not be optimal for all patients. Further research will be necessary to define these patients and examine alternative strategies. Finally, implementation of structured approaches to sedation management is a challenging, time-consuming process for clinicians that must be supported with sufficient resources to be successful.
Collapse
Affiliation(s)
- Curtis N Sessler
- Division of Pulmonary & Critical Care Medicine, Department of Internal Medicine, Virginia Commonwealth University Health System, Box 980050, Richmond, VA 23298-0050, USA.
| | | |
Collapse
|
35
|
Ceelie I, Wildt S, Jong M, Ista E, Tibboel D, Dijk M. Protocolized post-operative pain management in infants; do we stick to it? Eur J Pain 2011; 16:760-6. [DOI: 10.1002/j.1532-2149.2011.00056.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/28/2011] [Indexed: 11/08/2022]
Affiliation(s)
- I. Ceelie
- Department of Pediatric Surgery & Intensive Care; Erasmus MC - Sophia Children's Hospital; Rotterdam; The Netherlands
| | - S.N. Wildt
- Department of Pediatric Surgery & Intensive Care; Erasmus MC - Sophia Children's Hospital; Rotterdam; The Netherlands
| | - M. Jong
- Department of Pediatric Surgery & Intensive Care; Erasmus MC - Sophia Children's Hospital; Rotterdam; The Netherlands
| | - E. Ista
- Department of Pediatric Surgery & Intensive Care; Erasmus MC - Sophia Children's Hospital; Rotterdam; The Netherlands
| | - D. Tibboel
- Department of Pediatric Surgery & Intensive Care; Erasmus MC - Sophia Children's Hospital; Rotterdam; The Netherlands
| | - M. Dijk
- Department of Pediatric Surgery & Intensive Care; Erasmus MC - Sophia Children's Hospital; Rotterdam; The Netherlands
| |
Collapse
|
36
|
Influence of algorithm-based analgesia and sedation in patients after sudden cardiac arrest. Clin Res Cardiol 2011; 101:175-83. [PMID: 22048697 DOI: 10.1007/s00392-011-0378-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2011] [Accepted: 10/27/2011] [Indexed: 12/17/2022]
Abstract
PURPOSE The aim of this study was to analyse the effect of an algorithm-based analgesic-sedative management on mechanical ventilation time and length of stay in a cardiological ICU with critical ill patients after sudden cardiac arrest. METHODS We examined 100 patients after successful resuscitation in a retrospective-prospective single-centre trial by introducing an algorithm-based sedation management. Demographic data, severity of illness classified by APACHE II score (Acute Physiology and Chronic Health Evaluation II), neurological outcome and data for mechanical ventilation time and length of stay were acquired for both groups. RESULTS We found a shorter ventilation time for young patients without severe illness, whereby significant longer ventilation time was observed for patients with higher APACHE II score. Between both groups, we found no significant differences in mechanical ventilation time and length of stay. CONCLUSIONS Our results demonstrate a tendency towards a reduction of mechanical ventilation time for patients without severe illness after sudden cardiac arrest achieved by implementation of a new sedation management, whereby significant longer ventilation time was observed for severe ill patients. Because of lack of statistical significance of our present study, a randomized study with sufficient power is necessary to demonstrate positive effects of a standardized sedation management and its influence on severity of illness.
Collapse
|
37
|
Honiden S, Siegel MD. Analytic reviews: managing the agitated patient in the ICU: sedation, analgesia, and neuromuscular blockade. J Intensive Care Med 2011; 25:187-204. [PMID: 20663774 DOI: 10.1177/0885066610366923] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Physical and psychological distress is exceedingly common among critically ill patients and manifests generically as agitation. The dangers of over- and undertreatment of agitation have been well described, and the intensive care unit (ICU) physician must strike a balance in the fast-paced, dynamic ICU environment. Identification of common reversible etiologies for distress may obviate the need for pharmacologic therapy, but most patients receive some combination of sedative, analgesic, and neuroleptic medications during the course of their critical illness. As such, understanding key pharmacologic features of commonly used agents is critical. Structured protocols and objective assessment tools can optimize drug delivery and may ultimately improve patient outcomes by reducing ventilator days, ICU length of stay, and by reducing cognitive dysfunction.
