Optimizing Sedation in Critically Ill, Mechanically Ventilated Patients

Bundled Bispectral Index Monitoring and Sedation During Paralysis in Acute Respiratory Distress Syndrome

BACKGROUND

Clinical assessments of depth of sedation are insufficient for patients undergoing neuromuscular blockade during treatment of acute respiratory distress syndrome (ARDS). This quality initiative was aimed to augment objective assessment and improve sedation during therapeutic paralysis using the bispectral index (BIS).

METHODS

This quality improvement intervention provided education and subsequent implementation of a BIS monitoring and sedation/analgesia bundle in a large, urban, safety-net intensive care unit. After the intervention, a retrospective review of the first 70 admissions with ARDS assessed use and documented sedation changes in response to BIS.

RESULTS

Therapeutic neuromuscular blockade was initiated for 58 of 70 patients (82.8%) with ARDS, of whom 43 (74%) had BIS monitoring and 29.3% had bundled BIS sedation-titration orders. Explicit documentation of sedation titration in response to BIS values occurred in 27 (62.8%) of those with BIS recordings.

CONCLUSIONS

BIS sedation/analgesia bundled order sets are underused, but education and access to BIS monitoring led to high use of monitoring alone and subsequent sedation changes.

Sedation breaks: are they good for the critically ill patient? A review

BACKGROUND

Tradition has led us to believe that a heavily sedated patient is a comfortable, settled, compliant patient for whom sedation will improve outcome. The current move witnessed in clinical practice today of limiting sedation has led health care in recent years to question the benefit and necessity of routine, continuous sedation for all patients requiring mechanical ventilation. However, as a result there has been a rise in the amount of agitation being reported as being experienced by patients with the daily withdrawal of sedation.

AIMS

The purpose of this paper is to review current arguments for and against perserving with agitation versus re-sedating, when it presents during the daily sedation breaks.

FINDINGS

Of the literature reviewed, the question to re-sedate the mechanically ventilated agitated patient during sedation breaks remains an issue of contention. Although there is evidence focusing on the psychological effects of long-term sedation and sedation breaks specifically, the complex nature of critical illness in some cases means that individualized care is of paramount importance and in-depth assessment is crucial when deciding to re-sedate in the face of undetermined agitation. Agitation has been closely linked with several incidents that can be detrimental to patient safety, such as removal of lines and unplanned self-extubation.

CONCLUSION

The recommendations of this review are that nurses should re-commence sedation if the patient becomes agitated following a sedation break.

Sedation and analgesia management for mechanically ventilated adults: literature review, case study and recommendations for practice

The quality of sedation management in mechanically ventilated patients has been a source of concern in recent years. This paper summarises the literature on the principles of optimal sedation, discusses the consequences of over and undersedation, highlighting the importance of appropriate pain management, and presents a case study using the results of an audit of 48 mechanically ventilated adults. As a result of the review and audit, we are implementing changes to practice. The most important recommendations from the literature are the use of a sedation scale, setting of a goal sedation score, appropriate pain management and implementation of a nurse initiated sedation algorithm. Other recommendations include use of bolus rather than continuous sedative infusions and recommencing regular medications for anxiety, depression and other phychiatric disorders as soon as possible. A recommendation arising from our audit was the need to identify patients at high risk of oversedation and undersedation and adopt a proactive rather than reactive approach to management. The practice goal is to provide adequate and appropriate analgesia and anxiolysis for patients. This will improve patient comfort while reducing length of mechanical ventilation and minimising risk of complications.

Evaluation of a sedation protocol for intubated critically ill children

The aim of this study was to conduct an evaluation of a sedation protocol that transfers some decision-making authority for analgesia and sedation, within clearly defined parameters, to nurses in a pediatric intensive care unit (PICU). The sedation protocol used in this study was appropriate for any age group. The clinical course of 10 patients admitted to the PICU during a 5-month interval who were on the sedation protocol during their stay was examined using retrospective chart review. Time intervals when patients were on the protocol were compared with clinically comparable time intervals, in terms of acuity, when the same patient received conventional management. Data were collected on the number of days a child was ventilated, the number of days in the PICU, the number of days hospitalized and severity of illness. Additionally, data were collected on the amounts of sedation and analgesia required and the incidence of under-sedation. Physician and nurse satisfaction with the sedation protocol was examined using a self-report survey. The findings of this study indicate that the delegation of decision-making authority for analgesia and sedation to PICU nurses can provide effective and timely management of patient comfort, without an increase in morbidity, in a manner that is more satisfying for physicians and nurses.

Medications for Patient Comfort When Weaning Mechanical Ventilation in Palliative Care

Indications for mechanical ventilation in end of life care and the place for weaning are discussed. Preferred medications to facilitate weaning are short acting benzodiazepines. The importance of the environment in which ventilatory support is provided is discussed as are ethical issues including patient wishes and those of a patient' s proxy.

