This article is a report of a study conducted to determine if a nursing-implemented protocol of daily interruption of sedative infusions vs. sedation as directed by the intensive care unit team would decrease duration of mechanical ventilation.
Continuous rather than intermittent infusion of sedative and analgesic agents leads to greater stability in sedation level, but has been correlated with prolongation of mechanical ventilation and hospitalization of critical care patients. Daily interruption of sedative infusions in mechanically ventilated patients has reduced the duration of mechanical ventilation and length of stay in intensive care.
A randomized controlled trial was carried out from November 2004 to March 2006 with 97 patients receiving mechanical ventilation and continuous infusion of sedative drugs in an intensive care unit in Greece. The primary outcome measure was the duration of mechanical ventilation. Secondary outcomes were length of intensive care unit stay, length of hospital stay, overall mortality, total doses of sedative and analgesic medicines and Ramsay scores and duration of cessation of sedative infusions per day.
The median duration of mechanical ventilation was 8.7 days vs. 7.7 days (P = 0.7). Length of intensive care unit stay (median: 14 vs. 12, P = 0.5) and in the hospital (median: 31 vs. 21, P = 0.1) was similar between the intervention and control groups. The absence of statistically significant differences in these variables remained when patients with brain injury were examined separately.
The nursing-implemented protocol of daily interruption of sedative infusions was neither beneficial nor harmful compared with usual practice, which has as its primary target the earliest possible awakening of patients.
"A subsequent multicenter trial based on this pilot was conducted in Canada and the United States with 423 patients, and also evidenced no difference in time to successful extubation, ICU and hospital length of stay . A Greek trial included 97 patients, and also showed no difference in duration of mechanical ventilation, ICU and hospital stay between daily interruption of sedative infusions and a practice of early awakening of patients . A recent Danish study with 113 patients suggested that a protocol of no-sedation, that kept patients with scheduled infusions of morphine and instituted continuous infusion of propofol for short periods of time, if necessary, was associated with more days without mechanical ventilation and shorter ICU and hospital stays . "
[Show abstract][Hide abstract] ABSTRACT: Daily sedative interruption and intermittent sedation are effective in abbreviating the time on mechanical ventilation. Whether one is superior to the other has not yet been determined. Our aim was to compare daily interruption and intermittent sedation during the mechanical ventilation period in a low nurse staffing ICU.
Adult patients expected to need mechanical ventilation for more than 24 hours were randomly assigned, in a single center, either to daily interruption of continuous sedative and opioid infusion or to intermittent sedation. In both cases, our goal was to maintain a Sedation Agitation Scale (SAS) level of 3 or 4; that is patients should be calm, easily arousable or awakened with verbal stimuli or gentle shaking. Primary outcome was ventilator-free days in 28 days. Secondary outcomes were ICU and hospital mortality, incidence of delirium, nurse workload, self-extubation and psychological distress six months after ICU discharge.
A total of 60 patients were included. There were no differences in the ventilator-free days in 28 days between daily interruption and intermittent sedation (median: 24 versus 25 days, P = 0.160). There were also no differences in ICU mortality (40 versus 23.3%, P = 0.165), hospital mortality (43.3 versus 30%, P = 0.284), incidence of delirium (30 versus 40%, P = 0.472), self-extubation (3.3 versus 6.7%, P = 0.514), and psychological stress six months after ICU discharge. Also, the nurse workload was not different between groups, but it was reduced on day 5 compared to day 1 in both groups (Nurse Activity Score (NAS) in the intermittent sedation group was 54 on day 1 versus 39 on day 5, P < 0.001; NAS in daily interruption group was 53 on day 1 versus 38 on day 5, P < 0.001). Fentanyl and midazolam total dosages per patient were higher in the daily interruption group. The tidal volume was higher in the intermittent sedation group during the first five days of ICU stay.
There was no difference in the number of ventilator-free days in 28 days between both groups. Intermittent sedation was associated with lower sedative and opioid doses.
ClinicalTrials.gov Identifier: NCT00824239.
