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Paul N, Grunow JJ, Rosenthal M, Spies CD, Page VJ, Hanison J, Patel B, Rosenberg A, von Haken R, Pietsch U, Schrag C, Waydhas C, Schellongowski P, Lobmeyr E, Sander M, Piper SK, Conway D, Totzeck A, Weiss B. Enhancing European Management of Analgesia, Sedation, and Delirium: A Multinational, Prospective, Interventional Before-After Trial. Neurocrit Care 2024; 40:898-908. [PMID: 37697129 PMCID: PMC11147880 DOI: 10.1007/s12028-023-01837-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 08/08/2023] [Indexed: 09/13/2023]
Abstract
BACKGROUND The objective of this study was to analyze the impact of a structured educational intervention on the implementation of guideline-recommended pain, agitation, and delirium (PAD) assessment. METHODS This was a prospective, multinational, interventional before-after trial conducted at 12 intensive care units from 10 centers in Germany, Austria, Switzerland, and the UK. Intensive care units underwent a 6-week structured educational program, comprising online lectures, instructional videos, educational handouts, and bedside teaching. Patient-level PAD assessment data were collected in three 1-day point-prevalence assessments before (T1), 6 weeks after (T2), and 1 year after (T3) the educational program. RESULTS A total of 430 patients were included. The rate of patients who received all three PAD assessments changed from 55% (107/195) at T1 to 53% (68/129) at T2, but increased to 73% (77/106) at T3 (p = 0.003). The delirium screening rate increased from 64% (124/195) at T1 to 65% (84/129) at T2 and 77% (82/106) at T3 (p = 0.041). The pain assessment rate increased from 87% (170/195) at T1 to 92% (119/129) at T2 and 98% (104/106) at T3 (p = 0.005). The rate of sedation assessment showed no signficiant change. The proportion of patients who received nonpharmacological delirium prevention measures increased from 58% (114/195) at T1 to 80% (103/129) at T2 and 91% (96/106) at T3 (p < 0.001). Multivariable regression revealed that at T3, patients were more likely to receive a delirium assessment (odds ratio [OR] 2.138, 95% confidence interval [CI] 1.206-3.790; p = 0.009), sedation assessment (OR 4.131, 95% CI 1.372-12.438; p = 0.012), or all three PAD assessments (OR 2.295, 95% CI 1.349-3.903; p = 0.002) compared with T1. CONCLUSIONS In routine care, many patients were not assessed for PAD. Assessment rates increased significantly 1 year after the intervention. Clinical trial registration ClinicalTrials.gov: NCT03553719.
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Affiliation(s)
- Nicolas Paul
- Department of Anesthesiology and Intensive Care Medicine (CCM/CVK), Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Julius J Grunow
- Department of Anesthesiology and Intensive Care Medicine (CCM/CVK), Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Berlin Institute of Health, Berlin, Germany
| | - Max Rosenthal
- Department of Anesthesiology and Intensive Care Medicine (CCM/CVK), Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Claudia D Spies
- Department of Anesthesiology and Intensive Care Medicine (CCM/CVK), Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Valerie J Page
- Department of Anaesthesia, Watford General Hospital, Watford, Hertfordshire, UK
| | - James Hanison
- Manchester Royal Infirmary, Manchester University National Health Service Foundation Trust, Manchester, UK
| | - Brijesh Patel
- Division of Anaesthetics, Pain Medicine and Intensive Care, Imperial College London, London, UK
| | - Alex Rosenberg
- Royal Brompton and Harefield National Health Service Foundation Trust, London, UK
| | - Rebecca von Haken
- Department of Anesthesiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Urs Pietsch
- Department of Anesthesiology and Intensive Care Medicine, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Claudia Schrag
- Clinic of Intensive Care Medicine, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Christian Waydhas
- Department of General and Trauma Surgery, BG University Hospital Bergmannsheil, Bochum, Germany
- Medical Faculty, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | | | - Elisabeth Lobmeyr
- Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Michael Sander
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Giessen, UKGM, Justus-Liebig University Giessen, Giessen, Germany
| | - Sophie K Piper
- Berlin Institute of Health, Berlin, Germany
- Institute of Biometry and Clinical Epidemiology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Institute of Medical Informatics, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Daniel Conway
- Manchester Royal Infirmary, Manchester University National Health Service Foundation Trust, Manchester, UK
| | - Andreas Totzeck
- Department of Neurology and Center for Translational Neuro- and Behavioral Sciences, University Hospital Essen, Essen, Germany
| | - Björn Weiss
- Department of Anesthesiology and Intensive Care Medicine (CCM/CVK), Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany.
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Armstrong-Hough M, Lin P, Venkatesh S, Ghous M, Hough CL, Cook SH, Iwashyna TJ, Valley TS. Ethnic Disparities in Deep Sedation of Patients with Acute Respiratory Distress Syndrome in the United States: Secondary Analysis of a Multicenter Randomized Trial. Ann Am Thorac Soc 2024; 21:620-626. [PMID: 38324712 PMCID: PMC10995555 DOI: 10.1513/annalsats.202307-600oc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2023] [Accepted: 02/05/2024] [Indexed: 02/09/2024] Open
Abstract
Rationale: Patients identified as Hispanic, the largest minority group in the United States, are more likely to die from acute respiratory distress syndrome (ARDS) than non-Hispanic patients. Mechanisms to explain this disparity remain unidentified. However, Hispanic patients may be at risk of overexposure to deep sedation because of language differences between patients and clinicians, and deep sedation is associated with higher ARDS mortality.Objective: We examined associations between Hispanic ethnicity and exposure to deep sedation among patients with ARDS.Methods: A secondary analysis was conducted of patients enrolled in the control arm of a randomized trial of neuromuscular blockade for ARDS across 48 U.S. hospitals. Exposure to deep sedation was measured over the first 5 days that a patient was alive and received mechanical ventilation. Multilevel mixed-effects models were used to evaluate associations between Hispanic ethnicity and exposure to deep sedation, controlling for patient characteristics.Results: Patients identified as Hispanic had approximately five times the odds of deep sedation (odds ratio, 4.98; 95% confidence interval, 2.02-12.28; P < 0.0001) on a given day, compared with non-Hispanic White patients. Hospitals with at least one enrolled Hispanic patient kept all enrolled patients deeply sedated longer than hospitals without any enrolled Hispanic patients (85.8% of ventilator-days vs. 65.5%; P < 0.001).Conclusions: Hispanic patients are at higher risk of exposure to deep sedation than non-Hispanic White patients. There is an urgent need to understand and address disparities in sedation delivery.
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Affiliation(s)
- Mari Armstrong-Hough
- Department of Epidemiology and
- Department of Social and Behavioral Sciences, New York University School of Global Public Health, New York, New York
| | - Paul Lin
- Institute for Healthcare Policy and Innovation
| | | | - Muhammad Ghous
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, and
| | - Catherine L. Hough
- Division of Pulmonary and Critical Care, Oregon Health and Science University, Portland, Oregon
| | - Stephanie H. Cook
- Department of Social and Behavioral Sciences, New York University School of Global Public Health, New York, New York
| | - Theodore J. Iwashyna
- Department of Medicine and Department of Health Policy and Management, Johns Hopkins University, Baltimore, Maryland; and
| | - Thomas S. Valley
- Institute for Healthcare Policy and Innovation
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, and
- Center for Bioethics and Social Sciences in Medicine, University of Michigan, Ann Arbor, Michigan
- VA Center for Clinical Management Research, Ann Arbor, Michigan
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Sales A. Reporting on implementation trials with null findings: the need for concurrent process evaluation reporting. BMJ Qual Saf 2022; 31:779-781. [PMID: 35701169 DOI: 10.1136/bmjqs-2022-014693] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/01/2022] [Indexed: 11/03/2022]
Affiliation(s)
- Anne Sales
- Sinclair School of Nursing and Department of Family and Community Medicine, University of Missouri, Columbia, Missouri, USA
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
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Moran BL, Myburgh JA, Scott DA. The complications of opioid use during and post-intensive care admission: A narrative review. Anaesth Intensive Care 2022; 50:108-126. [PMID: 35172616 DOI: 10.1177/0310057x211070008] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Opioids are a commonly administered analgesic medication in the intensive care unit, primarily to facilitate invasive mechanical ventilation. Consensus guidelines advocate for an opioid-first strategy for the management of acute pain in ventilated patients. As a result, these patients are potentially exposed to high opioid doses for prolonged periods, increasing the risk of adverse effects. Adverse effects relevant to these critically ill patients include delirium, intensive care unit-acquired infections, acute opioid tolerance, iatrogenic withdrawal syndrome, opioid-induced hyperalgesia, persistent opioid use, and chronic post-intensive care unit pain. Consequently, there is a challenge of optimising analgesia while minimising these adverse effects. This narrative review will discuss the characteristics of opioid use in the intensive care unit, outline the potential short-term and long-term adverse effects of opioid therapy in critically ill patients, and outline a multifaceted strategy for opioid minimisation.
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Affiliation(s)
- Benjamin L Moran
- Critical Care Program, The George Institute of Global Health, Sydney, Australia.,Department of Intensive Care, 90112Gosford Hospital, Gosford Hospital, Gosford, Australia.,Department of Anaesthesia and Pain Medicine, Gosford Hospital, Gosford, Australia.,School of Medicine and Public Health, University of Newcastle, Callaghan, Australia
| | - John A Myburgh
- Critical Care Program, The George Institute of Global Health, Sydney, Australia.,Faculty of Medicine, 7800University of New South Wales, University of New South Wales, Kensington, Australia.,St George Hospital, Kogarah, Australia
| | - David A Scott
- Department of Anaesthesia and Acute Pain Medicine, St Vincent's Hospital, Fitzroy, Australia.,Department of Critical Care, University of Melbourne, Parkville, Australia
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Kerbage SH, Garvey L, Lambert GW, Willetts G. Pain assessment of the adult sedated and ventilated patients in the intensive care setting: A scoping review. Int J Nurs Stud 2021; 122:104044. [PMID: 34399307 DOI: 10.1016/j.ijnurstu.2021.104044] [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] [Received: 04/05/2021] [Revised: 06/23/2021] [Accepted: 07/17/2021] [Indexed: 11/15/2022]
Abstract
BACKGROUND Pain is frequently encountered in the intensive care setting. Given the impact of pain assessment on patient outcomes and length of hospital stay, studies have been conducted to validate tools, establish guidelines and cast light on practices relating to pain assessment. OBJECTIVE To examine the extent, range and nature of the evidence around pain assessment practices in adult patients who cannot self-report pain in the intensive care setting and summarise the findings from a heterogenous body of evidence to aid in the planning and the conduct of future research and management of patient care. The specific patient cohort studied was the sedated/ ventilated patient within the intensive care setting. DESIGN A scoping review protocol utilised the Preferred Reporting Items for Systematic Reviews and Meta-Analysis extension for Scoping review checklist (PRISMA-ScR). METHODS The review comprised of five phases: identifying the research question, identifying relevant studies, study selection, charting the data and collating, summarizing, and reporting the results. Databases were systematically searched from January to April 2020. Databases included were Scopus, Web of Science, Medline via Ovid, CINAHL COMPLETE via EBSCO host, Health Source and PUBMED. Limits were applied on dates (2000 to current), language (English), subject (human) and age (adult). Key words used were "pain", "assessment", "measurement", "tools", "instruments", "practices", "sedated", "ventilated", "adult". A hand search technique was used to search citations within articles. Database alerts were set to apprise the availability of research articles pertaining to pain assessment practices in the intensive care setting. RESULTS The review uncovered literature categorised under five general themes: behaviour pain assessment tools, pain assessment guidelines, position statements and quality improvement projects, enablers and barriers to pain assessment, and evidence appertaining to actual practices. Behaviour pain assessment tools are the benchmark for pain assessment of sedated and ventilated patients. The reliability and validity of physiologic parameters to assess pain is yet to be determined. Issues of compliance with pain assessment guidelines and tools exist and impact on practices. In some countries like Australia, there is a dearth of information regarding the prevalence and characteristics of patients receiving analgesia, type of analgesia used, pain assessment practices and the process of recording pain management. In general, pain assessment varies across different intensive care settings and lacks consistency. CONCLUSION Research on pain assessment practices requires further investigation to explore the causative mechanisms that contribute to poor compliance with established pain management guidelines. The protocol of this review was registered with Open Science Framework (https://osf.io/25a6) Tweetable abstract: Pain assessment in intensive care settings lacks consistency. New information is needed to understand the causative mechanisms underpinning poor compliance with guidelines.