A review of intensive care nurse staffing practices overseas: what lessons for Australia?

In view of market-driven health-care policies and the move to greater efficiencies within the health-care system, the cost of nursing care is being increasingly scrutinised. Different overseas practices are commonly cited as justification for changing practices within Australia. This study is based on a review of the literature on intensive care nurse staffing requirements in Australasia; specifically, New South Wales, the United States (US) and, to a lesser extent, Europe. It was found that looking to the US for cost-cutting strategies in intensive care units (ICUs) is based on a false premise: that we are comparing like with like. ICUs in the US have a different historical trajectory and culture, service wider constituencies, have technicians and unregistered personnel providing nursing care and do not provide demonstrably better outcomes or significant cost savings. Research indicates that continuous nursing care by trained professionals provides the best outcomes. If costs must be cut, technology, pharmaceuticals and laboratory tests should be targeted. Further, a greater commitment to the development of a 'progressive patient care' model in hospital planning is required, in order to establish or consolidate an intermediate level of nursing care between the ward and the ICU. Programs aiming to improve and continuously monitor patient care, such as adverse event monitoring, the prevention of unplanned extubation and facilitation of early extubation, should be instituted, as these have been shown to not only reduce ICU costs but also improve patient outcomes. (c) 2000 Harcourt Publishers Ltd.

Sedation of the mechanically ventilated patient

Goals in the care of the mechanically ventilated patient are sedation, analgesia, anxiolysis, and muscle relaxation. Causes of distress in these patients include: pain, sleep deprivation, anxiety, psychosis, agitation, and delirium. Drugs used to alleviate these stressors are opiates, benzodiazepines, neuromuscular blocking agents, anesthetic induction agents, and inhalational agents. When caring for the agitated patient on the mechanical ventilator, physiologic, mechanical, and emotional causes must all be investigated. Finally, nonpharmacologic therapy is of utmost importance in the care of these patients.

A review of intensive care nurse staffing practices overseas: what lessons for Australia?

In view of market-driven health-care policies and the move to greater efficiencies within the health-care system, the cost of nursing care is being increasingly scrutinised. Different overseas practices are commonly cited as justification for changing practices within Australia. This study is based on a review of the literature on intensive care nurse staffing requirements in Australasia; specifically, New South Wales, the United States (US) and, to a lesser extent, Europe. It was found that looking to the US for cost-cutting strategies in intensive care units (ICUs) is based on a false premise: that we are comparing like with like. ICUs in the US have a different historical trajectory and culture, service wider constituencies, have technicians and unregistered personnel providing nursing care and do not provide demonstrably better outcomes or significant cost savings. Research indicates that continuous nursing care by trained professionals provides the best outcomes. If costs must be cut, technology, pharmaceuticals and laboratory tests should be targeted. Further, a greater commitment to the development of a 'progressive patient care' model in hospital planning is required, in order to establish or consolidate an intermediate level of nursing care between the ward and the ICU. Programs aiming to improve and continuously monitor patient care, such as adverse event monitoring, the prevention of unplanned extubation and facilitation of early extubation, should be instituted, as these have been shown to not only reduce ICU costs but also improve patient outcomes.

Patient responses during rapid terminal weaning from mechanical ventilation: a prospective study

OBJECTIVE

To describe and analyze patient responses to rapid terminal weaning from mechanical ventilation.

DESIGN

A prospective, descriptive, correlational study.

SETTING

An urban, university-affiliated, trauma/emergency hospital.

PATIENTS

A convenience sample of 31 adult patients experiencing withdrawal of mechanical ventilation.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Physiologic (peripheral oxygen saturation, end-tidal CO2, heart rate, and respiratory rate) and comfort (electroencephalogram [EEG], Bizek Agitation Scale, and the COMFORT scale) measures were collected at baseline, during, and after the terminal weaning procedure. Clinical status was measured using the Acute Physiology and Chronic Health Evaluation score, Glasgow Coma Scale, and PaO2/F(IO2). Duration of survival after the wean inversely correlated with illness severity but did not correlate with consciousness, use of analgesia/sedation, or pulmonary function. Respiratory rate and oxygen saturation changed significantly during the wean but not end-tidal CO2. Patients remained comfortable with little or no analgesia/sedation, in a predominantly comatose sample. Subjective measures of comfort strongly correlated with objective data from bispectral analysis of EEG.

CONCLUSIONS

Patients with altered consciousness or coma can be kept comfortable during a rapid terminal weaning procedure with morphine and benzodiazepines in low doses. Comfort can be reliably evaluated using subjective scales.

Adverse responses to analgesia, sedation, and neuromuscular blocking agents in infants and children

Analgesics, sedation, and neuromuscular blocking agents are commonly used in treating critically ill infants and children. Although these medications are beneficial and imperative to the care of the child, their use is not risk free. Adverse responses occur in these children. With improved methods for use and monitoring, adverse responses can be minimized.