Introduction of sedative, analgesic, and neuromuscular blocking agent guidelines in a medical intensive care unit: physician and nurse adherence

Pain management interventions of the non-communicating patient in intensive care: What works for whom and why? A rapid realist review

AIM

The utility and uptake of pain management interventions across intensive care settings is inconsistent. A rapid realist review was conducted to synthesise the evidence for the purpose of theory building and refinement.

DESIGN

A five-step iterative process was employed to develop project scope/ research questions, collate evidence, appraise literature, synthesise evidence and interpret information from data sources.

METHODS

Realist synthesis method was employed to systematically review literature for developing a programme theory.

DATA SOURCES

Initial searches were undertaken in three electronic databases: MEDLINE, CINHAL and OVID. The review was supplemented with key articles from bibliographic search of identified articles. The first 200 hits from Google Scholar were screened.

RESULTS

Three action-oriented themes emerged as integral to successful implementation of pain management interventions. These included health facility actions, unit/team leader actions and individual nurses' actions.

CONCLUSION

Pain assessment interventions are influenced by a constellation of factors which trigger mechanisms yielding effective implementation outcomes.

IMPLICATIONS

The results have implications on policy makers, health organisations, nursing teams and nurses concerned with optimising the successful implementation of pain management interventions.

IMPACT

The review enabled formation of a programme theory concerned with explaining how to effectively implement pain management interventions in intensive care.

REPORTING METHOD

This review was informed by RAMESES publication standards for realist synthesis.

PUBLIC CONTRIBUTION

No patient or public contribution. The study protocol was registered in Open Science Framework. 10.17605/OSF.IO/J7AEZ.

Pain assessment of the adult sedated and ventilated patients in the intensive care setting: A scoping review

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.

A Quality Improvement Project to Increase Adherence to a Pain, Agitation, and Delirium Protocol in the Intensive Care Unit

BACKGROUND

In recent years, the incidence of delirium has grown to epidemic proportions in the intensive care setting with up to 80% of mechanically ventilated patients being affected. This can lead to adverse patient outcomes such as increased lengths of hospital stay, increased mortality rates, and increased long-term cognitive impairment.

OBJECTIVES

The objective of this project is to determine whether a quality improvement project can increase adherence to an existing pain, agitation, and delirium (PAD) protocol for enhanced patient outcomes.

METHODS

Chart audits were conducted to determine baseline compliance, use of the PAD protocol was measured, and the type of medications administered to each mechanically ventilated patient was assessed. Using the Knowledge-to-Action framework, a multidisciplinary, multidimensional educational module was then developed and implemented that included an online tutorial, point-of-care reminders, written materials, and verbal coaching. A 3-month postimplementation chart audit was conducted to determine whether increased protocol competence was achieved.

RESULTS

Protocol use unexpectedly decreased from 74% to 41% (P < .01);however, compliance with medication recommendations did increase despite the decrease in use. Intravenous opioid use increased from 12% to 40% (P ≤ .001), whereas sedative propofol infusions decreased from 82% to 35% (P ≤ .001).

CONCLUSIONS

The implementation of a multidimensional, multidisciplinary project was successful in increasing compliance to the clinical practice guidelines for the management of PAD in adult intensive care unit patients, despite a decrease in protocol use. This unanticipated decrease in protocol use indicates the need for additional research in this area. Future recommendations also include a review of the existing PAD protocol to determine whether revisions could be made to better suit the needs of the staff while also improving patient outcomes in the arena of delirium experienced during critical care stays.

Analgesia and sedation post-coronary artery bypass graft surgery: a review of the literature

This review aimed to study the role of analgesia and sedation after coronary artery bypass graft (CABG) surgery, regarding pain management, assisted respiration, overall postoperative health care, and hospitalization. Data were collected from Pubmed, Scopus, and Cochrane databases. The following terms were used for the search: “analgesia”, “sedation”, “coronary artery bypass grafting”, CABG”, and “opioids”. Articles between the years 1988 and 2018 were evaluated. Several opioid and non-opioid analgesics used to relieve surgical pain are regarded as critical risk factors for developing pulmonary and cardiovascular complications in all kinds of thoracic surgery, especially CABG procedures. Effective pain management in post-CABG patients is largely dependent on effective pain assessment, type of sedatives and analgesics administered, and evaluation of their effects on pain relief. A significant challenge is to determine adequate amounts of administered analgesics and sedatives for postoperative CABG patients, because patients often order more sedatives and analgesics than needed. The pain management process is deemed successful when patients feel comfortable after surgery, with no negative side effects. However, postoperative pain management patterns have not included many modern methods such as patient-controlled analgesia, and postoperative pain management drugs are still limited to a restricted range of opioid and non-opioid analgesics.

Methods in the design and implementation of the Randomized Evaluation of Sedation Titration for Respiratory Failure (RESTORE) clinical trial

Background

Few papers discuss the pragmatics of conducting large, cluster randomized clinical trials. Here we describe the sequential steps taken to develop methods to implement the Randomized Evaluation of Sedation Titration for Respiratory Failure (RESTORE) trial that tested the effect of a nurse-implemented, goal-directed, comfort algorithm on clinical outcomes in pediatric patients with acute respiratory failure.

Methods

After development in a single institution, the RESTORE intervention was pilot-tested in two pediatric intensive care units (PICUs) to evaluate safety and feasibility. After the pilot, the RESTORE intervention was simplified to enhance reproducibility across multiple PICUs. The final RESTORE trial was developed as a cluster randomized clinical trial where the unit of randomization was the PICU, stratified by PICU size, and the unit of inference was the patient. Study execution was revised based on our Data and Safety Monitoring Board’s recommendation to consult with the Department of Health and Human Services’ Office of Human Research Protection (OHRP) on how best to consent eligible subjects. OHRP deemed that the RESTORE intervention posed greater than minimal risk and that all enrolled subjects provide consent reflecting their level of participation.

Results

Thirty-one PICUs of varying size, organization and academic affiliation participated and over 2800 critically ill infants and children supported on mechanical ventilation for acute pulmonary disease were enrolled. The primary outcome for the trial was the duration of mechanical ventilation; secondary outcomes included time awake and comfortable, total sedative exposure and iatrogenic withdrawal symptoms. Throughout the clinical trial the investigative team worked to maintain treatment fidelity, enrollment milestones and co-investigator enthusiasm. We considered the potential impact of competing clinical trials through a decision-making framework.

Conclusions

The RESTORE clinical trial was a large and complex multicenter study that has provided the necessary evidence to guide sedation practices in the field of pediatric critical care. Specific issues that were unique to this trial included level of consent, adding clinical sites to augment enrollment and evaluating the potential impact of competing clinical trials.

Trial registration

ClinicalTrials.gov, Identifiers: Pilot trial: NCT00142766; Retrospectively registerd on 2 September 2005.

Cluster randomized trial: NCT00814099. Registered on 23 December 2008.

Sedation After Cardiac Surgery: Is One Drug Better Than Another?