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Affiliation(s)
| | - Loretta Garvey
- Department of Nursing and Allied Health; Faculty of Health, Arts and Design
| | - Gavin W Lambert
- Iverson Health Innovation Research Institute, Swinburne University of Technology, Hawthorn, VIC, Australia
| | - Georgina Willetts
- Department of Nursing and Allied Health; Faculty of Health, Arts and Design; Iverson Health Innovation Research Institute, Swinburne University of Technology, Hawthorn, VIC, Australia
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Madhuvu A, Endacott R, Plummer V, Morphet J. Ventilation bundle compliance in two Australian intensive care units: An observational study. Aust Crit Care 2020; 34:327-332. [PMID: 33268313 PMCID: PMC8205301 DOI: 10.1016/j.aucc.2020.09.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2020] [Revised: 09/01/2020] [Accepted: 09/02/2020] [Indexed: 11/15/2022] Open
Abstract
Background The ventilation bundle has been used in adult intensive care units to decrease harm and improve quality of care for mechanically ventilated patients. The ventilation bundle focuses on prevention of specific complications of mechanical ventilation; ventilator-associated pneumonia, sepsis, barotrauma, pulmonary oedema, pulmonary embolism, and acute respiratory distress syndrome. The Institute for Healthcare Improvement ventilation bundle consists of five structured evidence-based interventions: head of the bed elevation at 30–45°; daily sedation interruptions and assessment of readiness to extubate; peptic ulcer prophylaxis; deep vein thrombosis prophylaxis; and daily oral care with chlorhexidine. Objectives The objective of the study was to evaluate the use of the ventilation bundle in two intensive care units in Victoria, Australia. Methods This is a 3-month prospective observational study in two intensive care units. Patient medical records were reviewed on days 3, 4, and 5 of mechanical ventilation using a prevalidated ventilation bundle checklist. Results A total of 96 critically ill patients required mechanical ventilation for more than 2 d. Patients had a mean age of 64.50 y (standard deviation = 14.89), with an Acute Physiology, Age, Chronic Health Evaluation (APACHE) III mean score of 79.27 (standard deviation = 27.11). The mean ventilation bundle compliance rate was 88.3% on the three consecutive mechanical ventilation days (day 3 = 79.4%, day 4 = 91.1%, and day 5 = 96.7%). There was a statistically significant difference in the mean APACHE III score between patients who had head of bed elevation and those without head of bed elevation, on days 3 (p = <0.001) and 4 (p = 0.007). Conclusion The ventilation bundle elements were used in Australian intensive care units. The likelihood of having all ventilation bundle elements on day 3 was low if the patient's APACHE III score was high. However, the ventilation bundle compliance rate increased with mechanical ventilation days.
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Affiliation(s)
- Auxillia Madhuvu
- School of Nursing and Midwifery, Monash University, McMahons Road, Frankston, Victoria, Australia; Monash Health, Dandenong Hospital, 135 David Street, Dandenong, Victoria, Australia.
| | - Ruth Endacott
- School of Nursing and Midwifery, Monash University, McMahons Road, Frankston, Victoria, Australia; Plymouth University/Royal Devon and Exeter Hospital Clinical School, Drake Circus, Plymouth, Devon, PL4 8AA, United Kingdom
| | - Virginia Plummer
- School of Nursing and Midwifery, Monash University, McMahons Road, Frankston, Victoria, Australia; School of Nursing and Healthcare Professions, Federation University, Berwick, Victoria, Australia
| | - Julia Morphet
- School of Nursing and Midwifery, Monash University, McMahons Road, Frankston, Victoria, Australia; Monash Health, Dandenong Hospital, 135 David Street, Dandenong, Victoria, Australia
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Sutton-Smith L. A quality improvement project to improve the identification and management of delirium. Nurs Crit Care 2020; 26:183-189. [PMID: 32906223 DOI: 10.1111/nicc.12549] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2020] [Revised: 08/01/2020] [Accepted: 08/18/2020] [Indexed: 12/23/2022]
Abstract
BACKGROUND Efforts to reduce delirium burden through screening, identification, and prevention is considered one of the major public health priorities of the last decade. In 2017, an audit of delirium screening in our unit revealed suboptimum assessment of our patients, with compliance with the Confusion Assessment Method for the ICU (CAM-ICU) assessments highly variable and ad hoc, and sometimes not at all. A separate sedation audit also revealed that our sedation practices did not align with current critical care guidelines emphasizing light sedation strategies. AIM The aim of this project was to develop resources to educate the unit on delirium, improve the management of sedation with a sedation algorithm, formalize the elements of delirium prevention and care into a delirium pathway, and improve the compliance with delirium screening. METHODS We developed a delirium clinical pathway and sedation algorithm, a delirium resource book, and an online educational module on the district health board (DHB) intranet. We provided extensive teaching of all these resources over delirium month. We used pre- and post-auditing of sedation practices and delirium screening compliance to inform the success of this project. RESULTS Of the 140 members of staff, 85% (n = 120) received delirium education. In 2018/2019, 84% of 145 patient charts reached the unit standard of four to six hourly CAM-ICU assessments compared with 45% in 2017. The sedation audit revealed a slight improvement in the trend towards lighter sedation, with Richmond Agitation Sedation Scoring (RASS) scores reflecting light sedation, increasing from a mean of 31% in 2017 to 41% in 2019 from 41 patient charts. CONCLUSIONS This project provides a useful framework to enable future quality improvement work around delirium and sedation management. The clinical pathway and sedation algorithm have been a useful tool to introduce to the unit as a way of formalizing the elements of delirium care and assessment.
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Affiliation(s)
- Lynsey Sutton-Smith
- Intensive Care Unit, Wellington Regional Hospital (Capital & Coast DHB), Wellington Regional Hospital, Wellington, New Zealand.,Teaching Fellow: School of Nursing, Midwifery and Health Practice, Victoria University of Wellington, Newtown, Wellington, New Zealand
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Guttormson JL, Chlan L, Tracy MF, Hetland B, Mandrekar J. Nurses' Attitudes and Practices Related to Sedation: A National Survey. Am J Crit Care 2019; 28:255-263. [PMID: 31263007 DOI: 10.4037/ajcc2019526] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND Nurses are fundamental to the implementation of sedation protocols for patients receiving mechanical ventilation. A 2005 survey showed that nurses' attitudes toward sedation affected their sedation practices. Since then, updated guidelines on managing pain, agitation, and delirium have been published. OBJECTIVE To explore nurses' self-reported attitudes and practices related to sedation and determine whether they have changed in the past decade. METHODS Members of the American Association of Critical-Care Nurses were invited to complete the Nurse Sedation Practices Scale, which measures nurses' self-reported sedation practices and factors that affect them. Item and subscale responses were analyzed, and differences in item responses by respondent characteristics were determined. RESULTS Respondents (N = 177) were mostly staff nurses (68%) with a bachelor's degree in nursing (63%). Nurses' attitudes toward the effectiveness of sedation in relieving patients' distress during mechanical ventilation correlated positively with their intention to administer sedatives (r s = 0.65). Sixty-six percent of nurses agreed that sedation was necessary for patients' comfort, and 34% agreed that limiting patients' recall was a desired outcome of sedation. Respondents with more experience or CCRN certification had a less positive evaluation of the effectiveness of sedation in minimizing distress. CONCLUSIONS Nurses' attitudes toward sedating patients receiving mechanical ventilation have shifted in the past decade, with fewer nurses now believing that all patients should be sedated. However, more than half of nurses still agree that sedation is needed for patients' comfort, highlighting the need to consider nurses' attitudes when seeking to optimize sedation practices during mechanical ventilation.
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Affiliation(s)
- Jill L Guttormson
- Jill L. Guttormson is an associate professor, Marquette University College of Nursing, Milwaukee, Wisconsin. Linda Chlan is associate dean for nursing research and a professor of nursing, Department of Nursing, and Jay Mandrekar is a professor of biostatistics, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota. Mary Fran Tracy is an associate professor, University of Minnesota School of Nursing, and nurse scientist, University of Minnesota Medical Center, Minneapolis, Minnesota. Breanna Hetland is an assistant professor, University of Nebraska Medical Center College of Nursing, Omaha, Nebraska.
| | - Linda Chlan
- Jill L. Guttormson is an associate professor, Marquette University College of Nursing, Milwaukee, Wisconsin. Linda Chlan is associate dean for nursing research and a professor of nursing, Department of Nursing, and Jay Mandrekar is a professor of biostatistics, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota. Mary Fran Tracy is an associate professor, University of Minnesota School of Nursing, and nurse scientist, University of Minnesota Medical Center, Minneapolis, Minnesota. Breanna Hetland is an assistant professor, University of Nebraska Medical Center College of Nursing, Omaha, Nebraska
| | - Mary Fran Tracy
- Jill L. Guttormson is an associate professor, Marquette University College of Nursing, Milwaukee, Wisconsin. Linda Chlan is associate dean for nursing research and a professor of nursing, Department of Nursing, and Jay Mandrekar is a professor of biostatistics, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota. Mary Fran Tracy is an associate professor, University of Minnesota School of Nursing, and nurse scientist, University of Minnesota Medical Center, Minneapolis, Minnesota. Breanna Hetland is an assistant professor, University of Nebraska Medical Center College of Nursing, Omaha, Nebraska
| | - Breanna Hetland
- Jill L. Guttormson is an associate professor, Marquette University College of Nursing, Milwaukee, Wisconsin. Linda Chlan is associate dean for nursing research and a professor of nursing, Department of Nursing, and Jay Mandrekar is a professor of biostatistics, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota. Mary Fran Tracy is an associate professor, University of Minnesota School of Nursing, and nurse scientist, University of Minnesota Medical Center, Minneapolis, Minnesota. Breanna Hetland is an assistant professor, University of Nebraska Medical Center College of Nursing, Omaha, Nebraska
| | - Jay Mandrekar
- Jill L. Guttormson is an associate professor, Marquette University College of Nursing, Milwaukee, Wisconsin. Linda Chlan is associate dean for nursing research and a professor of nursing, Department of Nursing, and Jay Mandrekar is a professor of biostatistics, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota. Mary Fran Tracy is an associate professor, University of Minnesota School of Nursing, and nurse scientist, University of Minnesota Medical Center, Minneapolis, Minnesota. Breanna Hetland is an assistant professor, University of Nebraska Medical Center College of Nursing, Omaha, Nebraska
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García-Sánchez M, Caballero-López J, Ceniceros-Rozalén I, Giménez-Esparza Vich C, Romera-Ortega M, Pardo-Rey C, Muñoz-Martínez T, Escudero D, Torrado H, Chamorro-Jambrina C, Palencia-Herrejón E. Prácticas de analgosedación y delirium en Unidades de Cuidados Intensivos españolas: Encuesta 2013-2014. Med Intensiva 2019; 43:225-233. [DOI: 10.1016/j.medin.2018.12.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Revised: 12/02/2018] [Accepted: 12/04/2018] [Indexed: 01/17/2023]
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10
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Nin Vaeza N. Analgosedation and delirium practices in Spanish ICUs. Med Intensiva 2019; 43:195-196. [PMID: 30795924 DOI: 10.1016/j.medin.2019.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Accepted: 01/10/2019] [Indexed: 11/29/2022]
Affiliation(s)
- N Nin Vaeza
- Coordinador de la Unidad de Cuidados Intensivos, Hospital Español, Montevideo, Uruguay.