Collapse
Affiliation(s)
- Shyoko Honiden
- Department of Medicine, Section of Pulmonary and Critical Care Medicine, Yale University School of Medicine, New Haven, CT 06520, USA
| | | |
Collapse
|
38
|
Jarachovic M, Mason M, Kerber K, McNett M. The role of standardized protocols in unplanned extubations in a medical intensive care unit. Am J Crit Care 2011; 20:304-11; quiz 312. [PMID: 21724634 DOI: 10.4037/ajcc2011334] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND Many patients admitted to medical intensive care units require mechanical ventilation to assist with respiratory management. Unplanned extubations of these patients are associated with poor outcomes for patients and organizations. No previous research has investigated the role of standardized protocols in unplanned extubations when examined in conjunction with traditional risk factors. OBJECTIVE To identify risk factors associated with unplanned extubation among patients receiving mechanical ventilation and determine degree of compliance with pain, sedation, and weaning protocols. METHODS A prospective cohort study design was used. Data on all patients admitted to the medical intensive care unit who required mechanical ventilation were gathered daily. Additional data were gathered on those patients who experienced unplanned extubation. Descriptive, correlational, and regression analyses were performed. RESULTS Weaning protocols were a significant predictor of unplanned extubation: patients who had weaning protocols ordered and followed were least likely to experience unplanned extubation. Only 10% of the 190 patients in the study required reintubation, resulting in a significantly shorter ventilation time and unit length of stay among the unplanned extubation group. CONCLUSIONS Weaning protocols were associated with decreased incidence of unplanned extubation. Use of standardized protocols was feasible, as compliance among health care providers was high when protocols were medically prescribed. The reintubation rate in this study was low and associated with a significantly shorter ventilatory period and unit length of stay in the unplanned extubation group.
Collapse
Affiliation(s)
- Mary Jarachovic
- Mary Jarachovic is a clinical nurse, Maggie Mason is a nurse manager, and Kathleen Kerber is a clinical nurse specialist in the medical intensive care unit and Molly McNett is director of nursing research in the Department of Nursing at MetroHealth Medical Center in Cleveland, Ohio
| | - Maggie Mason
- Mary Jarachovic is a clinical nurse, Maggie Mason is a nurse manager, and Kathleen Kerber is a clinical nurse specialist in the medical intensive care unit and Molly McNett is director of nursing research in the Department of Nursing at MetroHealth Medical Center in Cleveland, Ohio
| | - Kathleen Kerber
- Mary Jarachovic is a clinical nurse, Maggie Mason is a nurse manager, and Kathleen Kerber is a clinical nurse specialist in the medical intensive care unit and Molly McNett is director of nursing research in the Department of Nursing at MetroHealth Medical Center in Cleveland, Ohio
| | - Molly McNett
- Mary Jarachovic is a clinical nurse, Maggie Mason is a nurse manager, and Kathleen Kerber is a clinical nurse specialist in the medical intensive care unit and Molly McNett is director of nursing research in the Department of Nursing at MetroHealth Medical Center in Cleveland, Ohio
| |
Collapse
|
39
|
Degrado JR, Anger KE, Szumita PM, Pierce CD, Massaro AF. Evaluation of a local ICU sedation guideline on goal-directed administration of sedatives and analgesics. J Pain Res 2011; 4:127-34. [PMID: 21647216 PMCID: PMC3100227 DOI: 10.2147/jpr.s18161] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2011] [Indexed: 12/31/2022] Open
Abstract
PURPOSE Sedatives and analgesics are commonly used in mechanically ventilated patients in the intensive care unit. Sedation guidelines have been shown to improve sedation management as well as various patient outcomes. The main objective was to evaluate adherence to a sedation guideline with both sedative prescribing and documentation of Richmond Agitation-Sedation Scale (RASS) scores. METHODS In a retrospective chart review, data was collected on 111 medical intensive care unit patients mechanically ventilated via endotracheal tube for 12 hours or greater at Brigham and Women's Hospital. Fifty-seven patients were evaluated pre-guideline implementation and 54 patients were evaluated post-guideline. RESULTS Significant increases were seen in the post-guideline group in goal-directed sedation with a patient-specific RASS goal in the sedation order: 21.3 vs 85.4% (P < 0.001), and mean number of sedation assessments per 24 hours using the RASS: 4.7 vs 11.4 (P < 0.001). Similarly, this group experienced a higher percentage of RASS scores at their sedation goal: 31.4 vs 44.1% (P < 0.001). No difference was seen in other clinical endpoints. CONCLUSION Implementation and routine application of a hospital pain and sedation guideline was associated with significantly improved sedation metrics, such as goal-directed sedation, as well as frequency of sedation level assessment and documentation. An increase was observed in the time that post-guideline patients spent at or near their RASS goal.