The classic high-dose narcotic-based cardiac anesthetic has been modified to facilitate a fast-track, rapid recovery in the intensive care unit (ICU). Postoperative sedation is consequently now an essential component in recovery of the patient undergoing cardiac surgery. It must facilitate the patient's unawareness of the environment as well as reduce the discomfort and anxiety caused by surgery, intubation, mechanical ventilation, suction, and physiotherapy. Benzodiazepines seem well suited for this role, but propofol, opioids, and dexmedetomidine are among other agents commonly used for sedation in the ICU. However, what is an ideal sedative for this application? When compared with benzodiazepine-based sedation regimens, nonbenzodiazepines have been associated with shorter duration of mechanical ventilation and ICU length of stay. Current sedation guidelines recommend avoiding benzodiazepine use in the ICU. However, there are no recommendations on which alternatives should be used. In postcardiac surgery patients, inotropes and vasoactive medications are often required because of the poor cardiac function. This makes sedation after cardiac surgery unique in comparison with the requirements for most other ICU patient populations. We reviewed the current literature to try to determine if 1 sedative regimen might be better than others; in particular, we compare outcomes of propofol and dexmedetomidine in postoperative sedation in the cardiac surgical ICU.

The Impact of Pain Assessment on Critically Ill Patients' Outcomes: A Systematic Review

In critically ill patients, pain is a major problem. Efficient pain management depends on a systematic, comprehensive assessment of pain. We aimed to review and synthesize current evidence on the impact of a systematic approach to pain assessment on critically ill patients' outcomes. A systematic review of published studies (CINAHL, PUBMED, SCOPUS, EMBASE, and COCHRANE databases) with predetermined eligibility criteria was undertaken. Methodological quality was assessed by the EPHPP quality assessment tool. A total of 10 eligible studies were identified. Due to big heterogeneity, quantitative synthesis was not feasible. Most studies indicated the frequency, duration of pain assessment, and types of pain assessment tools. Methodological quality assessment yielded “strong” ratings for 5/10 and “weak” ratings for 3/10 studies. Implementation of systematic approaches to pain assessment appears to associate with more frequent documented reports of pain and more efficient decisions for pain management. There was evidence of favorable effects on pain intensity, duration of mechanical ventilation, length of ICU stay, mortality, adverse events, and complications. This systematic review demonstrates a link between systematic pain assessment and outcome in critical illness. However, the current level of evidence is insufficient to draw firm conclusions. More high quality randomized clinical studies are needed.

Implementation of a pain management algorithm in intensive care units and evaluation of nurses' level of adherence with the algorithm

OBJECTIVES

To implement a pain management algorithm in intensive care units (ICU) and to evaluate nurses' level of adherence with the algorithm.

BACKGROUND

Many ICU patients experience pain. Therefore, an evidence-based algorithm for pain management was developed.

METHODS

A pain management algorithm was implemented in three units over three weeks. Nurses' level of adherence with the algorithm and associations between level of adherence and patient and unit characteristics over 22 weeks were evaluated using multivariate regression analysis.

RESULTS

Nurses' level of adherence was 74.6%. Adherence rates were lower on the evening and night shifts compared to the day shift. Males were assessed significantly less frequently than females. Patients with "injury, poisoning, or certain other consequences of external causes" were assessed significantly less frequently than patients with "diseases of the respiratory system."

CONCLUSIONS

ICU nurses can use a pain management algorithm consistently. Findings from this study suggest that a pain management algorithm is a useful tool to increase ICU nurses' adherence with pain assessment.

Weaning from mechanical ventilation: where were we then, and where are we now?

Weaning patients from long-term mechanical ventilation (LTMV) has been an important focus of clinical process improvement initiatives and research for decades. The purpose of this article is to describe the science that drives our current weaning practices, including (1) preweaning assessment, (2) individualized weaning plans, (3) weaning prediction, (4) the use of protocols and guidelines for weaning trials and sedation management, (5) timing of tracheostomy placement, and (6) system initiatives for the management of LTMV patients. Finally, this article discusses potential interventions for improving the outcomes of patients who require prolonged mechanical ventilation.

The role of standardized protocols in unplanned extubations in a medical intensive care unit

BACKGROUND

Many patients admitted to medical intensive care units require mechanical ventilation to assist with respiratory management. Unplanned extubations of these patients are associated with poor outcomes for patients and organizations. No previous research has investigated the role of standardized protocols in unplanned extubations when examined in conjunction with traditional risk factors.

OBJECTIVE

To identify risk factors associated with unplanned extubation among patients receiving mechanical ventilation and determine degree of compliance with pain, sedation, and weaning protocols.

METHODS

A prospective cohort study design was used. Data on all patients admitted to the medical intensive care unit who required mechanical ventilation were gathered daily. Additional data were gathered on those patients who experienced unplanned extubation. Descriptive, correlational, and regression analyses were performed.

RESULTS

Weaning protocols were a significant predictor of unplanned extubation: patients who had weaning protocols ordered and followed were least likely to experience unplanned extubation. Only 10% of the 190 patients in the study required reintubation, resulting in a significantly shorter ventilation time and unit length of stay among the unplanned extubation group.

CONCLUSIONS

Weaning protocols were associated with decreased incidence of unplanned extubation. Use of standardized protocols was feasible, as compliance among health care providers was high when protocols were medically prescribed. The reintubation rate in this study was low and associated with a significantly shorter ventilatory period and unit length of stay in the unplanned extubation group.

Impact of policy change on US Army combat transfusion practices

BACKGROUND

Clinical practice guidelines (CPGs) are used to keep providers up-to-date with the most recent literature and to guide in decision making. Adherence is typically improved although many have a muted impact. In March 2006, the US Army issued a damage control resuscitation CPG, encouraging 1:1 plasma:red blood cell (RBC) transfusions and limiting crystalloid use. The objective of this study was to determine whether the CPG was associated with a change in the transfusion practices in combat-wounded patients.

METHODS

All US service members injured in Operation Iraqi Freedom/Operation Enduring Freedom who received massive transfusions (MTs; > or = 10 RBC in 24 hours) were queried from the US Army Institute of Surgical Research transfusion database. Whole blood, when used, was counted as 1 unit of RBC, fresh frozen plasma (FFP), and platelet. Subjects were divided into pre- and post-CPG cohorts. Primary outcomes were ratios of FFP:RBC and crystalloid use.

RESULTS

A total of 777 MT patients were identified. The cohorts were similar in age (25 years +/- 6 years vs. 25 years +/- 6 years; p = ns) and injury severity scale score (24 +/- 12 vs. 25 +/- 12; p = ns). The post-CPG cohort was warmer (96.5 degrees F +/- 7.8 degrees F vs. 98.2 degrees F +/- 1.9 degrees F; p < 0.05) and was transfused more RBC, platelets, and plasma but received less crystalloid (17 units +/- 12 units vs. 19 units +/- 11 units, 1 unit +/- 2 units vs. 2 units +/- 3 units, 8 units +/- 8 units vs. 14 units +/- 11 units, 14 L +/- 14 L vs. 9 L +/- 13 L, respectively; p < 0.05). The post-CPG cohort also received a higher ratio transfusion (0.5 +/- 0.31 vs. 0.8 +/- 0.31; p < 0.05) representing a change in practice. Overall mortality was not different between the two groups (24 vs. 19%; p = 0.115).