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McGain F, Lam K, Bates S, Towns M, French C. An audit of propofol administration in the intensive care unit: Infusion pump-recorded versus electronically documented amounts. Aust Crit Care 2019; 33:25-29. [PMID: 30770268 DOI: 10.1016/j.aucc.2018.12.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Revised: 12/16/2018] [Accepted: 12/28/2018] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Although propofol is widely used for sedation in intensive care units around Australia, evaluation of bedside nursing practices of the administration of propofol have been limited. We investigated whether there was a discrepancy between the amount of propofol delivered by the infusion pump and that recorded electronically and consequently patient exposure to avoidable harms. AIMS The aim of this research was to compare the total amount of propofol administered to intensive care patients via a programmable infusion pump with that documented in the electronic medical record (EMR). Secondary objectives were to ascertain the percentage of 1) patients exposed to a propofol dose greater than recommended and 2) daily energy requirements administered as propofol infusion. METHODS This was a prospective, observational study of total propofol delivered to 50 patients in a 14-bed metropolitan, Australian intensive care unit. Infusion pump data and entries from the EMR were collated. RESULTS Propofol sedation was administered for a median 18 (interquartile range: 14-47) hours with median total propofol 3025 mg (interquartile range: 1840-7755 mg) by pump and 3250 mg (interquartile range: 1915-6960 mg) by EMR, i.e. 1.9 (interquartile range: 1.3-2.3) mg/kg/hour by pump (correlation coefficient = 0.99). The total bolus propofol documented in the EMR was a median 330 mg (interquartile range: -838 to -124) less than the pump amount. Nineteen (38%) patients had no EMR-documented propofol boluses yet had received at least one bolus via the pump. In two of 50 (4%) patients, the pump propofol infusion dose was above the recommended maximum safe dose of 4 mg/kg/h. CONCLUSION In this cohort of patients, the bolus administration of propofol was frequently not documented, potentially placing some patients at risk of drug-related toxicity. Further research to develop and implement strategies to improve the documentation of propofol administration is indicated.
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Affiliation(s)
- Forbes McGain
- Departments of Anaesthesia and Intensive Care, Western Health, Melbourne, Australia; Planetary Health Platform, Faculty of Medicine, University of Sydney, Sydney, Australia.
| | - Kelvin Lam
- Department of Anaesthesia, Dandenong Hospital, Melbourne, Australia.
| | - Samantha Bates
- Departments of Anaesthesia and Intensive Care, Western Health, Melbourne, Australia.
| | - Miriam Towns
- Departments of Anaesthesia and Intensive Care, Western Health, Melbourne, Australia.
| | - Craig French
- Departments of Anaesthesia and Intensive Care, Western Health, Melbourne, Australia; Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia.
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Aitken LM, Bucknall T, Kent B, Mitchell M, Burmeister E, Keogh SJ. Protocol-directed sedation versus non-protocol-directed sedation in mechanically ventilated intensive care adults and children. Cochrane Database Syst Rev 2018; 11:CD009771. [PMID: 30480753 PMCID: PMC6516800 DOI: 10.1002/14651858.cd009771.pub3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
BACKGROUND The sedation needs of critically ill patients have been recognized as a core component of critical care that is vital to assist recovery and ensure humane treatment. Evidence suggests that sedation requirements are not always optimally managed. Suboptimal sedation, both under- and over-sedation, have been linked to short-term (e.g. length of stay) and long-term (e.g. psychological recovery) outcomes. Strategies to improve sedation assessment and management have been proposed. This review was originally published in 2015 and updated in 2018. OBJECTIVES To assess the effects of protocol-directed sedation management compared to usual care on the duration of mechanical ventilation, intensive care unit (ICU) and hospital mortality and other patient outcomes in mechanically ventilated ICU adults and children. SEARCH METHODS We used the standard search strategy of the Cochrane Anaesthesia, Critical and Emergency Care Group (ACE). We searched the Cochrane Central Register of Controlled trials (CENTRAL) (December 2017), MEDLINE (OvidSP) (2013 to December 2017), Embase (OvidSP) (2013 to December 2017), CINAHL (BIREME host) (2013 to December 2017), LILACS (2013 to December 2017), trial registries and reference lists of articles. (The original search was run in November 2013). SELECTION CRITERIA We included randomized controlled trials (RCTs) and quasi-randomized controlled trials conducted in ICUs comparing management with and without protocol-directed sedation in intensive care adults and children. DATA COLLECTION AND ANALYSIS Two authors screened the titles and abstracts and then full-text reports identified from our electronic search. We assessed seven domains of potential risk of bias for the included studies. We examined clinical, methodological and statistical heterogeneity and used the random-effects model for meta-analysis where we considered it appropriate. We calculated the mean difference (MD) for duration of mechanical ventilation and risk ratio (RR) for mortality across studies, with 95% confidence intervals (CIs). MAIN RESULTS We included four studies with a total of 3323 participants (864 adults and 2459 paediatrics) in this update. Three studies were single-centre, patient-level RCTs and one study was a multicentre cluster-RCT. The settings were in metropolitan centres and included general, mixed medical-surgical, medical only and a range of paediatric units. All four included studies compared the use of protocol-directed sedation, specifically protocols delivered by nurses, with usual care. We rated the risk of selection bias due to random sequence generation low for two studies and unclear for two studies. The risk of bias was highly variable across the domains and studies, with the risk of selection and performance bias generally rated high and the risk of detection and attrition bias generally rated low.When comparing protocol-directed sedation with usual care, there was no clear evidence of difference in duration of mechanical ventilation in hours for the entire duration of the first ICU stay for each patient (MD -28.15 hours, 95% CI -69.15 to 12.84; I2 = 85%; 4 studies; adjusted sample 2210 participants; low-quality evidence). There was no clear evidence of difference in ICU mortality (RR 0.77, 95% CI 0.39 to 1.50; I2 = 67%; 2 studies; 513 participants; low-quality evidence), or hospital mortality (RR 0.90, 95% CI 0.72 to 1.13; I2 = 10%; 3 studies; adjusted sample 2088 participants; low-quality evidence). There was no clear evidence of difference in ICU length of stay (MD -1.70 days, 95% CI-3.71 to 0.31; I2 = 82%; 4 studies; adjusted sample of 2123 participants; low-quality of evidence), however there was evidence of a significant reduction in hospital length of stay (MD -3.09 days, 95% CI -5.08 to -1.10; I2 = 2%; 3 studies; adjusted sample of 1922 participants; moderate-quality evidence). There was no clear evidence of difference in the incidence of self-extubation (RR 0.88, 95% CI 0.55 to 1.42; I2 = 0%; 2 studies; adjusted sample of 1687 participants; high-quality evidence), or incidence of tracheostomy (RR 0.67, 95% CI 0.35 to 1.30; I2 = 66%; 3 studies; adjusted sample of 2008 participants; low-quality evidence). Only one study examined incidence of reintubation, therefore we could not pool data; there was no clear evidence of difference (RR 0.65, 95% CI 0.35 to 1.24; 1 study; 321 participants; low-quality evidence). AUTHORS' CONCLUSIONS There is currently limited evidence from RCTs evaluating the effectiveness of protocol-directed sedation on patient outcomes. The four included RCTs reported conflicting results and heterogeneity limited the interpretation of results for the primary outcomes of duration of mechanical ventilation and mortality. Further studies, taking into account differing contextual characteristics, are necessary to inform future practice. Methodological strategies to reduce the risk of bias need to be considered in future studies.
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Affiliation(s)
- Leanne M Aitken
- City, University of LondonSchool of Health SciencesMyddelton StreetLondonUKEC1V 0HB
- Griffith UniversityNational Centre of Research Excellence in Nursing, Menzies Health Institute QueenslandBrisbaneAustralia
- Princess Alexandra HospitalIntensive Care UnitIpswich RdWoolloongabbaQueenslandAustralia4102
| | - Tracey Bucknall
- Faculty of Health, Deakin UniversitySchool of Nursing and MidwiferyBurwood Campus221 Burwood Road, BurwoodGeelongVictoriaAustralia3125
- Alfred HealthDeakin University Centre for Quality and Patient Safety Research ‐ Alfred Health Partnership55 Commercial RoadMelbourneAustralia
| | - Bridie Kent
- Deakin UniversitySchool of Nursing and Midwifery, Deakin University Centre for Quality and Patient Safety ResearchGeelongAustralia
- University of PlymouthSchool of Nursing and Midwifery8 Portland VillasPlymouthUKPL4 8AA
| | - Marion Mitchell
- Princess Alexandra HospitalIntensive Care UnitIpswich RdWoolloongabbaQueenslandAustralia4102
- Griffith UniversityNHMRC Centre of Research Excellence in Nursing, Centre for Health Practice Innovation, Menzies Health Institute QueenslandBrisbaneQueenslandAustralia4102
| | - Elizabeth Burmeister
- Griffith UniversityNational Centre of Research Excellence in Nursing, Menzies Health Institute QueenslandBrisbaneAustralia
- Princess Alexandra HospitalNursing Practice and Development UnitBrisbaneAustralia
| | - Samantha J Keogh
- Queensland University of TechnologySchool of NursingVictoria Park RoadKelvin GroveBrisbaneQueenslandAustralia4059
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Staveski SL, Wu M, Tesoro TM, Roth SJ, Cisco MJ. Interprofessional Team's Perception of Care Delivery After Implementation of a Pediatric Pain and Sedation Protocol. Crit Care Nurse 2018; 37:66-76. [PMID: 28572103 DOI: 10.4037/ccn2017538] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND Pain and agitation are common experiences of patients in pediatric cardiac intensive care units. Variability in assessments by health care providers, communication, and treatment of pain and agitation creates challenges in management of pain and sedation. OBJECTIVES To develop guidelines for assessment and treatment of pain, agitation, and delirium in the pediatric cardiac intensive unit in an academic children's hospital and to document the effects of implementation of the guidelines on the interprofessional team's perception of care delivery and team function. METHODS Before and after implementation of the guidelines, interprofessional team members were surveyed about the members' perception of analgesia, sedation, and delirium management RESULTS: Members of the interprofessional team felt more comfortable with pain and sedation management after implementation of the guidelines. Team members reported improvements in team communication on patients' comfort. Members thought that important information was less likely to be lost during transfer of care. They also noted that the team carried out comfort management plans and used pharmacological and nonpharmacological therapies better after implementation of the guidelines than they did before implementation. CONCLUSIONS Guidelines for pain and sedation management were associated with perceived improvements in team function and patient care by members of the interprofessional team.
