Sedation in the mechanically ventilated patient

Ketamine-based Sedation Use in Mechanically Ventilated Critically Ill Patients with COVID-19: A Multicenter Cohort Study

Backgrounds

Ketamine possesses analgesia, anti-inflammation, anticonvulsant, and neuroprotection properties. However, the evidence that supports its use in mechanically ventilated critically ill patients with COVID-19 is insufficient. The study's goal was to assess ketamine's effectiveness and safety in critically ill, mechanically ventilated (MV) patients with COVID-19.

Methods

Adult critically ill patients with COVID-19 were included in a multicenter retrospective-prospective cohort study. Patients admitted between March 1, 2020, and July 31, 2021, to five ICUs in Saudi Arabia were included. Eligible patients who required MV within 24 hours of ICU admission were divided into two sub-cohort groups based on their use of ketamine (Control vs. Ketamine). The primary outcome was the length of stay (LOS) in the hospital. P/F ratio differences, lactic acid normalization, MV duration, and mortality were considered secondary outcomes. Propensity score (PS) matching was used (1:2 ratio) based on the selected criteria.

Results

In total, 1,130 patients met the eligibility criteria. Among these, 1036 patients (91.7 %) were in the control group, whereas 94 patients (8.3 %) received ketamine. The total number of patients after PS matching, was 264 patients, including 88 patients (33.3 %) who received ketamine. The ketamine group's LOS was significantly lower (beta coefficient (95 % CI): -0.26 (-0.45, -0.07), P = 0.008). Furthermore, the PaO2/FiO2 ratio significantly improved 24 hours after the start of ketamine treatment compared to the pre-treatment period (6 hours) (124.9 (92.1, 184.5) vs. 106 (73.1, 129.3; P = 0.002). Additionally, the ketamine group had a substantially shorter mean time for lactic acid normalization (beta coefficient (95 % CI): -1.55 (-2.42, -0.69), P 0.01). However, there were no significant differences in the duration of MV or mortality.

Conclusions

Ketamine-based sedation was associated with lower hospital LOS and faster lactic acid normalization but no mortality benefits in critically ill patients with COVID-19. Thus, larger prospective studies are recommended to assess the safety and effectiveness of ketamine as a sedative in critically ill adult patients.

THE EFFECT OF IN-BED LEG CYCLING EXERCISES ON MUSCLE STRENGTH IN PATIENTS WITH INTENSIVE CARE UNIT-ACQUIRED WEAKNESS: A SINGLE-CENTER RETROSPECTIVE STUDY

Objective

To examine the effect of in-bed leg cycling exercise on patients with intensive care unit-acquired weakness (ICU-AW).

Design

Single-center retrospective study.

Subjects/Patients

Patients admitted to the ICU between January 2019 and March 2023 were enrolled in the ergometer group, and those admitted to the ICU between August 2017 and December 2018 were enrolled in the control group.

Methods

The ergometer group performed in-bed leg cycling exercises 5 times per week for 20 min from the day of ICU-AW diagnosis. Furthermore, the ergometer group received 1 early mobilization session per day according to the early mobilization protocol, whereas the control group received 1 or 2 sessions per day. The number of patients with recovery from ICU-AW at ICU discharge and improvement in physical functions were compared.

Results

Significantly more patients in the ergometer group recovered from ICU-AW than in the control group (87.0% vs 60.6%, p = 0.039). Regarding physical function, the ergometer group showed significantly higher improvement efficiency in Medical Research Council sum score (1.0 [0.7-2.1] vs 0.1 [0.0-0.2], p < 0.001).

Conclusion

In-bed leg cycling exercise, in addition to the early mobilization protocol, reduced the number of patients with ICU-AW at ICU discharge.