CONCLUSIONS

MT patients are now receiving a higher FFP:RBC ratio and less crystalloid after implementation of the CPG. Additionally, patients are now presenting normothermic and have higher hemoglobin levels. All of these changes are consistent with the principles of damage control resuscitation. Changes in practice were associated with implementation of the CPG, maturity of the battlefield, and increased availability of products.

Early postoperative delirium after open-heart cardiac surgery is associated with decreased bispectral EEG and increased cortisol and interleukin-6

PURPOSE

It is difficult to substantiate the clinical diagnosis of postoperative delirium with objective parameters in intensive care units (ICU). The purpose of this study was to analyze (1) whether the bilateral bispectral (BIS) index, (2) cortisol as a stress marker, and (3) interleukin-6 as a marker of inflammation were different in delirious patients as compared to nondelirious ones after cardiac surgery.

METHODS

On the first postoperative day, delirium was analyzed in 114 patients by using the confusion assessment method for ICU (CAM-ICU). Bilateral BIS data were determined; immediately thereafter plasma samples were drawn to analyze patients' blood characteristics. The current ICU medication, hemodynamic characteristics, SOFA and APACHE II scores, and artificial ventilation were noted.

RESULTS

Delirium was detected at 19.1 ± 4.8 h after the end of surgery in 32 of 114 patients (28%). Delirious patients were significantly older than nondelirious ones and were artificially ventilated 4.7-fold more often during the testing. In delirious patients, plasma cortisol and interleukin-6 levels were higher (p = 0.01). The mean BIS index was significantly lower in delirious patients (72.6 (69.6-89.1); median [interquartile range (IQR), 25th-75th percentiles] than in nondelirious patients, 84.8 (76.8-89.9). BIS EEG raw data analysis detected significant lower relative alpha and higher theta power. A significant correlation was found between plasma cortisol levels and BIS index.

CONCLUSIONS

Early postoperative delirium after cardiac surgery was characterized by increased stress levels and inflammatory reaction. BIS index measurements showed lower cortical activity in delirious patients with a low sensitivity (27%) and high specificity (96%).

Impact of sustained neuromuscular blockade on outcome of mechanically ventilated children

BACKGROUND

Neuromuscular blocking agents (NMBA) are commonly administered to critically ill children in pediatric intensive care units (PICU) in the USA and Europe. Although NMBA are frequently used in PICU patients, their role in the PICU setting has not yet been clearly defined. The aim of this study was to describe the sustained administration of NMBA and its impact on outcome of PICU patients.

METHODS

A 3-year retrospective cohort study was conducted to compare mechanically-ventilated patients who received NMBA for at least 12 h with patients who did not (control group).

RESULTS

A total of 317 consecutive patients were ventilated over 3473 days. Patients were similar in age, weight and severity scores. Thirty-four children (10.7%) received NMBA. Compared with controls, the neuromuscular blockade (NMB) group had a longer duration of mechanical ventilation (13.7 vs 5.5 days, P= 0.000), longer PICU stay (20 vs 11 days, P= 0.000) and increased occurrence of ventilator-associated pneumonia (6.6 vs 4.1/1000 ventilator days, P= 0.010). The NMB use was not associated with higher mortality (8.8% vs 17.6%, P= 0.287) or longer hospital stay (30.5 vs 23 days, P= 0.117).

CONCLUSION

Although the use of NMBA was not associated with greater mortality, we found that sustained use of NMBA is associated with prolonged mechanical ventilation, longer PICU stay and higher incidence of ventilator-associated pneumonia when compared with controls. Larger studies are necessary to confirm these findings.

A systematic review of the impact of sedation practice in the ICU on resource use, costs and patient safety

Introduction

Patients in intensive care units (ICUs) often receive sedation for prolonged periods. In order to better understand the impact of sub-optimal sedation practice on outcomes, we performed a systematic review, including observational studies and controlled trials which were conducted in sedated patients in the ICU and which compared the impact of changes in or different protocols for sedation management on economic and patient safety outcomes.

Methods

We searched Medline, Embase and CINAHL online literature databases from 1988 to 15^th May 2008 and hand searched conferences. English-language studies set in the ICU, in sedated adult humans on mechanical ventilation, which reported the impact of sedation practice on cost and resource use and patient safety outcomes, were included. All abstracts were reviewed twice by two independent reviewers, with all conflicts resolved by a third reviewer, to check that they met the review inclusion criteria. Full-text papers of all included studies were retrieved and again reviewed twice against inclusion criteria. Data were doubly extracted from studies. Study aims, design, population, and outcomes including duration of mechanical ventilation, length of stay in ICU and hospital, costs and rates of mortality and adverse events were extracted. Due to heterogeneity between study designs and outcomes reported, no quantitative data synthesis such as meta-analysis was possible.

Results

Included studies varied in design, patient population and aim, with the majority being before-after studies. Overall, studies showed that improvements in sedation practice, such as the introduction of guidelines and protocols, or daily interruption of sedation, were associated with improvements in outcomes including ICU and hospital length of stay, duration of mechanical ventilation, and costs. Mortality and the incidence of nosocomial infections were also reduced.

Conclusions

Systematic interventions to improve sedation practice and maintain patients at an optimal sedation level in the ICU may improve patient outcomes and optimize resource usage.

Use of intravenous infusion sedation among mechanically ventilated patients in the United States

OBJECTIVES

Many studies compare the efficacy of different forms of intravenous infusion sedation for critically ill patients, but little is known about the actual use of these medications. We sought to describe current use of intravenous infusion sedation in mechanically ventilated patients in U.S. intensive care units.

DESIGN

Retrospective cohort study of intravenous infusion sedation among mechanically ventilated patients. Intravenous sedatives examined included benzodiazepines (midazolam and lorazepam), propofol, and dexmedetomidine. Use was defined as having received an intravenous infusion for any time period during the stay in intensive care.

SETTING

One hundred seventy-four intensive care units contributing data to Project IMPACT from 2001 through 2007.

PATIENTS

All patients who received mechanical ventilation.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Of 109,671 mechanically ventilated patients, 56,443 (51.5%, 95% confidence interval 51.2-51.8) received one or more intravenous infusion sedatives. Sedative use increased over time, from 39.7% (38.7-40.6) of patients in 2001 to 66.7% (65.7-67.7) in 2007 (p < .001). Most patients who received intravenous infusion sedation received propofol (82.2%, 81.9-82.5) vs. benzodiazepines (31.1%, 30.7-31.5) or dexmedetomidine (4.0%, 3.8-4.2). Of the patients, 66.2% (65.8-66.6) received only propofol, and 16.2% (15.9-16.5) only benzodiazepines. Among patients mechanically ventilated >96 hrs, propofol infusions were more common. Intravenous infusion narcotics (fentanyl, morphine, or hydromorphone) were used more frequently among patients who received benzodiazepines (70.1%, 69.1-71.0) compared with propofol (23.9%, 23.5-24.3), p < .001.

CONCLUSIONS

The percentage of mechanically ventilated patients receiving intravenous infusion sedation has increased over time. Sedation with an infusion of propofol was much more common than with benzodiazepines or dexmedetomidine, even for patients mechanically ventilated beyond 96 hrs.

Head CT is of limited diagnostic value in critically ill patients who remain unresponsive after discontinuation of sedation

Background

Prolonged sedation is common in mechanically ventilated patients and is associated with increased morbidity and mortality. We sought to determine the diagnostic value of head computed tomography (CT) in mechanically ventilated patients who remain unresponsive after discontinuation of sedation.