Collapse
|
40
|
Trupkovic T, Kinn M, Kleinschmidt S. Analgesia and Sedation in the Intensive Care of Burn Patients. J Intensive Care Med 2011; 26:397-407. [DOI: 10.1177/0885066610393442] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objective: A variety of agents and techniques are employed in different countries, settings, and medical specialities in order to provide analgesia and sedation in intensive care. Several national guidelines have been published in recent years regarding sedation and analgesia in a general intensive care patient population; however, to date no data exist for patients with burn injuries. The aim of the study was to evaluate analgesia and sedation practice in the intensive care of burn patients in Europe. Design: A postal survey was sent to 188 burn centers in Europe. The addresses were provided by the European Burn Association. The heads of the intensive care units were asked to fill in a structured questionnaire concerning the use of analgesia and sedation in their units. Results: The overall response rate was 27.04%; 63% of European burn centers reported standard operating procedures for sedation and analgesia. A regular score-based assessment of sedation, analgesia, and delirium is carried out by 58%, 60%, and 5%, respectively, of the units. Propofol is the sedative most frequently used for short-term sedation and the weaning phase, whereas benzodiazepines are the preferred substances for medium- and long-term sedation. α2-agonists are widely used during weaning. Opioids are the analgesics of choice for approximately two thirds of the patients. Ketamine is preferred for analgesia in 12% and for sedation in 13% of all substances used. For painful procedures (eg, dressing changes), a large variety of different combinations of analgesics and sedatives are used. Half of the responding intensive care units use neuromuscular blocking agents and supportive nonpharmacological techniques. Two thirds of the European burn centers perceive the need for change in their concepts of analgesia and sedation. Conclusion: A wide variety of drugs are used for analgesia and sedation in European burn centers. This would appear to be due to lack of guidelines or scientific evidence. The implementation of regular assessment of sedation, analgesia, and delirium must be improved. The widespread use of neuromuscular blocking agents should be restricted or even abandoned. Two thirds of the units identify a need for change in their concepts. Valid scientific data are needed to develop guidelines for sedation and analgesia of burn patients.
Collapse
Affiliation(s)
- Tomislav Trupkovic
- Department of Anaesthesia, Intensive Care Medicine and Pain Therapy, BG Trauma Centre Ludwigshafen, Ludwigshafen, Germany
| | - Michael Kinn
- Department of Anaesthesia, Intensive Care Medicine and Pain Therapy, BG Trauma Centre Ludwigshafen, Ludwigshafen, Germany
| | - Stefan Kleinschmidt
- Department of Anaesthesia, Intensive Care Medicine and Pain Therapy, BG Trauma Centre Ludwigshafen, Ludwigshafen, Germany
| |
Collapse
|
41
|
de Wit M, Jones DG, Sessler CN, Zilberberg MD, Weaver MF. Alcohol-use disorders in the critically ill patient. Chest 2010; 138:994-1003. [PMID: 20923804 DOI: 10.1378/chest.09-1425] [Citation(s) in RCA: 76] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Alcohol abuse and dependence, referred to as alcohol-use disorders (AUDs), affect 76.3 million people worldwide and account for 1.8 million deaths per year. AUDs affect 18.3 million Americans (7.3% of the population), and up to 40% of hospitalized patients have AUDs. This review discusses the development and progression of critical illness in patients with AUDs. In contrast to acute intoxication, AUDs have been linked to increased severity of illness in a number of studies. In particular, surgical patients with AUDs experience higher rates of postoperative hemorrhage, cardiac complications, sepsis, and need for repeat surgery. Outcomes from trauma are worse for patients with chronic alcohol abuse, whereas burn patients who are acutely intoxicated may not have worse outcomes. AUDs are linked to not only a higher likelihood of community-acquired pneumonia and sepsis but also a higher severity of illness and higher rates of nosocomial pneumonia and sepsis. The management of sedation in patients with AUDs may be particularly challenging because of the increased need for sedatives and opioids and the difficulty in diagnosing withdrawal syndrome. The health-care provider also must be watchful for the development of dangerous agitation and violence, as these problems are not uncommonly seen in hospital ICUs. Despite studies showing that up to 40% of hospitalized patients have AUDs, relatively few guidelines exist on the specific management of the critically ill patient with AUDs. AUDs are underdiagnosed, and a first step to improving patient outcomes may lie in systematically and accurately identifying AUDs.