A systematic review and critical appraisal of guidelines and their recommendations for sedation interruptions in adult mechanically ventilated patients

OBJECTIVE

The objectives of the review were to (i) assess the methodological quality of all accessible and published guidelines and care bundles that offer a recommendation related to sedation interruptions, using the AGREE-II instrument, to (ii) determine what is the recommended best practice for sedation interruptions from the available guidelines, and then to have (iii) a closer inspection of the overall credibility and applicability of the recommendations using the AGREE-REX instrument. This review will benefit the outcomes of critically ill patients and the multidisciplinary team responsible for the care of mechanically ventilated adults with continuous medication infusions by providing a synthesis of the recommended action(s), actor(s), contextual information, target(s), and timing related to sedation interruptions from current best practice.

REVIEW METHOD USED

We conducted a systematic review.

DATA SOURCES

We applied a peer-reviewed search strategy to four electronic databases from 2010 to November 2021-MEDLINE, CINAHL, Embase, and The Cochrane Database of Systematic Reviews-and included grey literature.

REVIEW METHOD

Findings are reported in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analyses checklist. We assessed overall quality using the validated Appraisal of Guidelines for Research and Evaluation II and AGREE Recommendation Excellence tools.

RESULTS

We identified 11 clinical practice guidelines and care bundles comprising 15 recommendations related to sedation interruption. There are three key findings: (i) deficiencies exist with the methodological quality of included guidelines, (ii) sedation interruption is recommended practice for the care of adult mechanically ventilated patients, and (iii) the current evidence is of low quality, which impacts overall credibility and applicability of the recommendations.

CONCLUSIONS

Sedation interruptions are currently best practice for adult mechanically ventilated patients; however, the available guidelines and recommendations have several deficiencies. Future research is needed to further understand the role of the nurse and other actors to enact this practice.

Midazolam versus Dexmedetomidine in Patients at Risk of Obstructive Sleep Apnea during Urology Procedures: A Randomized Controlled Trial

Benzodiazepines are the most commonly used sedatives for the reduction of patient anxiety. However, they have adverse intraoperative effects, especially in obstructive sleep apnea (OSA) patients. This study aimed to compare dexmedetomidine (DEX) and midazolam (MDZ) sedation considering intraoperative complications during transurethral resections of the bladder and prostate regarding the risk for OSA. This study was a blinded randomized clinical trial, which included 115 adult patients with a mean age of 65 undergoing urological procedures. Patients were divided into four groups regarding OSA risk (low to medium and high) and choice of either MDZ or DEX. The doses were titrated to reach a Ramsay sedation scale score of 4/5. The intraoperative complications were recorded. Incidence rates of desaturations (44% vs. 12.7%, p = 0.0001), snoring (76% vs. 49%, p = 0.0008), restlessness (26.7% vs. 1.8%, p = 0.0044), and coughing (42.1% vs. 14.5%, p = 0.0001) were higher in the MDZ group compared with DEX, independently of OSA risk. Having a high risk for OSA increased the incidence rates of desaturation (51.2% vs. 15.7%, p < 0.0001) and snoring (90% vs. 47.1%, p < 0.0001), regardless of the sedative choice. DEX produced fewer intraoperative complications over MDZ during sedation in both low to medium risk and high-risk OSA patients.

Suspected benzodiazepine withdrawal-associated seizures in 3 young dogs undergoing mechanical ventilation

OBJECTIVE

To describe new onset of generalized seizures in 3 young dogs following cessation of a benzodiazepine-containing sedation protocol to facilitate mechanical ventilation (MV) for hypoxemia.

SERIES SUMMARY

Three dogs under 5 months of age underwent MV due to severe hypoxemia. All 3 dogs were sedated with a constant rate infusion of benzodiazepines as part of their sedation protocol to facilitate MV. All 3 dogs had an acute onset of generalized seizures within 36 hours of sedation cessation and weaning from MV. All 3 dogs' seizures were successfully managed with a slow, tapering course of benzodiazepines. One dog was additionally treated with levetiracetam at the time of initial seizure activity, which was discontinued 1 year following discharge and absence of ongoing seizure activity. All 3 dogs were discharged successfully with no reports of ongoing seizures or neurologic deficits after discharge.

NEW OR UNIQUE INFORMATION PROVIDED

Young dogs managed with benzodiazepines to facilitate MV may have acute onset of generalized seizures following cessation, which can be successfully managed with short-term benzodiazepine therapy. The 3 cases in this series demonstrated a positive outcome and were successfully managed following acute onset of generalized seizure activity post-MV.