Methods

A retrospective review of adult (age >18 years of age) patients consecutively admitted to the medical intensive care unit of a tertiary care medical center. Patients requiring mechanical ventilation for management of respiratory failure for longer than 72 hours were included in the study group. A group that did not have difficulty with awakening was included as a control.

Results

The median time after sedation was discontinued until a head CT was performed was 2 days (interquartile range 1.375–2 days). Majority (80%) of patients underwent head CT evaluation within the first 48 hours after discontinuation of sedation. Head CT was non-diagnostic in all but one patient who had a small subarachnoid hemorrhage. Twenty-five patients (60%) had a normal head CT. Head CT findings did not alter the management of any of the patients. The control group was similar to the experimental group with respect to demographics, etiology of respiratory failure and type of sedation used. However, while 37% of subjects in the control group had daily interruption of sedation, only 19% in the patient group had daily interruption of sedation (p < 0.05).

Conclusion

In patients on mechanical ventilation for at least 72 hours and who remain unresponsive after sedative discontinuation and with a non-focal neurologic examination, head CT is performed early and is of very limited diagnostic utility. Routine use of daily interruption of sedation is used in a minority of patients outside of a clinical trial setting though it may decrease the frequency of unresponsiveness from prolonged sedation and the need for head CT in patients mechanically ventilated for a prolonged period.

Experiences of intensive care nurses assessing sedation/agitation in critically ill patients

BACKGROUND

Patients admitted to the intensive care unit (ICU) will more often than not require sedative and analgesic drugs to enable them to tolerate the invasive procedures and therapies caused as a result of their underlying condition and/or necessary medical interventions.

AIM

This article reports a study exploring the perceptions and experiences of intensive care nurses using a sedation/agitation scoring (SAS) tool to assess and manage sedation and agitation amongst critically ill patients. The principle aims and objectives of this study were as follows: to explore nurse's everyday experiences using a sedation scoring tool; to explore and understand nurse's attitudes and beliefs of the various components of assessing and managing sedation among critically ill patients.

METHOD

Using a descriptive qualitative approach, semistructured interviews were carried out with a purposive sample of eight ICU nurses within a district general hospital ICU. The interviews focused on nurses own experiences and perceptions of using a sedation scoring tool in clinical practice. Burnards 14-stage thematic content analysis framework was employed to assist in the data analysis process.

RESULTS

Three key themes emerged that may have implications not only for clinical practice but for further research into the use of the SAS tool. Benefits to patient care as a direct result of using a sedation scoring tool. The concerns of nursing staff. The implications of using such a tool in clinical practice.

CONCLUSION

This paper reinforces the potential benefits to patients as a direct result of implementing the SAS scoring tool and clinical guidelines. Furthermore, it highlights the reluctance of a number of staff to adhere to such guidelines and discusses the concerns regarding less experienced nurses administering sedative agents. Attention was also drawn to the educational requirements of nursing and medical staff when using the SAS scoring tool.

[Management of the sedated patient]

A sedation strategy aimed at minimizing alteration of consciousness once comfort, analgesia and adaptation to the ventilator have been ensured is feasible in critically-ill patients requiring mechanical ventilation, even if, in patients with severe ARDS or ICH, the high dosages of sedatives and analgesics transiently required to provide perfect adaptation to the ventilator often preclude preservation of consciousness. The main components of a sedation algorithm include a clear objective of sedation-analgesia, regular assessments of patient status using validated clinical tools and a precise yet simple dosage adaptation schedule. Development and implementation of a sedation algorithm requires a multidisciplinary approach and an important input from both physicians and nurses. However, several methodologically-correct interventional studies have shown that using an algorithm to administrate sedatives and analgesics results in a significant reduction of MV duration, reaching 50% in some studies. This might translate into a real benefit for the patient point of view provided that preserving patient's comfort remains a constant concern for the caregivers. There is no reliable evidence to date to use propofol rather than midazolam as a sedative agent. Indeed, the way the sedative drug is used, as part of a sedation algorithm, is very likely more important than the selection of the drug itself. Analgesia-based sedation, promoting the use of morphinics alone before the adjunction of hypnotics, represents a new alternative to the traditional combined administration of hypnotics and morphinics. However data on the impact of analgesia-based sedation on patients' outcomes remain sparse to date.

Duration of Mechanical Ventilation in an Adult Intensive Care Unit After Introduction of Sedation and Pain Scales

Background Sedation and analgesia scales promote a less-distressing experience in the intensive care unit and minimize complications for patients receiving mechanical ventilation.

Objectives To evaluate outcomes before and after introduction of scales for sedation and analgesia in a general intensive care unit.

Method A before-and-after design was used to evaluate introduction of the Richmond Agitation-Sedation Scale and the Behavioral Pain Scale for patients receiving mechanical ventilation. Data were collected for 6 months before and 6 months after training in and introduction of the scales.

Results A total of 769 patients received mechanical ventilation for at least 6 hours (369 patients before and 400 patients after implementation). Age, scores on the Acute Physiology and Chronic Health Evaluation (APACHE) II, and diagnostic groups were similar in the 2 groups, but the after group had more men than did the before group. Duration of mechanical ventilation did not change significantly after the scales were introduced (median, 24 vs 28 hours). For patients who received mechanical ventilation for 96 hours or longer (24%), mechanical ventilation lasted longer after implementation of the scales (P =.03). Length of stay in the intensive care unit was similar in the 2 groups (P = .18), but patients received sedatives for longer after implementation (P=.01). By logistic regression analysis, APACHE II score (P &lt;.001) and diagnostic group (P &lt;.001) were independent predictors of mechanical ventilation lasting 96 hours or longer.

Conclusion Sedation and analgesia scales did not reduce duration of ventilation in an Australian intensive care unit.

[Pain management]

Analgesia and hypnosis are two separate entities and should result in distinct assessment and management for patients admitted to an intensive care unit (ICU). Those patients are exposed to moderate-severe pain and they are likely to remember pain as one bothersome experience. Any cause of patient discomfort is sought with the priority given to pain and adequate analgesia. Assessing pain must rely upon the use of clinical scoring systems, although these instruments are still underused in ICU. Satisfactory levels of analgesia by continuous infusion of opioids during times without stimulation do not guarantee against pain reactions during procedures (endotracheal suctioning, mobilization, wound care and dressing change, removal of chest tube). The concept of multimodal analgesia should be extended to the ICU since it may reduce the opioids requirements. In order to facilitate systematic pain and sedation assessment and to adjust daily drug dosages accordingly, it appears crucial to promote educational programs and elaboration of protocols/guidelines in ICU. Protocols/guidelines may help caregivers to rationally use sedatives and opioids and possibly reduce mechanical ventilation and ICU length of stay.

Pain may be inevitable; inadequate management is not

Assessing and managing pain in the critically ill patient is challenging. Reproducible and clinically applicable pain measurement scales have yet to be validated and ubiquitously applied in the intensive care unit setting. Critical care clinicians, both physicians and nurses, should thoughtfully monitor their patient's pain level, periodically reassess their practice and critically evaluate the efficacy of pharmacological and nonpharmacological analgesic interventions.