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Affiliation(s)
- Sandra L Staveski
- Sandra L. Staveski is an assistant professor at Cincinnati Children's Hospital Medical Center, Department of Research in Patient Services, and the Heart Institute, Cincinnati, Ohio. .,May Wu is a clinical pharmacist at Lucile Packard Children's Hospital Stanford, Palo Alto, California. .,Tiffany M. Tesoro is a clinical pharmacist in the cardiovascular intensive care unit and coordinates the PGY-1 pharmacy residency program at Lucile Packard Children's Hospital-Stanford. She is also an assistant clinical professor, School of Pharmacy, University of California, San Francisco, California. .,Stephen J. Roth is chief of the division of pediatric cardiology and professor of pediatrics (cardiology), Stanford University School of Medicine, Stanford, California, and the director of the children's heart center at Lucile Packard Children's Hospital Stanford. .,Michael J. Cisco is a clinical assistant professor of pediatrics, Pediatric Critical Care Medicine, University of San Francisco School of Medicine, San Francisco, California, and an attending physician in the pediatric cardiac intensive care unit, University of California San Francisco-Benioff Children's Hospital, San Francisco, California.
| | - May Wu
- Sandra L. Staveski is an assistant professor at Cincinnati Children's Hospital Medical Center, Department of Research in Patient Services, and the Heart Institute, Cincinnati, Ohio.,May Wu is a clinical pharmacist at Lucile Packard Children's Hospital Stanford, Palo Alto, California.,Tiffany M. Tesoro is a clinical pharmacist in the cardiovascular intensive care unit and coordinates the PGY-1 pharmacy residency program at Lucile Packard Children's Hospital-Stanford. She is also an assistant clinical professor, School of Pharmacy, University of California, San Francisco, California.,Stephen J. Roth is chief of the division of pediatric cardiology and professor of pediatrics (cardiology), Stanford University School of Medicine, Stanford, California, and the director of the children's heart center at Lucile Packard Children's Hospital Stanford.,Michael J. Cisco is a clinical assistant professor of pediatrics, Pediatric Critical Care Medicine, University of San Francisco School of Medicine, San Francisco, California, and an attending physician in the pediatric cardiac intensive care unit, University of California San Francisco-Benioff Children's Hospital, San Francisco, California
| | - Tiffany M Tesoro
- Sandra L. Staveski is an assistant professor at Cincinnati Children's Hospital Medical Center, Department of Research in Patient Services, and the Heart Institute, Cincinnati, Ohio.,May Wu is a clinical pharmacist at Lucile Packard Children's Hospital Stanford, Palo Alto, California.,Tiffany M. Tesoro is a clinical pharmacist in the cardiovascular intensive care unit and coordinates the PGY-1 pharmacy residency program at Lucile Packard Children's Hospital-Stanford. She is also an assistant clinical professor, School of Pharmacy, University of California, San Francisco, California.,Stephen J. Roth is chief of the division of pediatric cardiology and professor of pediatrics (cardiology), Stanford University School of Medicine, Stanford, California, and the director of the children's heart center at Lucile Packard Children's Hospital Stanford.,Michael J. Cisco is a clinical assistant professor of pediatrics, Pediatric Critical Care Medicine, University of San Francisco School of Medicine, San Francisco, California, and an attending physician in the pediatric cardiac intensive care unit, University of California San Francisco-Benioff Children's Hospital, San Francisco, California
| | - Stephen J Roth
- Sandra L. Staveski is an assistant professor at Cincinnati Children's Hospital Medical Center, Department of Research in Patient Services, and the Heart Institute, Cincinnati, Ohio.,May Wu is a clinical pharmacist at Lucile Packard Children's Hospital Stanford, Palo Alto, California.,Tiffany M. Tesoro is a clinical pharmacist in the cardiovascular intensive care unit and coordinates the PGY-1 pharmacy residency program at Lucile Packard Children's Hospital-Stanford. She is also an assistant clinical professor, School of Pharmacy, University of California, San Francisco, California.,Stephen J. Roth is chief of the division of pediatric cardiology and professor of pediatrics (cardiology), Stanford University School of Medicine, Stanford, California, and the director of the children's heart center at Lucile Packard Children's Hospital Stanford.,Michael J. Cisco is a clinical assistant professor of pediatrics, Pediatric Critical Care Medicine, University of San Francisco School of Medicine, San Francisco, California, and an attending physician in the pediatric cardiac intensive care unit, University of California San Francisco-Benioff Children's Hospital, San Francisco, California
| | - Michael J Cisco
- Sandra L. Staveski is an assistant professor at Cincinnati Children's Hospital Medical Center, Department of Research in Patient Services, and the Heart Institute, Cincinnati, Ohio.,May Wu is a clinical pharmacist at Lucile Packard Children's Hospital Stanford, Palo Alto, California.,Tiffany M. Tesoro is a clinical pharmacist in the cardiovascular intensive care unit and coordinates the PGY-1 pharmacy residency program at Lucile Packard Children's Hospital-Stanford. She is also an assistant clinical professor, School of Pharmacy, University of California, San Francisco, California.,Stephen J. Roth is chief of the division of pediatric cardiology and professor of pediatrics (cardiology), Stanford University School of Medicine, Stanford, California, and the director of the children's heart center at Lucile Packard Children's Hospital Stanford.,Michael J. Cisco is a clinical assistant professor of pediatrics, Pediatric Critical Care Medicine, University of San Francisco School of Medicine, San Francisco, California, and an attending physician in the pediatric cardiac intensive care unit, University of California San Francisco-Benioff Children's Hospital, San Francisco, California
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Kotfis K, Zegan-Barańska M, Żukowski M, Kusza K, Kaczmarczyk M, Ely EW. Multicenter assessment of sedation and delirium practices in the intensive care units in Poland - is this common practice in Eastern Europe? BMC Anesthesiol 2017; 17:120. [PMID: 28865447 PMCID: PMC5581441 DOI: 10.1186/s12871-017-0415-2] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2017] [Accepted: 08/25/2017] [Indexed: 11/25/2022] Open
Abstract
Background The majority of critically ill patients experience distress during their stay in the Intensive Care Unit (ICU), resulting from systemic illness, multiple interventions and environmental factors. Providing humane care should address concomitant treatment of pain, agitation and delirium. The use of sedation and approaches to ICU delirium should be monitored according to structured guidelines. However, it is unknown to what extent these concepts are followed in Eastern European countries like Poland. The aim of this study was to evaluate sedation and delirium practices in ICUs in Poland, as a representative of the Eastern European block, particularly the implementation of sedation and ICU delirium screening tools, availability of written sedation guidelines, choice of sedation and delirium treatment agents. Methods A national postal survey was conducted in all Polish ICUs in early 2016. Results A total of 165 responses out of 436 addressed units were received (37.8%). Out of responding ICUs delirium is monitored in only 11.9% of the units in Poland. Sedation monitoring tool is used in only 46.1% of units. Only 19.4% of ICUs have written protocols for sedation and 32.1% do not practice daily sedation interruption. The most frequently used agents for short-term sedation (<24 h) were propofol and fentanyl infusions and benzodiazepines (midazolam) and morphine for longer sedation (>24 h). The preferred agents for delirium treatment were haloperidol (77.6%), dexmedetomidine (43.6%) and quetiapine (19.4%). Close to one-third (32.7%) of respondents chose a benzodiazepine (diazepam) for ICU delirium treatment. Non-pharmacological treatment for ICU delirium was reported by only 45% of the respondents. Conclusions A majority of Polish ICUs do not adhere to international guidelines regarding sedation and delirium practices. There continues to be inadequate use of sedation and delirium monitoring tools. High usage of benzodiazepines for sedation and ICU delirium treatment reveals persistence of non-evidence-based practice. This study should prompt further assessment of other Eastern Europe countries and help generate a collective response to update these aspects of patient safety and comfort.
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Affiliation(s)
- Katarzyna Kotfis
- Department of Anaesthesiology, Intensive Therapy and Acute Intoxications, Pomeranian Medical University, Szczecin, Poland.
| | - Małgorzata Zegan-Barańska
- Department of Anaesthesiology, Intensive Therapy and Acute Intoxications, Pomeranian Medical University, Szczecin, Poland
| | - Maciej Żukowski
- Department of Anaesthesiology, Intensive Therapy and Acute Intoxications, Pomeranian Medical University, Szczecin, Poland
| | - Krzysztof Kusza
- Department of Anesthesiology and Intensive Therapy, Poznan University of Medical Sciences University, Poznań, Poland
| | - Mariusz Kaczmarczyk
- Department of Clinical and Molecular Biochemistry, Pomeranian Medical University, Szczecin, Poland
| | - E Wesley Ely
- Department of Medicine/Allergy, Pulmonary and Critical Care, Vanderbilt University School ofMedicine, Vetaran's Affairs Geriatric Research Education Clinical Center (GRECC) for Tennessee Valley, Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, TN, USA
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15
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Silva DCD, Barbosa TP, Bastos ASD, Beccaria LM. Associação entre intensidades de dor e sedação em pacientes de terapia intensiva. ACTA PAUL ENFERM 2017. [DOI: 10.1590/1982-0194201700037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Resumo Objetivos Identificar o perfil clínico, intensidades de dor e sedação em pacientes na unidade de terapia intensiva e associar os dados. Métodos Estudo quantitativo e transversal, realizado em unidade de terapia intensiva de um hospital de ensino. Amostra de 240 pacientes. Os dados clínicos foram obtidos do prontuário eletrônico. Foram utilizadas escalas de sedação e agitação de Richmond, dor visual numérica e Behavioral pain scale, preenchidas por enfermeiros. Resultados Prevaleceram pacientes não idosos, masculinos, neurológicos, cirúrgicos, com sedação profunda. Houve maior mortalidade em pacientes com sedação profunda e maior tempo de internação naqueles com sedação moderada. A sedação não se mostrou efetiva para suprimir a dor, mas serviu para controlar sua intensidade. Conclusão A identificação da intensidade de dor e sedação realizada por enfermeiros auxilia na tomada de decisão e propicia adequado manejo da sedoanalgesia de pacientes em terapia intensiva.
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Costa DK, White MR, Ginier E, Manojlovich M, Govindan S, Iwashyna TJ, Sales AE. Identifying Barriers to Delivering the Awakening and Breathing Coordination, Delirium, and Early Exercise/Mobility Bundle to Minimize Adverse Outcomes for Mechanically Ventilated Patients: A Systematic Review. Chest 2017; 152:304-311. [PMID: 28438605 DOI: 10.1016/j.chest.2017.03.054] [Citation(s) in RCA: 99] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2016] [Revised: 03/22/2017] [Accepted: 03/23/2017] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Improved outcomes are associated with the Awakening and Breathing Coordination, Delirium, and Early exercise/mobility bundle (ABCDE); however, implementation issues are common. As yet, no study has integrated the barriers to ABCDE to provide an overview of reasons for less successful efforts. The purpose of this review was to identify and catalog the barriers to ABCDE delivery based on a widely used implementation framework, and to provide a resource to guide clinicians in overcoming barriers to implementation. METHODS We searched MEDLINE via PubMed, CINAHL, and Scopus for original research articles from January 1, 2007, to August 31, 2016, that identified barriers to ABCDE implementation for adult patients in the ICU. Two reviewers independently reviewed studies, extracted barriers, and conducted thematic content analysis of the barriers, guided by the Consolidated Framework for Implementation Research. Discrepancies were discussed, and consensus was achieved. RESULTS Our electronic search yielded 1,908 articles. After applying our inclusion/exclusion criteria, we included 49 studies. We conducted thematic content analysis of the 107 barriers and identified four classes of ABCDE barriers: (1) patient-related (ie, patient instability and safety concerns); (2) clinician-related (ie, lack of knowledge, staff safety concerns); (3) protocol-related (ie, unclear protocol criteria, cumbersome protocols to use); and, not previously identified in past reviews, (4) ICU contextual barriers (ie, interprofessional team care coordination). CONCLUSIONS We provide the first, to our knowledge, systematic differential diagnosis of barriers to ABCDE delivery, moving beyond the conventional focus on patient-level factors. Our analysis offers a differential diagnosis checklist for clinicians planning ABCDE implementation to improve patient care and outcomes.
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Affiliation(s)
| | | | - Emily Ginier
- Taubman Health Sciences Library, University of Michigan, Ann Arbor, MI
| | | | - Sushant Govindan
- Division of Pulmonary and Critical Care Medicine, University of Michigan Medical School, Ann Arbor, MI
| | - Theodore J Iwashyna
- Division of Pulmonary and Critical Care Medicine, University of Michigan Medical School, Ann Arbor, MI; VA Center for Clinical Management Research, Ann Arbor, MI
| | - Anne E Sales
- VA Center for Clinical Management Research, Ann Arbor, MI; Department of Learning Health Sciences, University of Michigan Medical School, Ann Arbor, MI
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Fan C, Qi B, Chen C. Current views of the Pediatric Intensive Care Unit. Minerva Pediatr 2017; 71:539-543. [PMID: 28260348 DOI: 10.23736/s0026-4946.17.04738-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
International best practice endorses the use of standardized approaches in the management of pediatric patients in the Pediatric Intensive Care Unit (PICU). There is increasing awareness of the risk of prolonged duration of mechanical ventilation as a consequence of morphine use leading to ventilator-associated pneumonia, extended PICU and hospital length of stay and increased morbidity and mortality. Accordingly, a fundamental outcome measure of this study was to determine whether raising awareness of these issues and the introduction of analgesia and sedation guidelines led to a reduction in the amount of analgesics and sedatives administered to PICU patients, while not exposing them to pain and distress. The present review article is devoted to discussing all important aspects of PICU.