Collapse
Affiliation(s)
- Marjolein de Wit
- Division of Pulmonary Disease and Critical Care Medicine, Department of Internal Medicine, Virginia Commonwealth University, Richmond, VA 23298-0050, USA.
| | | | | | | | | |
Collapse
|
42
|
O'Connor M, Bucknall T, Manias E. International variations in outcomes from sedation protocol research: where are we at and where do we go from here? Intensive Crit Care Nurs 2010; 26:189-95. [PMID: 20615706 DOI: 10.1016/j.iccn.2010.05.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2010] [Accepted: 05/08/2010] [Indexed: 11/16/2022]
Abstract
In this article, sedation protocol research in the intensive care environment is critically examined, focusing upon the differences in outcomes from research conducted on mechanically ventilated patients in various countries. Limitations of the current research are discussed, with suggestions of how sedation protocol research may be conducted in future. Also, the monitoring of important clinical factors is discussed so that clinicians can assess the impact upon patients of changes to sedation management practices within their own ICU.
Collapse
Affiliation(s)
- Mark O'Connor
- Alfred Hospital Intensive Care Unit, Prahran, Victoria, Australia.
| | | | | |
Collapse
|
43
|
Jackson DL, Proudfoot CW, Cann KF, Walsh T. A systematic review of the impact of sedation practice in the ICU on resource use, costs and patient safety. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2010; 14:R59. [PMID: 20380720 PMCID: PMC2887180 DOI: 10.1186/cc8956] [Citation(s) in RCA: 93] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/18/2009] [Revised: 02/19/2010] [Accepted: 04/09/2010] [Indexed: 01/20/2023]
Abstract
Introduction Patients in intensive care units (ICUs) often receive sedation for prolonged periods. In order to better understand the impact of sub-optimal sedation practice on outcomes, we performed a systematic review, including observational studies and controlled trials which were conducted in sedated patients in the ICU and which compared the impact of changes in or different protocols for sedation management on economic and patient safety outcomes. Methods We searched Medline, Embase and CINAHL online literature databases from 1988 to 15th May 2008 and hand searched conferences. English-language studies set in the ICU, in sedated adult humans on mechanical ventilation, which reported the impact of sedation practice on cost and resource use and patient safety outcomes, were included. All abstracts were reviewed twice by two independent reviewers, with all conflicts resolved by a third reviewer, to check that they met the review inclusion criteria. Full-text papers of all included studies were retrieved and again reviewed twice against inclusion criteria. Data were doubly extracted from studies. Study aims, design, population, and outcomes including duration of mechanical ventilation, length of stay in ICU and hospital, costs and rates of mortality and adverse events were extracted. Due to heterogeneity between study designs and outcomes reported, no quantitative data synthesis such as meta-analysis was possible. Results Included studies varied in design, patient population and aim, with the majority being before-after studies. Overall, studies showed that improvements in sedation practice, such as the introduction of guidelines and protocols, or daily interruption of sedation, were associated with improvements in outcomes including ICU and hospital length of stay, duration of mechanical ventilation, and costs. Mortality and the incidence of nosocomial infections were also reduced. Conclusions Systematic interventions to improve sedation practice and maintain patients at an optimal sedation level in the ICU may improve patient outcomes and optimize resource usage.