Use of sedatives, opioids, and neuromuscular blocking agents in patients with acute lung injury and acute respiratory distress syndrome

OBJECTIVE

The use of sedatives, opioids, and neuromuscular blocking agents (NMBAs) may delay weaning and prolong intensive care unit length of stay. We hypothesized that in patients on higher positive end-expiratory pressure (PEEP), sedatives, opioids, and NMBAs are used in a higher proportion of patients and in higher doses and that the use of these medications is associated with prolongation of weaning and mortality.

DESIGN

Retrospective analysis.

SETTING

The ALVEOLI trial.

PATIENTS

Five hundred forty-nine patients with acute lung injury/acute respiratory distress syndrome (ALI/ARDS) who were enrolled in the ALVEOLI trial.

INTERVENTIONS

We analyzed prospectively collected data regarding the impact of sedatives, opioids, and NMBAs in ALI/ARDS patients on duration of mechanical ventilation, time to weaning landmarks, and mortality.

MEASUREMENTS AND MAIN RESULTS

Sedatives and opioids were used in >80% of the patients in similar proportion in the two groups. The use of sedatives and opioids, but not the use of NMBAs, was associated with longer time on mechanical ventilation and an increased time to achieve a 2-hr spontaneous breathing trial (p < .0001). Sedatives were also associated with increased time to achieve unassisted breathing. NMBAs were used for a short period of time, in a higher proportion of patients in the lower PEEP group, and for a longer time (0.23 days).

CONCLUSIONS

Sedatives and opioids use was similar in the higher and lower PEEP groups. The use of sedatives and opioids, but not NMBAs, was associated with a longer time to achieve important weaning landmarks.

Combined didactic and scenario-based education improves the ability of intensive care unit staff to recognize delirium at the bedside

BACKGROUND

While nurses play a key role in identifying delirium, several authors have noted variability in their ability to recognize delirium. We sought to measure the impact of a simple educational intervention on the ability of intensive care unit (ICU) nurses to clinically identify delirium and to use a standardized delirium scale correctly.

METHODS

Fifty ICU nurses from two different hospitals (university medical and community teaching) evaluated an ICU patient for pain, level of sedation and presence of delirium before and after an educational intervention. The same patient was concomitantly, but independently, evaluated by a validated judge (rho = 0.98) who acted as the reference standard in all cases. The education consisted of two script concordance case scenarios, a slide presentation regarding scale-based delirium assessment, and two further cases.

RESULTS

Nurses' clinical recognition of delirium was poor in the before-education period as only 24% of nurses reported the presence or absence of delirium and only 16% were correct compared with the judge. After education, the number of nurses able to evaluate delirium using any scale (12% vs 82%, P < 0.0005) and use it correctly (8% vs 62%, P < 0.0005) increased significantly. While judge-nurse agreement (Spearman rho) for the presence of delirium was relatively high for both the before-education period (r = 0.74, P = 0.262) and after-education period (r = 0.71, P < 0.0005), the low number of nurses evaluating delirium before education lead to statistical significance only after education. Education did not alter nurses' self-reported evaluation of delirium (before 76% vs after 100%, P = 0.125).

CONCLUSION

A simple composite educational intervention incorporating script concordance theory improves the capacity for ICU nurses to screen for delirium nearly as well as experts. Self-reporting by nurses of completion of delirium screening may not constitute an adequate quality assurance process.

Implementing and assessing an evidence-based electrolyte dosing order form in the medical ICU

The purpose of this study was to evaluate the efficacy, safety, and nursing acceptability of a nursing initiated, evidence-based order form to replace potassium, magnesium, and phosphate in the MICU.

METHODS

This retrospective study compared patients receiving electrolyte replacement with the order form to matched historical control patients receiving traditional electrolyte replacement (no order form). The primary outcomes were absolute change in serum concentrations and the proportion of doses achieving normal serum concentrations. Other outcomes were adverse events as documented in the medical record and nursing acceptability as assessed by survey.

RESULTS

The 2 groups (12 in each group) were similar. The order form and control groups received 36 and 62 potassium doses, 14 and 48 magnesium doses, and 34 and 13 phosphorus doses, respectively. Doses of all three electrolytes were significantly larger with the order form. Absolute changes in potassium, magnesium, and phosphorus serum concentrations for the order form group and control group were 0.36+/-0.42 versus 0.11+/-0.43 mmol/l (p<0.01), 0.56+/-0.69 versus 0.13+/-0.40 mequiv./l (p=0.07), and 0.53+/-0.82 versus 0.66+/-0.83 mg/dl (p=0.63), respectively. Normal serum concentrations achieved for each electrolyte replacement dose in the order form group and control group were 72% versus 18% (p<0.001), 86% versus 21% (p<0.001), and 47% versus 62% (p=0.57), respectively. No adverse events occurred. The nursing survey showed satisfaction and comfort using the order form.

CONCLUSIONS

The use of the order form provided greater efficiency for replacing potassium and magnesium but not phosphorus without increasing the occurrence of adverse events. The order form was well received by nursing staff.

Use of a validated delirium assessment tool improves the ability of physicians to identify delirium in medical intensive care unit patients

OBJECTIVE

Although medical intensive care unit nurses at our institution routinely use the Intensive Care Delirium Screening Checklist (ICDSC) to identify delirium, physicians rely on traditional diagnostic methods. We sought to measure the effect of physicians' use of the ICDSC on their ability to detect delirium.

DESIGN

Before-after study.

SETTING

Medical intensive care unit of an academic medical center.

PATIENTS AND PARTICIPANTS

A total of 25 physicians with >or=1 month of clinical experience in the medical intensive care unit conducted 300 delirium assessments in 100 medical intensive care unit patients.

MEASUREMENTS AND MAIN RESULTS

Physicians sequentially evaluated two patients for delirium using whatever diagnostic method preferred. Following standardized education regarding ICDSC use, each physician evaluated two different patients for delirium using the ICDSC. Each physician assessment was preceded by consecutive, but independent, evaluations for delirium by the patient's nurse and then a validated judge using the ICDSC. Before (PRE) physician ICDSC use, the validated judge identified delirium in five patients; the physicians and nurses identified delirium in zero and four of these patients, respectively. The physicians incorrectly identified delirium in four additional patients. After (POST) physician ICDSC use, the validated judge identified delirium in 11 patients; the physicians and nurses identified delirium in eight and ten of these patients, respectively. The physicians incorrectly identified delirium in one patient. After physician ICDSC use, agreement improved between both the physicians and validated judge (PRE kappa = -0.14 [95% confidence interval {CI} = -0.27 to -0.02] to POST kappa = 0.67 [95% CI = 0.38 to 0.96]) and physicians and nurses (PRE kappa = -0.15 [95% CI = -0.29 to -0.02] to POST kappa = 0.58 [95% CI = 0.25 to 0.91]). Nurses vs. validated judge agreement was strong in both periods (PRE kappa = 0.65 [95% CI = 0.29 to 1.00] and POST kappa = 0.92 [95% CI = 0.76 to 1.00]).

CONCLUSIONS

Use of the ICDSC, along with education supporting its use, improves the ability of physicians to detect delirium in the medical intensive care unit.

