A protocol of no sedation for critically ill patients receiving mechanical ventilation: A randomized trial

Department of Anesthesia and Intensive Care Medicine, Odense University Hospital, University of Southern Denmark, Denmark.
The Lancet (Impact Factor: 45.22). 02/2010; 375(9713):475-80. DOI: 10.1016/S0140-6736(09)62072-9
Source: PubMed

ABSTRACT Standard treatment of critically ill patients undergoing mechanical ventilation is continuous sedation. Daily interruption of sedation has a beneficial effect, and in the general intesive care unit of Odense University Hospital, Denmark, standard practice is a protocol of no sedation. We aimed to establish whether duration of mechanical ventilation could be reduced with a protocol of no sedation versus daily interruption of sedation.
Of 428 patients assessed for eligibility, we enrolled 140 critically ill adult patients who were undergoing mechanical ventilation and were expected to need ventilation for more than 24 h. Patients were randomly assigned in a 1:1 ratio (unblinded) to receive: no sedation (n=70 patients); or sedation (20 mg/mL propofol for 48 h, 1 mg/mL midazolam thereafter) with daily interruption until awake (n=70, control group). Both groups were treated with bolus doses of morphine (2.5 or 5 mg). The primary outcome was the number of days without mechanical ventilation in a 28-day period, and we also recorded the length of stay in the intensive care unit (from admission to 28 days) and in hospital (from admission to 90 days). Analysis was by intention to treat. This study is registered with, number NCT00466492.
27 patients died or were successfully extubated within 48 h, and, as per our study design, were excluded from the study and statistical analysis. Patients receiving no sedation had significantly more days without ventilation (n=55; mean 13.8 days, SD 11.0) than did those receiving interrupted sedation (n=58; mean 9.6 days, SD 10.0; mean difference 4.2 days, 95% CI 0.3-8.1; p=0.0191). No sedation was also associated with a shorter stay in the intensive care unit (HR 1.86, 95% CI 1.05-3.23; p=0.0316), and, for the first 30 days studied, in hospital (3.57, 1.52-9.09; p=0.0039), than was interrupted sedation. No difference was recorded in the occurrences of accidental extubations, the need for CT or MRI brain scans, or ventilator-associated pneumonia. Agitated delirium was more frequent in the intervention group than in the control group (n=11, 20%vs n=4, 7%; p=0.0400).
No sedation of critically ill patients receiving mechanical ventilation is associated with an increase in days without ventilation. A multicentre study is needed to establish whether this effect can be reproduced in other facilities.
Danish Society of Anesthesiology and Intensive Care Medicine, the Fund of Danielsen, the Fund of Kirsten Jensa la Cour, and the Fund of Holger og Ruth Hess.