Initiative to Improve Postintubation Sedation in a Pediatric Emergency Department

BACKGROUND

Previous research has shown that appropriate pediatric postintubation sedation (PIS) after rapid sequence intubation only occurs 28% of the time. Factors such as high provider variability, cognitive overload, and errors of omission can delay time to PIS in a paralyzed patient.

PURPOSE

To increase the proportion of children receiving timely PIS by 20% within 6 months.

METHODS

A multidisciplinary team identified key drivers and targeted interventions to improve timeliness of PIS. The primary outcome of "sedation in an adequate time frame" was defined as a time to post-Rapid Sequence Intubation sedative administration less than the duration of action of the RSI sedative agent. Secondary outcomes included the proportion of patients receiving any sedation and time to PIS administration.

RESULTS

Pediatric postintubation sedation in an adequate time was improved from 27.9% of intubated patients to 55.6% after intervention (p = .001). The number of patients receiving any PIS improved from 74% to 94% (p = .006). The median time from RSI to PIS was reduced from 13 to 9 minutes (p < .001). Process control charts showed a reduction in PIS variability and a centerline reduction from 19 to 10 minutes.

CONCLUSIONS

Implementation of an intubation checklist and a multidisciplinary approach improved the rate of adequate pediatric PIS.

The Administration of Postintubation Sedation in the Pediatric Emergency Department

BACKGROUND

The administration of postintubation sedation (PIS) is an essential component of postintubation care. Recent studies in the adult emergency medicine literature have highlighted both delays in time to administration of PIS and subtherapeutic dosing of sedative agents in the emergency department. We aimed to investigate the administration of PIS in the pediatric population as this has not been adequately reviewed to date.

OBJECTIVES

The aim of this study was to determine the percentage of pediatric emergency department patients who received PIS within an adequate time frame. We also investigated the relationship between this primary outcome and the rapid sequence intubation (RSI) agents used, the reason for intubation, and individual patient characteristics.

METHODS

This was a retrospective cohort analysis of all pediatric patients who underwent RSI at a tertiary care pediatric emergency department from July 2007 to January 2016. The primary outcome of "sedation in an adequate time frame" was defined as a time to post-RSI sedative administration that was shorter than the duration of action of the RSI sedative agent used. Logistic regression was performed to identify predictors of adequate sedation.

RESULTS

A total of 240 patients were included in the analysis. Of these, 28% (95% confidence interval, 22.7%-34.1%) met the primary outcome of sedation within an adequate time frame; 72.8% (95% confidence interval, 66.8%-78.1%) of patients received some form of PIS during their emergency department stay. Patients receiving long-acting paralytic agents were much less likely to receive PIS with an odds ratio (OR) of 0.16 for meeting the primary outcome (P < 0.001, adjusted OR [AOR] = 0.13, P < 0.001). Children with higher systolic blood pressure were more likely to receive appropriate PIS with an OR of 1.02 for every mm Hg increase in systolic blood pressure (P = 0.006, AOR = 1.02, P = 0.021). Finally, patients who were ultimately admitted to the pediatric intensive care unit (vs the operating room, transfer, or neonatal intensive care unit) were less likely to receive PIS as evidenced by an OR of 0.37 (P = 0.009, AOR = 0.27, P = 0.004).

CONCLUSIONS

Most pediatric patients do not receive PIS within an adequate time frame. Patients who receive long-acting paralytic agents are much less likely to be adequately sedated after RSI compared with those receiving succinylcholine.

Ketamine infusion as a sedative-analgesic in severe ARDS (KISS)

Rationale

Ketamine has been used as a sedative analgesic in trauma setting, but data regarding its efficacy and safety is lacking in severe ARDS. This retrospective study aims to determine if Ketamine is safer as a sedative agent in mechanically ventilated patients. During the COVID pandemic, as there was a shortage of sedative agents, Ketamine was used.