The sedation of critically ill adults: part 2: management

The prevention and treatment of pain, anxiety, and delirium in the ICU are important goals. But achieving a balance between sedation and analgesia, especially in critically ill patients on mechanical ventilation, can be challenging. Both under- and oversedation carry grave risks. Without having an agreed-upon end point for sedation, different providers will likely have disparate treatment goals, increasing the risk of iatrogenic complications and possibly impeding recovery. In 2002 the Society of Critical Care Medicine, along with the American Society of Health-System Pharmacists, updated recommendations in its clinical practice guidelines for the sustained use of sedatives and analgesics in adults. This two-part series examines those recommendations concerning sedation assessment and management, as well as the current literature. Last month, Part 1 reviewed pertinent recommendations concerning pain and delirium and discussed tools for assessing pain, delirium, and sedation. This month, Part 2 explores pharmacologic and nonpharmacologic management of anxiety and agitation in the ICU. The second in a two-part series focuses on the pharmacologic and nonpharmacologic management of anxiety and agitation in the ICU.

The sedation of critically ill adults: Part 1: Assessment. The first in a two-part series focuses on assessing sedated patients in the ICU

The prevention or treatment of pain, anxiety, and delirium in the ICU is an important goal. But achieving a balance between sedation and analgesia, especially in critically ill patients on mechanical ventilation, can be challenging. Both under- and oversedation carry serious risks. In 2002 the Society of Critical Care Medicine, along with the American Society of Health-System Pharmacists, updated recommendations in its clinical practice guidelines for the sustained use of sedatives and analgesics in adults. This two-part series examines those recommendations that relate to sedation assessment and management, as well as the current literature. This month Part 1 also reviews pertinent recommendations concerning pain and delirium and discusses tools for assessing pain, delirium, and sedation. In August Part 2 will explore pharmacologic and nonpharmacologic management of anxiety and agitation in critically ill patients. The prevention or treatment of pain, anxiety, and delirium in the ICU is an important goal. But achieving a balance between sedation and analgesia, especially in critically ill patients on mechanical ventilation, can be challenging. Both under- and oversedation carry serious risks. In 2002 the Society of Critical Care Medicine, along with the American Society of Health-System Pharmacists, updated recommendations in its clinical practice guidelines for the sustained use of sedatives and analgesics in adults. This two-part series examines those recommendations that relate to sedation assessment and management, as well as the current literature. This month Part 1 also reviews pertinent recommendations concerning pain and delirium and discusses tools for assessing pain, delirium, and sedation. In August Part 2 will explore pharmacologic and nonpharmacologic management of anxiety and agitation in critically ill patients.

Economic evaluation of sustained sedation/analgesia in the intensive care unit

Lorazepam, midazolam, propofol and opioids are the primary agents that are used for sustained sedation and analgesia of critically ill patients. The choice of agent depends on safety profiles, expected outcomes, cost, patient characteristics and clinical experience. Few studies have comparatively evaluated the sedatives in terms of cost. Many factors, aside from drug costs, influence the total cost of sedation in the intensive care unit. This article reviews the cost parameters of intensive care unit sedation that are specific to the characteristics of commonly used sedatives and analgesics, evaluates economic studies and cost models, summarises alternative methods of sedation and analgesia, and provides practical recommendations for methods of cost containment, including daily sedation interruption, sedation monitoring and protocol implementation.

[Knowledge and application level of the Ramsay Scale by Mexican nurses specialized in intensive care]

INTRODUCTION

Among the intensive care specialized nursing staff, knowing the sedation level of the patient under their responsibility is of crucial importance. The present study evaluated the knowledge that nurses specialized in intensive care (NSIC) have on the Ramsay Scale (RS) and the way in which they apply it.

MATERIAL AND METHODS

Those personnel who were developing their activity in the intensive care units (ICU) of four public hospitals of the cities of Merida, Yucatan, Mexico were enrolled during May 2003. The information was obtained by applying an expressly designed questionnaire that contained both demographic endpoints (age, years of experience as NSIC and type of ICU) and those related with the RS (clinical components that it evaluates, operative definitions, frequency of use per week or day). 95% (95% CI) confidence intervals were applied and odds ratio (OR) was used to determined the likelihood of the event.

RESULTS

Of the 60 nurses interviewed, 75% did not know the RS. Age was a significant factor associated with its knowledge, since 11 of 23 with an age equal to or less than 38 years (47.8%) and 4 of 37 over 38 years (10.8%) knew what it evaluated (OR of 4 for the group of lower age, 95% CI 1.5 to 12.3, p = 0.002). Of 15 NSIC who knew what it evaluated, 9 (60%) also knew its operative definitions, and stated that they applied it adequately per day.

CONCLUSIONS

In this sample, there is an elevated percentage of NSIC who did not know the RS. Age was the factor associated with lack of knowledge.

State Behavioral Scale: a sedation assessment instrument for infants and young children supported on mechanical ventilation

OBJECTIVE

To develop and test the reliability and validity of the State Behavioral Scale for use in describing sedation/agitation levels in young intubated patients supported on mechanical ventilation.

DESIGN

: In this prospective, psychometric evaluation, pairs of trained pediatric critical care nurse evaluators simultaneously and independently assessed a convenience sample of pediatric intensive care unit patients along eight state/behavioral dimensions and a numeric rating scale (NRS) of 0 (extremely sedated) to 10 (extremely agitated). The eight dimensions were derived from the sedation/agitation literature and expert opinion and included respiratory drive, response to ventilation, coughing, best response to stimulation, attentiveness to careprovider, tolerance to care, consolability, and movement after consoled, each with 3-5 levels.

SETTING

An 18-bed pediatric medical-surgical intensive care unit and 26-bed pediatric cardiovascular intensive care unit in a university-affiliated academic children's hospital.

PATIENTS

A total of 91 intubated mechanically ventilated patients 6 wks to 6 yrs of age provided a median of two observations (interquartile range, 1-3) for a total of 198 sets of observations. Excluded were postoperative patients or those receiving neuromuscular blockade.

INTERVENTIONS

Patients were observed for 1 min, and then incremental levels of stimulation were applied until patient response. After 2 mins of consoling, the state behavioral assessment and NRS were completed.

MEASUREMENTS

Weighted kappa and intraclass coefficients were generated to assess interrater reliability of the eight dimension and NRS ratings. Distinct state behavior profiles were empirically identified from the dimension ratings using hierarchical cluster analysis using a squared Euclidean distance measure and between-groups linkage. Construct validity of these profiles was assessed by comparing group mean NRS scores using one-way analysis of variance.

MAIN RESULTS

Weighted kappa scores for all 198 dimension ratings ranged from .44 to .76, indicating moderate to good interrater reliability. The intraclass coefficient of .79 was high for NRS ratings. Cluster analysis revealed five distinct state profiles, with mean NRS ratings of 1.1, 2.5, 4.0, 5.3, and 7.6, all of which differed significantly from each other (F = 75.8, p < .001), supporting the profiles' construct validity.

CONCLUSIONS

Based on empirically derived state behavior profiles, we have constructed the State Behavioral Scale to allow systematic description of the sedation-agitation continuum in young pediatric patients supported on mechanical ventilation. Further studies including prospective validation and describing the effect of State Behavioral Scale implementation on clinical outcomes, including the quality of sedation and length of mechanical ventilation, are warranted.