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Affiliation(s)
- Conghai Fan
- Intensive Care Unit, Xuzhou Children's Hospital, Xuzhou, China
| | - Boxiang Qi
- Intensive Care Unit, Xuzhou Children's Hospital, Xuzhou, China -
| | - Chao Chen
- Intensive Care Unit, Xuzhou Children's Hospital, Xuzhou, China
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Li R, Qi F, Zhang J, Ji Y, Zhang D, Shen Z, Lei W. Antinociceptive effects of dexmedetomidine via spinal substance P and CGRP. Transl Neurosci 2017; 6:259-264. [PMID: 28123811 PMCID: PMC4936635 DOI: 10.1515/tnsci-2015-0028] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2015] [Accepted: 11/26/2015] [Indexed: 12/29/2022] Open
Abstract
The aim of this study was to examine the role played by substance P and calcitonin gene-related peptide (CGRP) within the dorsal horn of the spinal cord in engagement of antinociception evoked by dexmedetomidine (DEX). Paw withdrawal threshold (PWT) to mechanical stimulation was determined after chronic intrathecal infusion of DEX and enzyme-linked immunosorbent assay (ELISA) was employed to examine the levels of spinal substance P and CGRP. Our results show that PWT was significantly increased by intrathecal administration of DEX in rats (P < 0.05 vs. vehicle control, n = 20 in each group). Also, intrathecal infusion of DEX significantly decreased the concentrations of substance P and CGRP as compared with vehicle control (P < 0.05 DEX vs. vehicle control, n = 20 in each group). Blocking α2-adrenoreceptors (α2-AR) blunted the decreases of substance P and CGRP levels and the enhancement of PWT evoked by DEX. Additionally, a linear relationship was observed between PWT and the levels of spinal substance P (r = 0.87; P < 0.005) and CGRP (r = 0.85; P < 0.005). Moreover, blocking individual substance P and CGRP receptors amplified PWT without altering substance P and CGRP levels. Thus, DEX plays a role in stimulating α2-AR receptors, which thereby decreases substance P and CGRP levels within the dorsal horn. This contributes to DEX-evoked antinociception.
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Affiliation(s)
- Ruiqin Li
- Shandong University, Jinan City, Shandong 250012, P.R. China
| | - Feng Qi
- Department of Anesthesiology, Qilu Hospital of Shandong University, Jinan, Shandong 250012, P.R. China
| | - Junlong Zhang
- Department of Anesthesiology, Wuxi Forth People's Hospital and Affiliated Hospital of Jiangnan University, Jinan, Shandong 250012, P. R. China
| | - Yong Ji
- Department of Anesthesiology, Wuxi Forth People's Hospital and Affiliated Hospital of Jiangnan University, Jinan, Shandong 250012, P. R. China
| | - Dengxin Zhang
- Department of Anesthesiology, Wuxi Forth People's Hospital and Affiliated Hospital of Jiangnan University, Jinan, Shandong 250012, P. R. China
| | - Zhiyun Shen
- Department of Anesthesiology, Wuxi Forth People's Hospital and Affiliated Hospital of Jiangnan University, Jinan, Shandong 250012, P. R. China
| | - Weifu Lei
- Department of Anesthesiology, Qilu Hospital of Shandong University, Jinan, Shandong 250012, P.R. China
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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.
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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
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Richards-Belle A, Canter RR, Power GS, Robinson EJ, Reschreiter H, Wunsch H, Harvey SE. National survey and point prevalence study of sedation practice in UK critical care. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2016; 20:355. [PMID: 27788680 PMCID: PMC5084331 DOI: 10.1186/s13054-016-1532-x] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/08/2016] [Accepted: 10/14/2016] [Indexed: 12/11/2022]
Abstract
Background The present study was designed to (1) establish current sedation practice in UK critical care to inform evidence synthesis and potential future primary research and (2) to compare practice reported via a survey with actual practice assessed in a point prevalence study (PPS). Methods UK adult general critical care units were invited to participate in a survey of current sedation practice, and a representative sample of units was invited to participate in a PPS of sedation practice at the patient level. Survey responses were compared with PPS data where both were available. Results Survey responses were received from 214 (91 %) of 235 eligible critical care units. Of these respondents, 57 % reported having a written sedation protocol, 94 % having a policy of daily sedation holds and 94 % using a sedation scale to assess depth of sedation. In the PPS, across units reporting a policy of daily sedation holds, a median of 50 % (IQR 33–75 %) of sedated patients were considered for a sedation hold. A median of 88 % (IQR 63–100 %) of patients were assessed using the same sedation scale as reported in the survey. Both the survey and the PPS indicated propofol as the preferred sedative and alfentanil, fentanyl and morphine as the preferred analgesics. In most of the PPS units, all patients had received the unit’s reported first-choice sedative (median across units 100 %, IQR 64–100 %), and a median of 80 % (IQR 67–100 %) of patients had received the unit’s reported first-choice analgesic. Most units (83 %) reported in the survey that sedatives are usually administered in combination with analgesics. Across units that participated in the PPS, 69 % of patients had received a combination of agents – most frequently propofol combined with either alfentanil or fentanyl. Conclusions Clinical practice reported in the national survey did not accurately reflect actual clinical practice at the patient level observed in the PPS. Employing a mixed methods approach provided a more complete picture of sedation practice in terms of breadth and depth of information. Electronic supplementary material The online version of this article (doi:10.1186/s13054-016-1532-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Alvin Richards-Belle
- Intensive Care National Audit & Research Centre (ICNARC), Napier House, 24 High Holborn, London, WC1V 6AZ, UK
| | - Ruth R Canter
- Intensive Care National Audit & Research Centre (ICNARC), Napier House, 24 High Holborn, London, WC1V 6AZ, UK
| | - G Sarah Power
- Intensive Care National Audit & Research Centre (ICNARC), Napier House, 24 High Holborn, London, WC1V 6AZ, UK
| | - Emily J Robinson
- Intensive Care National Audit & Research Centre (ICNARC), Napier House, 24 High Holborn, London, WC1V 6AZ, UK
| | - Henrik Reschreiter
- Poole Hospital NHS Foundation Trust, Longfleet Road, Poole, BH15 2JB, UK
| | - Hannah Wunsch
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Toronto, ON, Canada
| | - Sheila E Harvey
- Intensive Care National Audit & Research Centre (ICNARC), Napier House, 24 High Holborn, London, WC1V 6AZ, UK.
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Minton C, Batten L. Rethinking the intensive care environment: considering nature in nursing practice. J Clin Nurs 2016; 25:269-77. [PMID: 26769214 DOI: 10.1111/jocn.13069] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/22/2015] [Indexed: 11/29/2022]
Abstract
AIMS AND OBJECTIVES With consideration of an environmental concept, this paper explores evidence related to the negative impacts of the intensive care unit environment on patient outcomes and explores the potential counteracting benefits of 'nature-based' nursing interventions as a way to improve care outcomes. BACKGROUND The impact of the environment in which a patient is nursed has long been recognised as one determinant in patient outcomes. Whilst the contemporary intensive care unit environment contains many features that support the provision of the intensive therapies the patient requires, it can also be detrimental, especially for long-stay patients. DESIGN This narrative review considers theoretical and evidence-based literature that supports the adoption of nature-based nursing interventions in intensive care units. METHODS Research and theoretical literature from a diverse range of disciplines including nursing, medicine, psychology, architecture and environmental science were considered in relation to patient outcomes and intensive care nursing practice. CONCLUSION There are many nature-based interventions that intensive care unit nurses can implement into their nursing practice to counteract environmental stressors. These interventions can also improve the environment for patients' families and nurses. RELEVANCE TO CLINICAL PRACTICE Intensive care unit nurses must actively consider and manage the environment in which nursing occurs to facilitate the best patient outcomes.
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Affiliation(s)
- Claire Minton
- School of Nursing, Massey University, Palmerston North, New Zealand
| | - Lesley Batten
- Research Centre for Maori Health and Development, Palmerston North, New Zealand
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Manias E, Ho N, Kusljic S. Trajectory of sedation assessment and sedative use in intubated and ventilated patients in intensive care: A clinical audit. Collegian 2016. [DOI: 10.1016/j.colegn.2015.06.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Aitken LM, Bucknall T, Kent B, Mitchell M, Burmeister E, Keogh S. Sedation protocols to reduce duration of mechanical ventilation in the ICU: a Cochrane Systematic Review. J Adv Nurs 2016; 72:261-72. [PMID: 26541275 DOI: 10.1111/jan.12843] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/15/2015] [Indexed: 11/26/2022]
Abstract
AIMS Assess the effects of protocol-directed sedation management on the duration of mechanical ventilation and other relevant patient outcomes in mechanically ventilated intensive care unit patients. BACKGROUND Sedation is a core component of critical care. Sub-optimal sedation management incorporates both under- and over-sedation and has been linked to poorer patient outcomes. DESIGN Cochrane systematic review of randomized controlled trials. DATA SOURCES Cochrane Central Register of Controlled trials, MEDLINE, EMBASE, CINAHL, Database of Abstracts of Reviews of Effects, LILACS, Current Controlled Trials and US National Institutes of Health Clinical Research Studies (1990-November 2013) and reference lists of articles were used. REVIEW METHODS Randomized controlled trials conducted in intensive care units comparing management with and without protocol-directed sedation were included. Two authors screened titles, abstracts and full-text reports. Potential risk of bias was assessed. Clinical, methodological and statistical heterogeneity were examined and the random-effects model used for meta-analysis where appropriate. Mean difference for duration of mechanical ventilation and risk ratio for mortality, with 95% confidence intervals, were calculated. RESULTS Two eligible studies with 633 participants comparing protocol-directed sedation delivered by nurses vs. usual care were identified. There was no evidence of differences in duration of mechanical ventilation or hospital mortality. There was statistically significant heterogeneity between studies for duration of mechanical ventilation. CONCLUSIONS There is insufficient evidence to evaluate the effectiveness of protocol-directed sedation as results from the two randomized controlled trials were conflicting.