Collapse
Affiliation(s)
- Daniel L Jackson
- GE Healthcare, Pollards Wood, Nightingales Lane, Chalfont St, Giles, Bucks, UK.
| | | | | | | |
Collapse
|
44
|
Jackson DL, Proudfoot CW, Cann KF, Walsh TS. The incidence of sub-optimal sedation in the ICU: a systematic review. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2009; 13:R204. [PMID: 20015357 PMCID: PMC2811948 DOI: 10.1186/cc8212] [Citation(s) in RCA: 96] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/20/2009] [Revised: 10/12/2009] [Accepted: 12/16/2009] [Indexed: 11/10/2022]
Abstract
Introduction Patients in intensive care units (ICUs) are generally sedated for prolonged periods. Over-sedation and under-sedation both have negative effects on patient safety and resource use. We conducted a systematic review of the literature in order to establish the incidence of sub-optimal sedation (both over- and under-sedation) in ICUs. Methods We searched Medline, Embase and CINAHL (Cumulative Index to Nursing and Allied Health Literature) online literature databases from 1988 to 15 May 2008 and hand-searched conferences. English-language studies set in the ICU, in sedated adult humans on mechanical ventilation, which reported the incidence of sub-optimal sedation, were included. All abstracts were reviewed twice by two independent reviewers, with all conflicts resolved by a third reviewer, to check that they met the review inclusion criteria. Full papers of all included studies were retrieved and were again reviewed twice against inclusion criteria. Data were doubly extracted. Study aims, design, population, comparisons made, and data on the incidence of sub-optimal, optimal, over-sedation or under-sedation were extracted. Results There was considerable variation between included studies in the definition of optimal sedation and in the scale or method used to assess sedation. Across all included studies, a substantial incidence of sub-optimal sedation was reported, with a greater tendency toward over-sedation. Conclusions Our review suggests that improvements in the consistent definition and measurement of sedation may improve the quality of care of patients within the ICU.
Collapse
Affiliation(s)
- Daniel L Jackson
- GE Healthcare, Pollards Wood, Nightingales Lane, Chalfont St, Giles, Bucks, HP8 4SP, UK.
| | | | | | | |
Collapse
|
45
|
Abstract
Administering sedative and analgesic medications is a cornerstone of optimizing patient comfort and minimizing distress, yet may lead to unintended consequences including delayed recovery from critical illness and slower liberation from mechanical ventilation. The use of structured approaches to sedation management, including guidelines, protocols, and algorithms can promote evidence-based care, reduce variation in clinical practice, and systematically reduce the likelihood of excessive and/or prolonged sedation. Patient-focused sedation algorithms are multidisciplinary, including physician, nurse, and pharmacist development and implementation. Key components of sedation algorithms include identification of goals and specific targets, use of valid and reliable tools to assess analgesia, agitation, and sedation, and incorporation of logical medication selection. Sedation protocols generally focus on a) algorithms that incorporate treating sedation and analgesia based upon escalation, de-escalation, or changing medications according to specific targets, or b) daily interruption of sedative and opioid analgesic infusions. Many published sedation protocols have been tested in controlled clinical trials, often demonstrating benefit such as shorter duration of mechanical ventilation, reduced ICU length of stay, and/or superior sedation management compared to usual care. Implementation of sedation algorithms in ICUs is a challenging process for which sufficient resources must be allocated.
