A protocol of no sedation for critically ill patients receiving mechanical ventilation: a randomised trial
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 ClinicalTrials.gov, 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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ABSTRACT: There is increasing evidence that deep sedation is detrimental to critically ill patients. The aim of this study was to examine effects of deep sedation during the early period after ICU admission on short- and long-term survival. In this observational, matched-pair analysis, patients with mechanical ventilation that were admitted to ICUs of a tertiary university hospital in six consecutive years were grouped as either lightly or deeply sedated within the first 48 hours after ICU admission. The Richmond-Agitation and Sedation Score (RASS) was used to assess sedation depth (light sedation: -2 to 0; deep: -3 or below). Multivariate Cox regression was conducted to investigate the impact of early deep sedation within the first 48 hours of admission on in-hospital and two-years follow-up survival. In total, 1,884 patients met inclusion criteria out of which 27.2% (n = 513) were deeply sedated. Deeply sedated patients had longer ventilation times, increased length of stay and higher rates of mortality. Early deep sedation was associated with a hazard ratio of 1.661 (95% CI: 1.074-2.567; p = 0.022) for in-hospital survival and 1.866 (95% CI: 1.351-2.576; p < 0.001) for two-years follow-up survival. Early deep sedation during the first 48 hours of intensive care treatment was associated with decreased in-hospital and two-years follow-up survival. Since early deep sedation is a modifiable risk factor, this data shows an urgent need for prospective clinical trials focusing on light sedation in the early phase of ICU treatment.Critical care (London, England) 04/2015; 19(1-1):197. DOI:10.1186/s13054-015-0929-2
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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
Critical care research and practice 01/2015; DOI:10.1155/2015/491780