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Affiliation(s)
- Leanne M Aitken
- NHMRC, Centre for Research Excellence in Nursing, Menzies Health Institute Queensland, Griffith University, Queensland, Australia
- Intensive Care Unit, Princess Alexandra Hospital, Queensland, Australia
- School of Health Sciences, City University London, UK
| | - Tracey Bucknall
- Centre for Quality and Patient Safety, School of Nursing and Midwifery, Faculty of Health, Deakin University, Victoria, Australia
- Director of Nursing Research Alfred Health, Melbourne, Victoria, Australia
| | - Bridie Kent
- School of Nursing and Midwifery, Plymouth University, UK
| | - Marion Mitchell
- NHMRC, Centre for Research Excellence in Nursing, Menzies Health Institute Queensland, Griffith University, Queensland, Australia
- Intensive Care Unit, Princess Alexandra Hospital, Queensland, Australia
| | - Elizabeth Burmeister
- Menzies Health Institute Queensland, Griffith University, Queensland, Australia
- Princess Alexandra Hospital, Queensland, Australia
| | - Samantha Keogh
- NHMRC, Centre for Research Excellence in Nursing, Menzies Health Institute Queensland, Griffith University, Queensland, Australia
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Frade-Mera MJ, Regueiro-Díaz N, Díaz-Castellano L, Torres-Valverde L, Alonso-Pérez L, Landívar-Redondo MM, Muñoz-Pasín R, Terceros-Almanza LJ, Temprano-Vázquez S, Sánchez-Izquierdo-Riera JÁ. [A first step towards safer sedation and analgesia: A systematic evaluation of outcomes and level of sedation and analgesia in the mechanically ventilated critically ill patient]. ENFERMERIA INTENSIVA 2016; 27:155-167. [PMID: 26803376 DOI: 10.1016/j.enfi.2015.10.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2015] [Accepted: 10/19/2015] [Indexed: 10/22/2022]
Abstract
INTRODUCTION Safe analgesia and sedation strategies are necessary in order to avoid under or over sedation, as well as improving the comfort and safety of critical care patients. OBJECTIVES To compare and contrast a multidisciplinary protocol of systematic evaluation and management of analgesia and sedation in a group of critical care patients on mechanical ventilation with the usual procedures. MATERIALS AND METHODS A cohort study with contemporary series was conducted in a tertiary care medical-surgical ICU February to November during 2013 and 2014. The inclusion criteria were mechanical ventilation ≥ 24h and use of sedation by continuous infusion. Sedation was monitored using the Richmond agitation-sedation scale or bispectral index, and analgesia were measured using the numeric rating scale, or behavioural indicators of pain scale. The study variables included; mechanical ventilation time, weaning time, ventilation support time, artificial airway time, continuous sedative infusion time, daily dose and frequency of analgesic and sedative drug use, hospital stay, and ICU and hospital mortality, Richmond agitation-sedation scale, bispectral index, numeric rating scale, and behavioural indicators of pain scale measurements. Kruskal Wallis and Chi2, and a significance of p<.05 were used. RESULTS The study included 153 admissions, 75 pre-intervention and 78 post-intervention, with a mean age of 55.7±13 years old, and 67% men. Both groups showed similarities in age, reason for admission, and APACHE. There were non-significant decreases in mechanical ventilation time 4 (1.4-9.2) and 3.2 (1.4-8.1) days, respectively; p= 0.7, continuous sedative infusion time 6 (3-11) and 5 (3-11) days; p= 0.9, length of hospital stay 29 (18-52); 25 (14-41) days; p= 0.1, ICU mortality (8 vs. 5%; p= 0.4), and hospital mortality (10.6 vs. 9.4%: p= 0.8). Daily doses of midazolam and remifentanil decreased 347 (227-479) mg/day; 261 (159-358) mg/day; p= 0.02 and 2175 (1427-3285) mcg/day; 1500 (715-2740) mcg/day; p= 0.02, respectively. There were increases in the use of remifentanil (32% vs. 51%; p= 0.01), dexmedetomidine (0 vs.6%; p= 0.02), dexketoprofen (60 vs. 76%; p= 0.03), and haloperidol (15 vs.28%; p= 0.04). The use of morphine decreased (71 vs. 54%; p= 0.03). There was an increase in the number of measurements and Richmond agitation-sedation scale scores 6 (3-17); 21 (9-39); p< 0.0001, behavioural indicators of pain scale 6 (3-18); 19(8-33); p< 0.001 and numeric rating scale 4 (2-6); 8 (6-17); p< 0.0001. CONCLUSIONS The implementation of a multidisciplinary protocol of systematic evaluation of analgesia and sedation management achieved an improvement in monitoring and adequacy of dose to patient needs, leading to improved outcomes.
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Affiliation(s)
- M J Frade-Mera
- UCI Polivalente, Hospital Universitario 12 de Octubre, Madrid, España.
| | - N Regueiro-Díaz
- UCI Polivalente, Hospital Universitario 12 de Octubre, Madrid, España
| | - L Díaz-Castellano
- UCI Polivalente, Hospital Universitario 12 de Octubre, Madrid, España
| | - L Torres-Valverde
- UCI Polivalente, Hospital Universitario 12 de Octubre, Madrid, España
| | - L Alonso-Pérez
- UCI Polivalente, Hospital Universitario 12 de Octubre, Madrid, España
| | | | - R Muñoz-Pasín
- UCI Polivalente, Hospital Universitario 12 de Octubre, Madrid, España
| | - L J Terceros-Almanza
- Servicio de Medicina Intensiva, Hospital Universitario 12 de Octubre, Madrid, España
| | - S Temprano-Vázquez
- Servicio de Medicina Intensiva, Hospital Universitario 12 de Octubre, Madrid, España
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Shinotsuka CR, Salluh JIF. Perceptions and practices regarding delirium, sedation and analgesia in critically ill patients: a narrative review. Rev Bras Ter Intensiva 2015; 25:155-61. [PMID: 23917981 PMCID: PMC4031827 DOI: 10.5935/0103-507x.20130027] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2013] [Accepted: 06/13/2013] [Indexed: 11/20/2022] Open
Abstract
A significant number of landmark studies have been published in the last decade that
increase the current knowledge on sedation for critically ill patients. Therefore,
many practices that were considered standard of care are now outdated. Oversedation
has been shown to be hazardous, and light sedation and no-sedation protocols are
associated with better patient outcomes. Delirium is increasingly recognized as a
major form of acute brain dysfunction that is associated with higher mortality,
longer duration of mechanical ventilation and longer lengths of stay in the intensive
care unit and hospital. Despite all the available evidence, translating research into
bedside care is a daunting task. International surveys have shown that practices such
as sedation interruption and titration are performed only in the minority of cases.
Implementing best practices is a major challenge that must also be addressed in the
new guidelines. In this review, we summarize the findings of sedation and delirium
research over the last years. We also discuss the gap between evidence and clinical
practice and highlight ways to implement best practices at the bedside.
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A web-based survey of United Kingdom sedation practice in the intensive care unit. J Crit Care 2015; 30:436.e1-6. [DOI: 10.1016/j.jcrc.2014.11.006] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2014] [Revised: 10/02/2014] [Accepted: 11/06/2014] [Indexed: 11/17/2022]
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Aitken LM, Bucknall T, Kent B, Mitchell M, Burmeister E, Keogh SJ. Protocol-directed sedation versus non-protocol-directed sedation to reduce duration of mechanical ventilation in mechanically ventilated intensive care patients. Cochrane Database Syst Rev 2015; 1:CD009771. [PMID: 25562750 DOI: 10.1002/14651858.cd009771.pub2] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND The sedation needs of critically ill patients have been recognized as a core component of critical care and meeting these is vital to assist recovery and ensure humane treatment. There is growing evidence to suggest that sedation requirements are not always optimally managed. Sub-optimal sedation incorporates both under- and over-sedation and has been linked to both short-term (e.g. length of stay) and long-term (e.g. psychological recovery) outcomes. Various strategies have been proposed to improve sedation management and address aspects of assessment as well as delivery of sedation. OBJECTIVES To assess the effects of protocol-directed sedation management on the duration of mechanical ventilation and other relevant patient outcomes in mechanically ventilated intensive care unit (ICU) patients. We looked at various outcomes and examined the role of bias in order to examine the level of evidence for this intervention. SEARCH METHODS We searched the Cochrane Central Register of Controlled trials (CENTRAL) (2013; Issue 11), MEDLINE (OvidSP) (1990 to November 2013), EMBASE (OvidSP) (1990 to November 2013), CINAHL (BIREME host) (1990 to November 2013), Database of Abstracts of Reviews of Effects (DARE) (1990 to November 2013), LILACS (1990 to November 2013), Current Controlled Trials and US National Institutes of Health Clinical Research Studies (1990 to November 2013), and reference lists of articles. We re-ran the search in October 2014. We will deal with any studies of interest when we update the review. SELECTION CRITERIA We included randomized controlled trials (RCTs) conducted in adult ICUs comparing management with and without protocol-directed sedation. DATA COLLECTION AND ANALYSIS Two authors screened the titles and abstracts and then the full-text reports identified from our electronic search. We assessed seven domains of potential risk of bias for the included studies. We examined the clinical, methodological and statistical heterogeneity and used the random-effects model for meta-analysis where we considered it appropriate. We calculated the mean difference (MD) for duration of mechanical ventilation and risk ratio (RR) for mortality across studies, with 95% confidence intervals (CI). MAIN RESULTS We identified two eligible studies with 633 participants. Both included studies compared the use of protocol-directed sedation, specifically protocols delivered by nurses, with usual care. We rated the risk of selection bias due to random sequence generation low for one study and unclear for one study. The risk of selection bias related to allocation concealment was low for both studies. We also assessed detection and attrition bias as low for both studies while we considered performance bias high due to the inability to blind participants and clinicians in both studies. Risk due to other sources of bias, such as potential for contamination between groups and reporting bias, was considered unclear. There was no clear evidence of differences in duration of mechanical ventilation (MD -5.74 hours, 95% CI -62.01 to 50.53, low quality evidence), ICU length of stay (MD -0.62 days, 95% CI -2.97 to 1.73) and hospital length of stay (MD -3.78 days, 95% CI -8.54 to 0.97) between people being managed with protocol-directed sedation versus usual care. Similarly, there was no clear evidence of difference in hospital mortality between the two groups (RR 0.96, 95% CI 0.71 to 1.31, low quality evidence). ICU mortality was only reported in one study preventing pooling of data. There was no clear evidence of difference in the incidence of tracheostomy (RR 0.77, 95% CI 0.31 to 1.89). The studies reported few adverse event outcomes; one study reported self extubation while the other study reported re-intubation; given this difference in outcomes, pooling of data was not possible. There was significant heterogeneity between studies for duration of mechanical ventilation (I(2) = 86%, P value = 0.008), ICU length of stay (I(2) = 82%, P value = 0.02) and incidence of tracheostomy (I(2) = 76%, P value = 0.04), with one study finding a reduction in duration of mechanical ventilation and incidence of tracheostomy and the other study finding no difference. AUTHORS' CONCLUSIONS There is currently insufficient evidence to evaluate the effectiveness of protocol-directed sedation. Results from the two RCTs were conflicting, resulting in the quality of the body of evidence as a whole being assessed as low. Further studies, taking into account contextual and clinician characteristics in different ICU environments, are necessary to inform future practice. Methodological strategies to reduce the risk of bias need to be considered in future studies.
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Affiliation(s)
- Leanne M Aitken
- NHMRC Centre of Research Excellence in Nursing, Centre for Health Practice Innovation, Griffith Health Institute, Griffith University, 170 Kessels Road, Brisbane, Queensland, Australia, 4111
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Rose L, Fitzgerald E, Cook D, Kim S, Steinberg M, Devlin JW, Ashley BJ, Dodek P, Smith O, Poretta K, Lee Y, Burns K, Harvey J, Skrobik Y, Fergusson D, Meade M, Kraguljac A, Burry L, Mehta S. Clinician perspectives on protocols designed to minimize sedation. J Crit Care 2014; 30:348-52. [PMID: 25466317 DOI: 10.1016/j.jcrc.2014.10.021] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2014] [Revised: 10/06/2014] [Accepted: 10/17/2014] [Indexed: 11/27/2022]
Abstract
PURPOSE Within a multicenter randomized trial comparing protocolized sedation with protocolized sedation plus daily interruption (DI), we sought perspectives of intensive care unit (ICU) clinicians regarding each strategy. METHODS At 5 ICUs, we administered a questionnaire daily to nurses and physicians, asking whether they liked using the assigned strategy, reasons for their responses, and concerns regarding DI. RESULTS A total of 301 questionnaires were completed, for 31 patients (15 protocol only and 16 DI); 117 (59 physicians and 58 nurses) were the first questionnaire completed by that health care provider for that patient and were included in analyses. Most respondents liked using the assigned strategy (81% protocol only and 81% DI); more physicians than nurses liked DI (100% vs 61%; P < .001). Most common reasons for liking the assigned sedation strategy were better neurologic assessment (70% DI), ease of use (58% protocol only), and improved patient outcomes (51% protocol only and 44% DI). Only 19% of clinicians disliked the assigned sedation strategy (equal numbers for protocol only and DI). Respondents' concerns during DI were respiratory compromise (61%), pain (48%), agitation (45%), and device removal (26%). More questionnaires from nurses than physicians expressed concerns about DI. CONCLUSIONS Most respondents liked both sedation strategies. Nurses and physicians had different preferences and rationales for liking or disliking each strategy.