Collapse
|
46
|
O'Connor M, Bucknall T, Manias E. A critical review of daily sedation interruption in the intensive care unit. J Clin Nurs 2008; 18:1239-49. [PMID: 19077018 DOI: 10.1111/j.1365-2702.2008.02513.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND Daily sedation interruption (DSI) has been proposed as a method of improving sedation management of critically ill patients by reducing the adverse effects of continuous sedation infusions. AIM To critique the research regarding daily sedation interruption, to inform education, research and practice in this area of intensive care practice. DESIGN Literature review. METHOD Medline, CINAHL and Web of Science were searched for relevant key terms. Eight research-based studies, published in the English language between 1995-December 2006 and three conference abstracts were retrieved. RESULTS Of the eight articles and three conference abstracts reviewed, five originated from one intensive care unit (ICU) in the USA. The research indicates that DSI reduces ventilation time, length of stay in ICU, complications of critical illness, incidence of post-traumatic stress disorder and is reportedly used by 15-62% of ICU clinicians in Australia, Europe, USA and Canada. CONCLUSIONS DSI improves patients' physiological and psychological outcomes when compared with routine sedation management. However, research relating to these findings has methodological limitations, such as the use of homogenous samples, single-centre trials and retrospective design, thus limiting their generalisability. RELEVANCE TO CLINICAL PRACTICE DSI may provide clinicians with a simple, cost-effective method of reducing some adverse effects of sedation on ICU patients. However, the evidence supporting DSI is limited and cannot be generalised to heterogeneous ICU populations internationally. More robust research is required to assess the potential impact of DSI on the physical and mental health of ICU survivors.
Collapse
Affiliation(s)
- Mark O'Connor
- Alfred Hospital Intensive Care Unit, School of Nursing, The University of Melbourne, Carlton, Victoria, Australia.
| | | | | |
Collapse
|
47
|
Abstract
A sedation strategy aimed at minimizing alteration of consciousness once comfort, analgesia and adaptation to the ventilator have been ensured is feasible in critically-ill patients requiring mechanical ventilation, even if, in patients with severe ARDS or ICH, the high dosages of sedatives and analgesics transiently required to provide perfect adaptation to the ventilator often preclude preservation of consciousness. The main components of a sedation algorithm include a clear objective of sedation-analgesia, regular assessments of patient status using validated clinical tools and a precise yet simple dosage adaptation schedule. Development and implementation of a sedation algorithm requires a multidisciplinary approach and an important input from both physicians and nurses. However, several methodologically-correct interventional studies have shown that using an algorithm to administrate sedatives and analgesics results in a significant reduction of MV duration, reaching 50% in some studies. This might translate into a real benefit for the patient point of view provided that preserving patient's comfort remains a constant concern for the caregivers. There is no reliable evidence to date to use propofol rather than midazolam as a sedative agent. Indeed, the way the sedative drug is used, as part of a sedation algorithm, is very likely more important than the selection of the drug itself. Analgesia-based sedation, promoting the use of morphinics alone before the adjunction of hypnotics, represents a new alternative to the traditional combined administration of hypnotics and morphinics. However data on the impact of analgesia-based sedation on patients' outcomes remain sparse to date.
Collapse
Affiliation(s)
- B De Jonghe
- Réanimation médicochirurgicale, centre hospitalier de Poissy, 10, rue du Champ-Gaillard, 78300 Poissy, France.
| | | | | |
Collapse
|
48
|
Tanios MA, de Wit M, Epstein SK, Devlin JW. Perceived barriers to the use of sedation protocols and daily sedation interruption: a multidisciplinary survey. J Crit Care 2008; 24:66-73. [PMID: 19272541 DOI: 10.1016/j.jcrc.2008.03.037] [Citation(s) in RCA: 88] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2007] [Revised: 03/11/2008] [Accepted: 03/29/2008] [Indexed: 10/21/2022]
Abstract
BACKGROUND Although use of sedation protocols and daily sedation interruption (DSI) improve outcome, their current use and barriers affecting their use are unclear. METHODS We designed a multidisciplinary, Web-based survey to determine current use of sedation protocols and DSI and the perceived barriers to each, and administered it to members of the Society of Critical Care Medicine. RESULTS The 904 responders were physicians (60%), nurses (14%), or pharmacists (12%); 45% worked in a university hospital. Of 64% having a sedation protocol, 78% used it for >or=50% of ventilated patients. Reasons for lack of protocol use included no physician order (35%), lack of nursing support (11%), and a fear of oversedation (7%). Daily sedation interruption was used by only 40%. Barriers to DSI included lack of nursing acceptance (22%), concern about risk of patient-initiated device removal (19%), and inducement of either respiratory compromise (26%) or patient discomfort (13%). Clinicians who prefer propofol were more likely to use DSI than those who prefer benzodiazepines (55% vs 40, P < .0001). CONCLUSIONS Current intensive care unit sedation practices are heterogeneous, and the barriers preventing the use of both sedation protocols and DSI are numerous. These barriers should be addressed on an institutional basis to boost the use of these evidence-based practices.