Annals of Intensive Care 01/2014; 4(1):14. DOI:10.1186/2110-5820-4-14 · 3.31 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Le changement des pratiques de sédation-analgésie en réanimation au cours de la dernière décennie s’est illustré à la fois par l’utilisation de nouveaux médicaments mais aussi par de nouvelles stratégies d’administration de la sédation, comme l’administration protocolisée par l’équipe infirmière et l’épreuve d’arrêt quotidien. La mise en place de l’une ou l’autre de ces deux stratégies a démontré son efficacité pour réduire non seulement la durée de ventilation mécanique et de séjour en réanimation mais aussi la mortalité à six mois pour l’une des études. Si l’arrêt quotidien de la sédation est une stratégie aisée à mettre en œuvre au niveau individuel de chaque médecin, la mise en place d’un protocole de sédation requiert au contraire la formation de l’ensemble de l’équipe infirmière. Cette formation a pour objectif de maîtriser d’une part les outils cliniques permettant de standardiser la mesure subjective du niveau de sédation et de douleur, et d’autre part le protocole proprement dit dont la complexité peut être variable. Le protocole de sédation et son épreuve d’arrêt quotidien ont été évalués dans la littérature, le plus souvent de façon intriquée, et il n’est pas possible de déterminer précisément si l’une ou l’autre de ces stratégies est plus efficace ou plus faisable. Ces stratégies devraient être considérées comme complémentaires et ne devraient pas être opposées l’une à l’autre. En effet, si la sédation-analgésie doit être protocolisée au sein de l’équipe afin d’en éviter le surdosage au moment de son administration, l’équipe médicale devrait aussi rechercher quotidiennement les critères indiquant son arrêt afin d’éviter sa prolongation inutile. Des études cliniques sont encore nécessaires pour mieux préciser les critères précis d’arrêt de la sédation. L’impact de la prise en charge de la douleur et des troubles neuropsychologiques à l’arrêt de la sédation devrait également être déterminé plus précisément. La formation de l’équipe infirmière tant à la gestion de la sédation que de son arrêt paraît fondamentale.
[Show abstract][Hide abstract] ABSTRACT: CD-ROM invited Background: Over-sedation has significant impact on intensive care resources and patient outcome. Recent protocols that constrain and/or interrupt sedation delivery have reduced resource utilisation but have not significantly addressed difficulties in agitation control. Thus, patient outcomes have not changed significantly. The primary objective of sedation delivery in critical care is to control patient agitation at a minimum sedation concentration. Thus, it is a balance between minimizing sedation delivery and managing acute, and sometimes quite significant, episodes of patient agitation. In particular, agitation episodes tend to be sudden, “spiky” or acute, while, for convenience, sedation delivery tends to be continuous. Hence, many current methods and therapeutics used to control patient agitation are not matched to what is demanded by patient behaviour. This review examines sedation management in critical illness and explores how new methods of sedation delivery and new therapeutics can offer advantages over accepted practice. Methods: The current literature is reviewed and results summarized to compare and contrast differing approaches to sedation administration. In particular, emphasis is placed on randomized control trials (RCTs) in the past 5 years highlighting new and existing methods of employing well accepted, existing drug therapies. Over 30 such articles were found and their results summarized for analysis in terms of drug type, critical care unit type. Results and Outcomes: There currently exists no common approach to sedation therapy delivery due to a lack of full understanding of the underlying dynamics (both pharmacological and physiological). In particular, despite a large range of therapeutics, the majority of studies (over 65%) focused on new drug types at the expense of the most commonly used therapeutics. Many studies were hard to compare due to different definitions or applications of patient agitation resulting in potentially very different outcomes for otherwise similar protocols. In addition, different target patient groups and very short term studies with no long-term outcomes also made further analysis difficult. As a result, sedation delivery is still very much a custom therapy, delivered individually to each patient, with great variability across patients and units. Conclusions: The lack of an underlying framework or structure for sedation delivery that is based on a first principles approach to therapy should be a focal point for new research. Questions as to the underlying causes of patient agitation and the specific physiological and psychological goals of sedation delivery should be addressed to provide the foundation for consistent best practice methods. In particular, there is a desperate need for an objective, repeatable and entirely non-subjective approach to measuring or quantifying patient agitation before we can begin to develop a consensus on how best to treat or manage it.
Anna Purcell Kirk, Andrea McGlinsey, Alanna Beckett, Patricia Rudd, Richard Arbour
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