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Affiliation(s)
- Louise Rose
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
| | - Emma Fitzgerald
- Academic Department of Critical Care, Queen Alexandra Hospital, University of Portsmouth, Portsmouth, UK
| | - Deborah Cook
- Departments of Medicine, Clinical Epidemiology & Biostatistics, McMaster University, St Joseph's Healthcare, Hamilton, Ontario, Canada
| | - Scott Kim
- Mount Sinai Hospital, Toronto, Ontario, Canada
| | | | - John W Devlin
- School of Pharmacy, Northeastern University, Boston, MA
| | | | - Peter Dodek
- Division of Critical Care Medicine and Center for Health Evaluation and Outcome Sciences, St Paul's Hospital and University of British Columbia, Vancouver, British Columbia, Canada
| | - Orla Smith
- St Michael's Hospital, Toronto, Ontario, Canada
| | | | - Yoon Lee
- St Michael's Hospital, Toronto, Ontario, Canada
| | - Karen Burns
- Keenan Research Centre and the Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada; Interdepartmental Division of Critical Care Medicine and the Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Johanne Harvey
- Hôpital Maisonneuve Rosemont, Université de Montréal, Montréal, Québec, Canada
| | - Yoanna Skrobik
- Département de Médecine, Soins Intensifs, Hôpital Maisonneuve Rosemont, Université de Montréal, Montréal, Québec, Canada
| | - Dean Fergusson
- Clinical Epidemiology Program, Ottawa Hospital Research Institute and Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Maureen Meade
- Departments of Medicine, Clinical Epidemiology & Biostatistics, McMaster University, Department of Critical Care, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Alan Kraguljac
- Mount Sinai Hospital, and Program in Developmental Stem Cell Biology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Lisa Burry
- Department of Pharmacy and Medicine, Mount Sinai Hospital and University of Toronto, Toronto, Ontario, Canada
| | - Sangeeta Mehta
- Department of Medicine and Interdepartmental Division of Critical Care, Mount Sinai Hospital and University of Toronto, Toronto, Ontario, Canada.
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Varndell W, Elliott D, Fry M. The validity, reliability, responsiveness and applicability of observation sedation-scoring instruments for use with adult patients in the emergency department: a systematic literature review. ACTA ACUST UNITED AC 2014; 18:1-23. [PMID: 25103566 DOI: 10.1016/j.aenj.2014.07.001] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2014] [Revised: 07/11/2014] [Accepted: 07/15/2014] [Indexed: 12/14/2022]
Abstract
AIM This paper reports a systematic literature review examining the range of published observational sedation-scoring instruments available in the assessment, monitoring and titration of continuous intravenous sedation to critically ill adult patients in the Emergency Department, and the extent to which validity, reliability, responsiveness and applicability of the instruments has been addressed. BACKGROUND Emergency nurses are increasingly responsible for the ongoing assessment, monitoring and titration of continuous intravenous sedation, in addition to analgesia for the critically ill adult patient. One method to optimise patient sedation is to use a validated observational sedation-scoring tool. It is not clear however what the optimal instrument available is for use in this clinical context. METHODS A systematic literature review methodology was employed. A range of electronic databases were searched for the period 1946-2013. Search terms incorporated "sedation scale", "sedation scoring system", "measuring sedation", and "sedation tool" and were used to retrieve relevant literature. In addition, manual searches were conducted and articles retrieved from those listed in key papers. Articles were assessed using the Critical Appraisal Skills Program (CASP) making sense of evidence tools. RESULTS A total of 27 observational sedation-scoring instruments were identified. Sedation-scoring instruments can be categorised as linear or composite, the former being the most common. A wide variety of patient behaviours are used within the instruments to measure depth and quality of patient sedation. Typically sedation-scoring instruments incorporated three patient behaviours, which were then rated to generate a numerical score. The majority of the instruments have been subjected to validity and reliability testing, however few have been examined for responsiveness or applicability. CONCLUSIONS None of the 27 observational sedation-scoring instruments were designed or trialled within ED. The Richmond Agitation and Assessment Scale was identified as most suitable to be trialled prospectively within an Australian ED.
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Affiliation(s)
- Wayne Varndell
- Prince of Wales Hospital Emergency Department, Australia; Faculty of Health, University of Technology, Sydney, Australia.
| | - Doug Elliott
- Faculty of Health, University of Technology, Sydney, Australia
| | - Margaret Fry
- Faculty of Health, University of Technology, Sydney, Australia; School of Nursing, University of Sydney, Australia
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Clinical practice guidelines for evidence-based management of sedoanalgesia in critically ill adult patients. ACTA ACUST UNITED AC 2013. [DOI: 10.1016/j.medine.2013.04.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
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Celis-Rodríguez E, Birchenall C, de la Cal M, Castorena Arellano G, Hernández A, Ceraso D, Díaz Cortés J, Dueñas Castell C, Jimenez E, Meza J, Muñoz Martínez T, Sosa García J, Pacheco Tovar C, Pálizas F, Pardo Oviedo J, Pinilla DI, Raffán-Sanabria F, Raimondi N, Righy Shinotsuka C, Suárez M, Ugarte S, Rubiano S. Guía de práctica clínica basada en la evidencia para el manejo de la sedoanalgesia en el paciente adulto críticamente enfermo. Med Intensiva 2013; 37:519-74. [DOI: 10.1016/j.medin.2013.04.001] [Citation(s) in RCA: 73] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2013] [Accepted: 04/16/2013] [Indexed: 01/18/2023]
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Ueshima H, Inada T, Shingu K. Suppression of phagosome proteolysis and Matrigel migration with the α2-adrenergic receptor agonist dexmedetomidine in murine dendritic cells. Immunopharmacol Immunotoxicol 2013; 35:558-66. [PMID: 23927488 DOI: 10.3109/08923973.2013.822509] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Dexmedetomidine is a highly-selective α2-adrenergic receptor agonist used for sedation of critically ill patients in an intensive care setting. Dendritic cells (DCs) in peripheral tissues sense certain foreign antigens and ingest and process them, while migrating to the regional lymph node. Then, DCs present the processed antigen on their surface to stimulate the clonal proliferation of cognitive lymphocytes, leading to the establishment of adaptive immunity. In murine bone marrow-derived DCs, dexmedetomidine significantly delayed the intracellular proteolytic degradation of ovalbumin, while it did not affect phagocytosis, decreased the expression of the surface molecules I-A(b) and CD86, and suppressed cognitive helper T-cell proliferation. Furthermore, dexmedetomidine significantly suppressed DC migration both in vitro, using a Matrigel migration assay, and in vivo, using a foot pad-popliteal lymph node migration assay, which may be ascribed to the inhibition of type IV collagenase/gelatinase activity. Finally, vaccination with dexmedetomidine-treated DCs significantly suppressed the contact hypersensitivity reaction in vivo. These results indicate that dexmedetomidine may suppress immunity by inhibiting DC antigen processing/presentation and migration.
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Affiliation(s)
- Hironobu Ueshima
- Department of Anesthesiology, Kansai Medical University , Osaka , Japan
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Hager DN, Dinglas VD, Subhas S, Rowden AM, Neufeld KJ, Bienvenu OJ, Touradji P, Colantuoni E, Reddy DRS, Brower RG, Needham DM. Reducing deep sedation and delirium in acute lung injury patients: a quality improvement project. Crit Care Med 2013; 41:1435-42. [PMID: 23507716 DOI: 10.1097/ccm.0b013e31827ca949] [Citation(s) in RCA: 76] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
OBJECTIVE Deep sedation and delirium are common in the ICU. Mechanically ventilated patients with acute lung injury are at especially high risk for deep sedation, delirium, and associated long-term physical and neuropsychiatric impairments. We undertook an ICU-wide structured quality improvement project to decrease sedation and delirium. DESIGN Prospective quality improvement project in comparison with a retrospective acute lung injury control group. SETTING Sixteen-bed medical ICU in an academic teaching hospital with pre-existing use of goal-directed sedation with daily interruption of sedative infusions. PATIENTS Consecutive acute lung injury patients. INTERVENTION A "4Es" framework (engage, educate, execute, evaluate) was used as part of the quality improvement process. A new sedation protocol was created and implemented, which recommends a target Richmond Agitation Sedation Scale score of 0 (alert and calm) and requires failure of intermittent sedative dosing prior to starting continuous infusions. In addition, twice-daily delirium screening using the Confusion Assessment Method for the ICU was introduced into routine practice. MEASUREMENTS AND MAIN RESULTS Sedative use and delirium status in acute lung injury patients after implementation of the quality improvement project (n = 82) were compared with a historical control group (n = 120). During the quality improvement vs. control periods, use of narcotic and benzodiazepine infusions were substantially lower (median proportion of medical ICU days per patient: 33% vs. 74%, and 22% vs. 70%, respectively, both p < 0.001). Further, wakefulness increased (median Richmond Agitation Sedation Scale score per patient: -1.5 vs. -4.0, p < 0.001), and days awake and not delirious increased (median proportion of medical ICU days per patient: 19% vs. 0%, p < 0.001). CONCLUSION Through a structured quality improvement process, use of sedative infusions can be substantially decreased and days awake without delirium significantly increased, even in severely ill, mechanically ventilated patients with acute lung injury.
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Affiliation(s)
- David N Hager
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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Jarman A, Duke G, Reade M, Casamento A. The association between sedation practices and duration of mechanical ventilation in intensive care. Anaesth Intensive Care 2013; 41:311-5. [PMID: 23659391 DOI: 10.1177/0310057x1304100306] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Choice of sedation agent may influence duration of mechanical ventilation in the intensive care unit (ICU). We conducted a retrospective observational analysis of 2102 consecutive mechanically ventilated ICU patients over an eight-year period at a Melbourne metropolitan hospital with a ten-bed general ICU to determine if propofol was associated with shorter duration of mechanical ventilation (MV) than midazolam. Data were extracted from the hospital administrative database, pharmacy supply order records and ICU database, to calculate rates of MV and tracheostomy, length-of-stay, propofol and midazolam infusion doses, illness severity and casemix and use of 'sedation scores' and 'sedation break' respectively. The primary end-points were duration of MV, tracheostomy rate and hospital outcome. Negative binomial regression and logistic regression were used to identify temporal trends. From 1 July 2002 to 30 June 2010 there were 5751 ICU admissions including 2102 (36.6%) with MV. Over this period there was a 70% decline in annual midazolam use and a greater than fivefold rise in propofol use. 'Sedation scoring' and 'sedation break' procedures were introduced from 2006. Over the eight-year observation period there were significant increases in the numbers of annual MV admissions and long-term (>96 hours) MV patients, but a decline in median duration of MV, tracheostomy rate, median ICU length-of-stay and median hospital length-of-stay. All temporal trends were significant (P <0.05). The temporal association with changes in sedation management practice, including primary sedative agent choice during MV, may explain these findings.
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Affiliation(s)
- Am Jarman
- Intensive Care Department, The Northern Hospital, Epping, Victoria, Australia.
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Paul BS, Paul G. Sedation in neurological intensive care unit. Ann Indian Acad Neurol 2013; 16:194-202. [PMID: 23956563 PMCID: PMC3724073 DOI: 10.4103/0972-2327.112465] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2012] [Revised: 11/10/2012] [Accepted: 12/04/2012] [Indexed: 11/12/2022] Open
Abstract
Analgesia and sedation has been widely used in intensive care units where iatrogenic discomfort often complicates patient management. In neurological patients maximal comfort without diminishing patient responsiveness is desirable. In these patients successful management of sedation and analgesia incorporates a patient based approach that includes detection and management of predisposing and causative factors, including delirium, monitoring using sedation scales, proper medication selection, emphasis on analgesia based drugs and incorporation of protocols or algorithms. So, to optimize care clinician should be familiar with the pharmacokinetic and pharmacodynamic variables that can affect the safety and efficacy of analgesics and sedatives.