Use of a sedation-analgesia datasheet in closed shoulder reductions

A three-page conscious sedation (CS) monitoring datasheet and sedation-analgesia policy were implemented at the Lincoln Hospital Emergency Department (LHED) to maintain compliance with JCAHO and New York State standards on CS monitoring. The datasheet included areas for physical examination, medications, and vital signs. To determine effects of the new datasheet and policy, charts containing all closed shoulder reductions done at LHED from April 3, 1996 to June 30, 1999 (n = 237) were reviewed for use of CS, defined as the use of an analgesic and sedative-hypnotic concurrently. Utilization of CS during equal time periods of 591 days before and after datasheet implementation was analyzed and compared. Before use of the datasheet, 64.3% received CS before closed shoulder reduction, compared with 41.8% after its use began (p < 0.05). A subsequent survey was conducted to determine physician perception of the CS datasheet. Attending-level LHED physicians suggested that use of the datasheet increased charting time and liability.

Use of Sedatives and Neuromuscular Blockers in a Cohort of Patients Receiving Mechanical Ventilation

OBJECTIVE

To describe the use of sedatives and neuromuscular blocking agents (NMBs) and their impact in outcome in an international cohort of patients receiving mechanical ventilation.

METHODS

We analyzed the database of a prospective, multicenter cohort of 5,183 adult patients who received mechanical ventilation for > 12 h. We considered that a patient received a given agent when it was administered for at least 3 h in a 24-h period.

RESULTS

A total of 3,540 patients (68%; 95% confidence interval [CI], 67 to 69%) received a sedative at any time while receiving mechanical ventilation. The median number of days of use was 3 (interquartile range [IQR], 2 to 6 days). The persistent use of sedative was associated with more days of mechanical ventilation (median, 4 days [IQR, 2 to 8 days], vs 3 days [IQR, 2 to 4 days] in patients who did not receive sedatives [p < 0.001]); more weaning days (median, 2 days [IQR, 1 to 3 days], vs 2 days [IQR, 1 to 5 days] in patients who did not receive sedatives [p < 0.001]); and longer length of stay in the ICU (median, 8 days [IQR, 5 to 15 days], vs 5 days [IQR, 3 to 9 days] in patients who did not receive sedatives [p < 0.001]). Six hundred eighty-six patients (13%; 95% CI, 12 to 14%) received an NMB for at least 1 day. The median number of days of use was 2 (IQR, 1 to 4 days). The administration of an NMB was independently related with age, a normal previous functional status, main reason of mechanical ventilation (patients with ARDS received more NMBs), and with patient management (patients requiring permissive hypercapnia, prone position, high level of positive end-expiratory pressure, and high airways pressure).

CONCLUSIONS

The use of sedatives is very common, and their use is associated with a longer duration of mechanical ventilation, weaning time, and stay in the ICU. NMBs are used in 13% of the patients and are associated with longer duration of mechanical ventilation, weaning time, stay in the ICU, and higher mortality.

Large-scale implementation of sedation and delirium monitoring in the intensive care unit: a report from two medical centers

OBJECTIVE

To implement sedation and delirium monitoring via a process-improvement project in accordance with Society of Critical Care Medicine guidelines and to evaluate the challenges of modifying intensive care unit (ICU) organizational practice styles.

DESIGN

Prospective observational cohort study.

SETTING

The medical ICUs at two institutions: the Vanderbilt University Medical Center (VUMC) and a community Veterans Affairs hospital (York-VA).

SUBJECTS

Seven hundred eleven patients admitted to the medical ICUs for >24 hrs and followed over 4,163 days during a 21-month study period.

INTERVENTIONS

Unit-wide nursing documentation was changed to accommodate a sedation scale (Richmond Agitation-Sedation Scale) and delirium instrument (Confusion Assessment Method for the ICU). A 20-min introductory in-service was performed for all ICU nurses, followed by graded, staged educational interventions at regular intervals. Data were collected daily for compliance, and randomly 40% of nurses each day were chosen for accuracy spot-checks by reference raters. An implementation survey questionnaire was distributed at 6 months.

MEASUREMENTS AND MAIN RESULTS

The implementation project involved 64 nurses (40 at VUMC and 24 at York-VA). Sedation and delirium monitoring data were recorded for 711 patients (614 at VUMC and 97 at York-VA). Compliance with the Richmond Agitation-Sedation Scale was 94.4% (21,931 of 23,220) at VUMC and 99.7% (5,387 of 5,403) at York-VA. Compliance with the Confusion Assessment Method for the ICU was 90% (7,323 of 8,166) at VUMC and 84% (1,571 of 1,871) at York-VA. The Confusion Assessment Method for the ICU was performed more often than requested on 63% of shifts (5,146 of 8,166) at VUMC and on 8% (151 of 1871) of shifts at York-VA. Overall weighted-kappa between bedside nurses and references raters for the Richmond Agitation-Sedation Scale were 0.89 (95% confidence interval, 0.88 to 0.92) at VUMC and 0.77 (95% confidence interval, 0.72 to 0.83) at York-VA. Overall agreement (kappa) between bedside nurses and reference raters using the Confusion Assessment Method for the ICU was 0.92 (95% confidence interval, 0.90-0.94) at VUMC and 0.75 (95% confidence interval, 0.68-0.81) at York-VA. The two most-often-cited barriers to implementation were physician buy-in and time.

CONCLUSIONS

With minimal training, the compliance of bedside nurses using sedation and delirium instruments was excellent. Agreement of data from bedside nurses and a reference-standard rater was very high for both the sedation scale and the delirium assessment over the duration of this process-improvement project.

Comparison of two bispectral index algorithms in monitoring sedation in postoperative intensive care patients*

OBJECTIVE

Comparison of two versions of bispectral index (BIS) derived from the electroencephalogram in mechanically ventilated and continuously sedated patients after major abdominal surgery.

DESIGN

Prospective, cohort, observational, unblinded study.

SETTING

Surgical intensive care unit of a university hospital.

PATIENTS

Forty-six patients undergoing major abdominal surgery scheduled for postoperative mechanical ventilation and continuous sedation.

INTERVENTIONS

Patients were continuously sedated using propofol and sufentanil.

MEASUREMENTS AND MAIN RESULTS

Electrodes for determination of BIS were placed at the forehead of the patients according to the manufacturer's specifications immediately after arrival to the intensive care unit. The level of consciousness was assessed every 2 hrs by a clinical sedation scale (Ramsay sedation scale, levels 1-6). BIS, electromyographic activity, and signal quality index were recorded simultaneously at the same time as the Ramsay scale for 24 hrs or until patients were ready for extubation. BIS (version 2.10) and BIS XP (version 3.12) were determined at 2-hr intervals. BIS and BIS XP showed a high correlation of readings (rs = .79, p < .01). However, the methods did not yield identical results. Both variables were significantly influenced by electromyographic activity, especially at high values, whereas there was only a weak correlation with body temperature. Some of the deeply sedated patients (Ramsay 5 or 6) had BIS readings >80 (BIS, 16%; BIS XP, 13%; p = not significant).