Collapse
Affiliation(s)
- Maged A Tanios
- UCLA School of Medicine, St. Mary Medical Center, Long Beach, CA 90807, USA
| | | | | | | |
Collapse
|
49
|
Abstract
ICU-acquired neuromyopathy (NMAR) and delirium are the two most frequent and severe neurological complications of intensive care medicine. Their mechanisms still remain to be elucidated. The objective of this review is to address the potential role of sedation in occurrence of these complications. There is no evidence that sedation is involved in NMARs. However, the hypothesis that muscle inactivity induced by sedation fosters NMAR is an argument to discontinue or reduce sedatives infusion whenever possible. It is also recommended not to administer propofol more than 48 h at an infusion rate above 5 mg/kg per hour in patients with systemic inflammatory response syndrome, because of the risk of propofol infusion syndrome, which includes notably rhabdomyolysis. The relationship between delirium and sedation are controversial because in most studies, patients were considered delirious though being still sedated and multivariate analysis was lacking. One study showed that lorazepam given continuously was an independent risk factor for daily transition to delirium 24 h later with a 20% increase risk of every unit dose (expressed as log(e)mg). The impact of deepness, daily interruption or titration of sedation on the prevalence of delirium has never been assessed but it seems that deep sedation has to be avoided.
Collapse
Affiliation(s)
- T Sharshar
- Service de réanimation, hôpital Raymond-Poincaré, 104, boulevard Raymond-Poincaré, 92380 Garches, France.
| |
Collapse
|
50
|
de Wit M, Gennings C, Jenvey WI, Epstein SK. Randomized trial comparing daily interruption of sedation and nursing-implemented sedation algorithm in medical intensive care unit patients. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2008; 12:R70. [PMID: 18492267 PMCID: PMC2481461 DOI: 10.1186/cc6908] [Citation(s) in RCA: 94] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/01/2008] [Revised: 05/13/2008] [Accepted: 05/20/2008] [Indexed: 11/30/2022]
Abstract
Introduction Daily interruption of sedation (DIS) and sedation algorithms (SAs) have been shown to decrease mechanical ventilation (MV) duration. We conducted a randomized study comparing these strategies. Methods Mechanically ventilated adults 18 years old or older in the medical intensive care unit (ICU) were randomly assigned to DIS or SA. Exclusion criteria were severe neurocognitive dysfunction, administration of neuromuscular blockers, and tracheostomy. Study endpoints were total MV duration and 28-day ventilator-free survival. Results The study was terminated prematurely after 74 patients were enrolled (DIS 36 and SA 38). The two groups had similar age, gender, racial distribution, Acute Physiology and Chronic Health Evaluation II score, and reason for MV. The Data Safety Monitoring Board convened after DIS patients were found to have higher hospital mortality; however, no causal connection between DIS and increased mortality was identified. Interim analysis demonstrated a significant difference in primary endpoint, and study termination was recommended. The DIS group had longer total duration of MV (median 6.7 versus 3.9 days; P = 0.0003), slower improvement of Sequential Organ Failure Assessment over time (0.70 versus 0.23 units per day; P = 0.025), longer ICU length of stay (15 versus 8 days; P < 0.0001), and longer hospital length of stay (23 versus 12 days; P = 0.01). Conclusion In our cohort of patients, the use of SA was associated with reduced duration of MV and lengths of stay compared with DIS. Based on these results, DIS may not be appropriate in all mechanically ventilated patients. Trial registration ClinicalTrials.gov NCT00205517.
Collapse
Affiliation(s)
- Marjolein de Wit
- Pulmonary and Critical Care Division, Department of Internal Medicine, School of Medicine, Virginia Commonwealth University, PO Box 980050, Richmond, VA 23298-0050, USA.
| | | | | | | |
Collapse
|