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Affiliation(s)
- Birinder S. Paul
- Department of Neurology, Dayanand Medical College, Ludhiana, India
| | - Gunchan Paul
- Critical Care Division, Dayanand Medical College, Ludhiana, India
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Goodwin H, Lewin JJ, Mirski MA. 'Cooperative sedation': optimizing comfort while maximizing systemic and neurological function. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2012; 16:217. [PMID: 22429840 PMCID: PMC3681362 DOI: 10.1186/cc11231] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Haley Goodwin
- Johns Hopkins Medical Institutions, Baltimore, MD, USA
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Shehabi Y, Bellomo R, Reade MC, Bailey M, Bass F, Howe B, McArthur C, Seppelt IM, Webb S, Weisbrodt L. Early Intensive Care Sedation Predicts Long-Term Mortality in Ventilated Critically Ill Patients. Am J Respir Crit Care Med 2012; 186:724-31. [DOI: 10.1164/rccm.201203-0522oc] [Citation(s) in RCA: 344] [Impact Index Per Article: 28.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Gill KV, Voils SA, Chenault GA, Brophy GM. Perceived versus actual sedation practices in adult intensive care unit patients receiving mechanical ventilation. Ann Pharmacother 2012; 46:1331-9. [PMID: 22991132 DOI: 10.1345/aph.1r037] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND With drug shortages, newer sedative medications, and updates in research, management of sedation and delirium in patients receiving mechanical ventilation continues to evolve. OBJECTIVE To compare perceived and actual sedation practices for adults receiving mechanical ventilation in intensive care units (ICUs). METHODS This was a multicenter, 2-part study conducted in adult ICUs in US hospitals. It included a sedation practice survey completed by ICU pharmacists and an observational study evaluating actual sedation practices over a 24-hour period. RESULTS Surveys were completed for 85 ICUs; observational data for 496 patients were collected. Preferred sedatives from the survey data were propofol (short-term); propofol, midazolam, or lorazepam (intermediate); and lorazepam (long-term). Propofol was the most commonly used agent overall during the observational period (primarily for short-term and intermediate-length sedation); midazolam was the most commonly used for long-term sedation. Fentanyl was the preferred analgesic, and haloperidol and quetiapine were the preferred antipsychotics. Sedation treatment algorithms were used in only 50% of observed ICUs. Use of daily interruption of sedation was perceived to be 66% but was only observed in 36% of patients. Monitoring for delirium was reported among 25% of those surveyed but was observed in only 10% of patients. Targeted sedation goals were most frequently achieved when a treatment algorithm was used or when an opiate infusion was the single agent used for sedative management. CONCLUSIONS These data suggest differences in perceived and actual sedation practice in the US, as well as underutilization of evidence-based interventions. Most notable was the limited use of sedation treatment algorithms, daily interruption of sedation, and monitoring for delirium. Individual sedation and delirium protocols should be evaluated and updated based on evidence-based recommendations.
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Affiliation(s)
- Kimberly Varney Gill
- Virginia Commonwealth University Health System, Department of Pharmacy, Department of Pulmonary and Critical Care Medicine, Richmond, USA.
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Kher S, Roberts RJ, Garpestad E, Kunkel C, Howard W, Didominico D, Fergusson A, Devlin JW. Development, implementation, and evaluation of an institutional daily awakening and spontaneous breathing trial protocol: a quality improvement project. J Intensive Care Med 2012; 28:189-97. [PMID: 22596087 DOI: 10.1177/0885066612444255] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
INTRODUCTION While one controlled trial found that a daily awakening and spontaneous breathing trial (DA-SBT) decreases time on mechanical ventilation (MV), there is a paucity of real-world data surrounding the development, implementation, and impact of DA-SBT protocols. We describe a multidisciplinary process improvement effort in 2, 10-bed medical intensive care units (MICUs) at a 330-bed academic medical center that focused on the development, implementation, and evaluation of a new DA-SBT protocol. METHODS A DA-SBT protocol, developed using results from a nursing survey literature and available institutional resources, was implemented after extensive clinician education and institution of quality reminders to boost use. Postprotocol compliance was evaluated. Use of sedation, DA and SBT practices, and clinical outcomes were retrospectively compared between the before and after DA-SBT protocol groups (ie, consecutive MICU patients requiring a continuously infused sedative [CIS] ≥24 hours). RESULTS In the after group (n = 32), the DA and SBT compliances were 44% and 84%, respectively. Compared with the before group (n = 33), after group patients received CIS on fewer days of MV (100% vs 67%, P = .003) and had their CIS down-titrated by ≥25% on more days of CIS (40% vs 71%, P = .006). Neither total CIS dose (P = .49), total MV days (P = .75), days of MV where a SBT occurred (P = .38), nor episodes of self-extubation (15% vs 6%, P = .43) differed between the 2 groups. CONCLUSION Despite the implementation of a DA-SBT protocol that was individualized to clinician preferences and institutional resources and accompanied by substantial education and reminders for use, compliance to the DA component of this protocol was low and duration of MV remained unchanged. Additional quality improvement strategies are needed to overcome barriers to DA-SBT protocol use that may not exist in controlled clinical trials.
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Affiliation(s)
- Sucharita Kher
- Division of Pulmonary, Critical Care and Sleep Medicine, Tufts Medical Center, Boston, MA 02115, USA
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Hofhuis JGM, Langevoort G, Rommes JH, Spronk PE. Sleep disturbances and sedation practices in the intensive care unit--a postal survey in the Netherlands. Intensive Crit Care Nurs 2012; 28:141-9. [PMID: 22521860 DOI: 10.1016/j.iccn.2011.10.006] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2011] [Revised: 09/15/2011] [Accepted: 10/06/2011] [Indexed: 10/28/2022]
Abstract
BACKGROUND Sleep disturbances are common in critically ill patients treated in the intensive care unit (ICU) with possible serious consequences. OBJECTIVE The aim of this study was to get insight into sleeping and sedation practices in the adult ICUs in the Netherlands and survey which factors are important with respect to sleep in critically ill patients in the ICU. METHOD A multi-centre, exploratory survey sent via mail to nurse managers of all adult ICUs in the Netherlands. RESULTS Interventions without medication to improve the sleep of the critically ill patients were mostly defined as keeping patients awake during the day (94.2%), reducing noise of the ICU staff (89.7%) and reducing nursing interventions at night (86.8%). None of the ICUs used a sleep questionnaire. Nursing autonomy regarding sleep and sedation practices for patients (rated on a 10-point numerical scale) was judged as moderate (median 5, interquartile range (IQR) 3-7). How often nursing observations influence sleeping practices in the ICU was judged as good (median 8, IQR 7-8). How the average ICU patient was sleeping was judged as moderately well (median 6, IQR 5-7). Most intensive care units (83.8%) did not have a sleeping protocol, but 67.6% of these intensive care units suggested they should implement a sleeping protocol. CONCLUSIONS The average critically ill patient has sleep disturbances, that is, is sleeping moderately well according to nurses' views and opinions, mostly due to a disturbed sleep-awake cycle, delirium and nursing interventions. Intensive care nurses perceive only a moderate feeling of autonomy and influence regarding the management of sleeping practices.
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Affiliation(s)
- José G M Hofhuis
- Department of Intensive Care Gelre Hospitals, Apeldoorn, The Netherlands.
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Aitken LM, Bucknall T, Kent B, Mitchell M, Burmeister E, Keogh SJ. Protocol directed sedation versus non-protocol directed sedation to reduce duration of mechanical ventilation in mechanically ventilated intensive care patients. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2012. [DOI: 10.1002/14651858.cd009771] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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Mehta S, McCullagh I, Burry L. Current sedation practices: lessons learned from international surveys. Anesthesiol Clin 2011; 29:607-24. [PMID: 22078912 DOI: 10.1016/j.anclin.2011.09.003] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Limitations are inherent to surveys. Most surveys have low response rates, which raises the issue of responder bias. Another limitation of self-report surveys stems from the possible differences between stated and actual practice. That is, what physicians report that they do in surveys often contrasts significantly with what they do in observational studies, as highlighted by the Canadian surveys conducted in 2002 and 2008. Some surveys report estimates provided by ICU nurse managers or physician directors, potentially resulting in inaccurate estimates or data reflecting the individuals practice rather than the entire ICU. Surveys may not reflect how different specialists practice; for example, the German surveys collected data only in ICUs run by anesthesiologists.Notwithstanding these limitations, surveys provide a wealth of information on current practice and determinants of practice, and serve as a useful tool to guide future research and educational interventions. The authors identified substantial international variation in the use of sedative and analgesic drugs, and marked changes over the last 10 years. Overall, there is a trend toward lighter sedation, along with a shift from benzodiazepines toward propofol, and from morphine toward fentanyl and remifentanil. Despite the publication of numerous studies and guidelines for sedation and analgesia, actual practice differs from recommended practice, suggesting that the impact of clinical trials and guidelines on physician practice is quite low. It is clear that there remain substantial barriers to the incorporation of sedation scales, protocols,and daily interruption into routine ICU care.
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Affiliation(s)
- Sangeeta Mehta
- Medical Surgical Intensive Care Unit, Mount Sinai Hospital, 600 University Avenue Room 18-216, Toronto, Ontario M5G 1X5, Canada.
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Ali NA, Gutteridge D, Shahul S, Checkley W, Sevransky J, Martin GS. Critical Illness Outcome Study: An Observational Study on Protocols and Mortality in Intensive Care Units. OPEN ACCESS JOURNAL OF CLINICAL TRIALS 2011; 2011:55-65. [PMID: 25429244 DOI: 10.2147/oajct.s24223] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
INTRODUCTION Many individual Intensive Care Unit (ICU) characteristics have been associated with patient outcomes, including staffing, expertise, continuity and team structure. Separately, many aspects of clinical care in ICUs have been operationalized through the development of complex treatment protocols. The United State Critical Illness and Injury Trials Group-Critical Illness Outcomes Study (USCIITG-CIOS) was designed to determine whether the extent of protocol availability and use in ICUs is associated with hospital survival in a large cohort of United States ICUs. Here, we describe the study protocol and analysis plan approved by the USCIITG-CIOS Steering Committee. METHODS USCIITG-CIOS is a prospective, observational, ecological multi-centered "cohort" study of mixed ICUs in the U.S. The data collected include organizational information for the ICU (e.g., protocol availability and utilization, multi-disciplinary staffing assessment) and patient level information (e.g. demographics, acute and chronic medical conditions). The primary outcome is all-cause hospital mortality, with the objective being to determine whether there is an association between protocol number and hospital mortality for ICU patients. USCIITG-CIOS is powered to detect a 3% difference in crude hospital mortality between high and low protocol use ICUs, dichotomized according to protocol number at the median. The analysis will utilize regression modeling to adjust for outcome clustering by ICU, with secondary linear analysis of protocol number and mortality and a variety of a priori planned ancillary studies. There are presently 60 ICUs participating in USCIITG-CIOS to enroll approximately 6,000 study subjects. CONCLUSIONS USCIITG-CIOS is a large multicentric study examining the effect of ICU protocol use on patient outcomes. The primary results of this study will inform our understanding of the relationship between protocol availability, use, and patient outcomes in the ICU. Moreover, given the shortage of intensivists worldwide, the results of USCIITG-CIOS can be used to promote more effective ICU and care team design and will impact the delivery of intensive care services beyond individual practitioners. TRIAL REGISTRATION ClinicalTrials.gov Identifier NCT01109719.
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Affiliation(s)
- Naeem A Ali
- The Ohio State University Medical Center, Columbus, OH
| | | | - Sajid Shahul
- Beth Israel Deaconess Medical Center, Boston, MA
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Sakata RK. Analgesia and Sedation in Intensive Care Unit. Rev Bras Anestesiol 2010; 60:648-58, 360-5. [DOI: 10.1016/s0034-7094(10)70081-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2010] [Accepted: 06/04/2010] [Indexed: 10/26/2022] Open
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