CONCLUSIONS

The newer algorithm BIS XP did not perform better than the previous version BIS in patients after major surgery who were mechanically ventilated and sedated on an intensive care unit. This precludes the use of BIS or BIS XP for distinguishing, among deeply sedated ICU patients, those with and without preserved cerebral electrical activity.

Prospective evaluation of an internet-linked handheld computer critical care knowledge access system

Introduction

Critical care physicians may benefit from immediate access to medical reference material. We evaluated the feasibility and potential benefits of a handheld computer based knowledge access system linking a central academic intensive care unit (ICU) to multiple community-based ICUs.

Methods

Four community hospital ICUs with 17 physicians participated in this prospective interventional study. Following training in the use of an internet-linked, updateable handheld computer knowledge access system, the physicians used the handheld devices in their clinical environment for a 12-month intervention period. Feasibility of the system was evaluated by tracking use of the handheld computer and by conducting surveys and focus group discussions. Before and after the intervention period, participants underwent simulated patient care scenarios designed to evaluate the information sources they accessed, as well as the speed and quality of their decision making. Participants generated admission orders during each scenario, which were scored by blinded evaluators.

Results

Ten physicians (59%) used the system regularly, predominantly for nonmedical applications (median 32.8/month, interquartile range [IQR] 28.3–126.8), with medical software accessed less often (median 9/month, IQR 3.7–13.7). Eight out of 13 physicians (62%) who completed the final scenarios chose to use the handheld computer for information access. The median time to access information on the handheld handheld computer was 19 s (IQR 15–40 s). This group exhibited a significant improvement in admission order score as compared with those who used other resources (P = 0.018). Benefits and barriers to use of this technology were identified.

Conclusion

An updateable handheld computer system is feasible as a means of point-of-care access to medical reference material and may improve clinical decision making. However, during the study, acceptance of the system was variable. Improved training and new technology may overcome some of the barriers we identified.

Consciousness monitoring in ventilated patients: bispectral EEG monitors arousal not delirium

OBJECTIVE

Bispectral index (BIS) is being evaluated as a monitor of consciousness, yet it is unclear what components of consciousness (i.e., arousal vs. content of consciousness) the BIS measures. This study compared BIS levels to well-validated clinical measures of arousal and the presence or absence of delirium.

DESIGN

A prospective, blinded, observational cohort study.

PATIENTS

124 mechanically ventilated, adult, medical ICU patients.

MEASUREMENTS AND RESULTS

Using BIS 3.4 and BIS-XP 4.0 algorithms, BIS values were calculated immediately prior to clinical assessments. The clinical assessments included the Richmond Agitation-Sedation Scale (RASS) and presence or absence of delirium using the Confusion Assessment Method for the ICU. A total of 484 assessments were collected among 124 patients. BIS-XP values demonstrated greater correlation with RASS than BIS 3.4 ( R(2)=0.36 vs. 0.20), although considerable overlap of BIS-XP scores remained across RASS levels. Median BIS-XP values for delirious and nondelirious observations were 74 and 96, respectively, while BIS 3.4 values were 91 and 96, respectively. However, neither BIS 3.4 nor BIS-XP were significantly associated with delirium after controlling for RASS value.

CONCLUSIONS

In comparison with clinical measures of arousal in mechanically ventilated patients, BIS-XP algorithm demonstrated stronger correlation with RASS levels than did BIS 3.4, yet marked overlap across different levels of arousal persist using both algorithms. After controlling for level of arousal, neither BIS-XP nor BIS 3.4 algorithms distinguished between the presence and absence of delirium.

Severe agitation among ventilated medical intensive care unit patients: frequency, characteristics and outcomes

OBJECTIVE

To determine the frequency, characteristics and outcomes of severe agitation among ventilated medical intensive care unit (MICU) patients.

DESIGN

Prospective cohort study.

SETTING

Eighteen-bed MICU in 964-bed tertiary care center.

PATIENTS

All ventilated patients, aged 18 years or older and admitted for more than 24 h between January 1, 2001 and May 8, 2001.

INTERVENTIONS

None.

MEASUREMENTS

Data were collected daily by concurrent chart abstractions. Variables included sociodemographic, clinical, laboratory, pharmacologic and non-pharmacologic interventions, ventilator settings and adverse events. Severe agitation, the main outcome variable, was defined as two or more Motor Activity Assessment Scale (MAAS) scores above 4 in a 24-h period and sedative and/or narcotic doses above the established sedation and analgesia protocol or a combination of two or more sedatives.

RESULTS

Twenty-three (16.1%) of 143 enrolled patients exhibited severe agitation. Agitated patients were younger (hazard ratio [HR] 1.32), more likely to be admitted from an outside hospital ICU (HR 2.48), had lower pH (HR 1.55) and PaO(2)/FIO(2) less than 200 mmHg (HR 2.59). Agitated patients had longer MICU stays (median 12 versus 5 days, p<0.0001) and more ventilator days (median 14 versus 6, p<0.0001). Agitated patients were more likely to self-extubate (26% versus 6%, p=0.002). Benzodiazepines, narcotics and neuromuscular blocking agents were administered more frequently and at higher doses, but haloperidol was not.

CONCLUSION

Severe agitation occurs commonly in critically ill patients and is associated with adverse events including longer ICU stays, duration of mechanical ventilation and self-extubation.

ICU sedation after coronary artery bypass graft surgery: dexmedetomidine-based versus propofol-based sedation regimens

OBJECTIVE

To compare dexmedetomidine-based to propofol-based sedation after coronary artery bypass graft (CABG) surgery in the intensive care unit (ICU).

DESIGN

Randomized, open label.

SETTING

Twenty-five centers in the United States and Canada.

PARTICIPANTS

Two hundred ninety-five adults undergoing CABG surgery.

INTERVENTIONS

At sternal closure, patients in group A received 1.0 microg/kg of dexmedetomidine over 20 minutes and then 0.2 to 0.7 microg/kg/h to maintain a Ramsay sedation score > or =3 during assisted ventilation and > or =2 after extubation. Patients could be given propofol for additional sedation if necessary; group B patients received propofol-based care according to each investigator's standard practice.

MEASUREMENTS AND MAIN RESULTS

Mean sedation levels were within target ranges in both groups. Mean times to weaning and extubation were similar, although fewer dexmedetomidine patients remained on the ventilator beyond 8 hours. Morphine use was significantly reduced in the dexmedetomidine group. Only 28% of the dexmedetomidine patients required morphine for pain relief while ventilated versus 69% of propofol-based patients (p < 0.001). Propofol patients required 4 times the mean dose of morphine while in the ICU. Mean blood pressure increased initially in both groups, then decreased to 3 mmHg below baseline in dexmedetomidine patients; mean arterial pressure remained at 9 mmHg above baseline in propofol patients. No ventricular tachycardia occurred in the dexmedetomidine-sedated patients compared with 5% of the propofol patients (p = 0.007). Respiratory rates and blood gases were similar. Fewer dexmedetomidine patients received beta-blockers (p = 0.014), antiemetics (p = 0.015), nonsteroidal anti-inflammatory drugs (p < 0.001), epinephrine (p = 0.030), or high-dose diuretics (p < 0.001).

CONCLUSION

Dexmedetomidine provided safe and effective sedation for post-CABG surgical patients and significantly reduced the use of analgesics, beta-blockers, antiemetics, epinephrine, and diuretics.