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Available from: Thomas Strøm, Aug 23, 2015
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    • "The tools enable nurses to rapidly assess patients' sedation levels which then provides direction for sedation adequacy assessment and therapy titration according to patients' needs (Patel and Kress, 2012; Riggi and Glass, 2013). In addition, the use of such tools and protocols in critical care practices is effective in decreasing duration of mechanical ventilation, length of ICU stay and duration of sedation infusion (Treggiari et al., 2009; O'Connor et al., 2010; Strøm et al., 2010). "
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    ABSTRACT: Background Inappropriate sedation assessment can jeopardize patient comfort and safety. Therefore, nurses' abilities in assessing and managing sedation are vital for effective care of mechanically ventilated patients.Aims and objectivesThis study assessed nurses' sedation scoring and management abilities as primary outcomes following educational interventions. Nurses' perceived self-confidence and barriers to effective sedation management were assessed as secondary outcomes.DesignA post-test-only quasi-experimental design was used. Data were collected at 3 and 9 months post-intervention.MethodsA total of 66 nurses from a 14-bed intensive care unit of a Malaysian teaching hospital participated. The educational interventions included theoretical sessions, hands-on sedation assessment practice using the Richmond Agitation Sedation Scale, and a brief sedation assessment tool. Nurses' sedation scoring and management abilities and perceived self-confidence level were assessed at both time points using self-administered questionnaires with case scenarios. Sedation assessment and management barriers were assessed once at 9 months post-intervention.ResultsMedian scores for overall accurate sedation scoring (9 months: 4·00; 3 months: 2·00, p = 0·0001) and overall sedation management (9 months: 14·0; 3 months: 7·0, p = 0·0001) were significantly higher at 9 months compared to 3 months post-intervention. There were no significant differences in the perceived self-confidence level for rating sedation level. Overall perceived barrier scores were low (M = 27·78, SD = 6·26, possible range = 11·0–55·0). Patient conditions (M = 3·68, SD = 1·13) and nurses' workload (M = 3·54, SD = 0·95) were the greatest barriers to effective sedation assessment and management. Demographic variables did not affect sedation scoring or management abilities.Conclusions Positive changes in nurses' sedation assessment and management abilities were observed, indicating that adequate hands-on clinical practice following educational interventions can improve nurses' knowledge and skills.Relevance to clinical practiceEducational initiatives are necessary to improve ICU practice, particularly in ICUs with inexperienced nurses.
    Nursing in Critical Care 04/2015; DOI:10.1111/nicc.12180 · 0.87 Impact Factor
    • "Furthermore, everyday life changes in many ways after critical illness for both patients and relatives (Engstrom et al., 2008). Today, patients are kept more awake than previously, with less or no sedation, even though they are on a ventilator (Strom et al., 2010). Awake patients might have more vivid memories of their stay in an ICU, increasing the need and demand for care after ICU discharge. "
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    ABSTRACT: To determine the symptoms seen in patients after discharge from an intensive care unit (ICU) and the follow-up programmes offered to help patients deal with the problems that arise after an ICU stay. An increasing number of people are discharged from an ICU to continued treatment, care and rehabilitation in general hospital wards, rehabilitation facilities and at home. A prolonged stay in an ICU is associated with stressful memories that have long-term physical, mental and social consequences for health-related quality of life. We therefore conducted a data search to identify the programmes that have attempted to cope with these consequences. Searches of six online databases were conducted in December 2013. Qualitative or quantitative, original, empirical studies on symptoms and consequences associated with ICU stay and the follow-up programmes offered were reviewed. Excluded were studies in ICU patients younger than 18 years published in languages other than Scandinavian or English. We analysed original empirical studies according to symptoms, consequences and follow-up programmes and added a category ‘new ideas’. This was done to identify any possible evolution in the programmes offered to patients after ICU care. The review of the literature and the critical analysis were summarized in a figure in order to join the different parts together into a logical, coherent whole. Patients discharged from an ICU are heterogeneous, with a wide array of physical, mental and social problems. They and their close relatives can benefit from returning together to the ICU or participating in follow-up programmes. Little is known about the specific effects of the different types of follow-up. ICU staff as well as other professionals should prepare patients and relatives for the fact that they may need various types of help for many months after discharge from the ICU, and an overview of national and local opportunities for help should be offered.
    Nursing in Critical Care 02/2015; DOI:10.1111/nicc.12165 · 0.87 Impact Factor
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    • "Hypnotics, commonly either propofol or a benzodiazepine, are for amnesia, anxiolysis, and somnolence [2]. The choice of both opioid and sedative remains controversial, and more recently, there has been publication questioning the need for a hypnotic or " comfort " agent in its entirety [3]. There is consensus over sedative selection in specific situations, such as short-acting agents in neurologic assessment [4]. "
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    ABSTRACT: The purpose of this work was to obtain a detailed perspective of sedation practice. Sedation included sedative and opioid choice, presence of local guidelines, and use of scoring systems. A Web-based survey was designed. The aim was to gain sufficient detail of UK sedation while also being succinct enough to complete in 15 minutes. It was composed of relevant demographics, policy, sedative choice, and analgesia. The survey was piloted before launch. The investigators selected the intensive care unit (ICU) pharmacist as the respondent. One hundred fifty-seven ICUs responded. Eighty-nine (59%) reported use of sedation guidelines, 78% undertook sedation holds, and 87% use sedation scores. Only 42% used a daily sedation target. Seventy (43%) assess for delirium; 27 of those use a validated tool. Propofol (89%) use was common, followed by midazolam (49%). Morphine (49%), fentanyl (34%), and alfentanil (34%) were the most frequently used opioids. This survey confirmed expected variation in UK sedation practice. Recognized strategies such as target sedation score and sedation policy are underused. A 43% uptake in delirium screening suggests that larger engagement is required to meet national standards. Copyright © 2014 Elsevier Inc. All rights reserved.
    Journal of Critical Care 11/2014; 30(2). DOI:10.1016/j.jcrc.2014.11.006 · 2.19 Impact Factor
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