Objectives

The primary objective was to compare the safety of ketamine to other sedatives. The secondary objective was to compare the effect of ketamine to other sedatives regarding the need for vasopressor, incidence of delirium, infectious complications, acute kidney injury, hospital length of stay, and length of ventilator days.

Methods

A retrospective, observational cohort study was conducted.

Measurements and Main Results

One hundred and twenty-four patients (63 men and 61 women) were included. Thirty-four patients received ketamine, while 90 patients received other traditionally used sedatives such as propofol and midazolam. The patients’ median age was 64 years in the ketamine group and 68 years in the non-ketamine group. Seventeen patients in the ketamine group (50%) and 65 patients (72%) in the non-ketamine group had mortality (p < 0.02). The hospital length of stay was 22.85 days (± 16.36) in the ketamine group and 15.62 days (± 14.63) in the non-ketamine group (p < 0.02). There was no statistically significant difference among the outcomes of the need for vasopressor, the incidence of delirium, infectious complications, and acute kidney injury.

Conclusions

Ketamine as a sedative-analgesic agent in COVID-19 patients with severe acute respiratory distress syndrome demonstrated safety with reduced mortality. The ketamine group had a higher hospital length of stay, but a similar complication profile compared to the non-ketamine group. Further prospective randomized controlled trials are warranted to confirm these findings.

Oversedation in Postoperative Patients Requiring Ventilator Support Greater than 48 Hours: A 4-year National Surgical Quality Improvement Program-driven Project

Prolonged mechanical ventilation of postoperative patients can contribute to an increase in morbidity. Every effort should be made to wean patients from the ventilator after surgery. Over-sedation may prevent successful extubation. Cases identified by the National Surgical Quality Improvement Program (NSQIP) for Huntington Hospital were reviewed. Oversedation, days on the ventilator, type and duration of sedation, and cost were studied. Data were collected from the NSQIP database and patient charts. Oversedation was determined by the Richmond Agitation Sedation Score (RASS) of each patient. The hospital pharmacy provided data on propofol. Forty-three (35%) patients were oversedated. Propofol was used in 111 (90%) cases with an average use of 4.8 days. Propofol was used greater than 48 hours in 77 (62%) cases. After identifying inconsistent nurse documentation of sedation, corrective actions helped decrease oversedation, average number of days on the ventilator, number of days on propofol, hospital expenditure on propofol, and number of patients on the ventilator greater than 48 hours. Oversedation contributed to prolonged mechanical ventilation. Standardization of RASS and physician sedation order sheets contributed to improving our NSQIP rating. Sedation use decreased and fewer patients spent less time on the ventilator. NSQIP is an effective tool to identify issues with quality in surgical patients.

Ramsay Sedation Scale and Richmond Agitation Sedation Scale: A Cross-sectional Study

BACKGROUND

Many sedation scales and tools have been developed and compared for validity in critically ill patients. However, selection and use of sedation scales vary among intensive care units.

OBJECTIVE

The aim of this study is to compare the reliability of 2 sedation scales-Ramsay Sedation Scale and Richmond Agitation-Sedation Scale (RASS)-in the adult intensive care unit.

METHOD

Four hundred twenty-five patients were recruited in the study. Informed consent had been obtained from each patient guardian/relative. However, only 290 patients (68.24%) completed the study and were independently assessed for sedation effect by investigator and bedside nurses simultaneously using Ramsay scale and RASS.

RESULTS

Agreement between the nurse and investigator scores on Ramsay scale (weighted κ = 0.449, P < .001) indicated weak level of agreement. Agreement between the nurse and investigator on RASS (weighted κ = 0.879, P < .001) indicated a strong level of agreement. Cronbach α analysis showed that 10 items of RASS had an excellent level of internal consistency (α = .989) compared with good level of internal consistency of Ramsay scale (α = .828).

DISCUSSION

Richmond Agitation-Sedation Scale showed excellent interrater agreement compared with weak interrater agreement of Ramsay scale. The results also support that RASS has consistent agreement with clinical observation and practice among different observers. The results suggest that use of RASS is linked to a more reliable assessment of sedation levels in the intensive care unit.

Efficacy and Safety of Fentanyl in Combination with Midazolam in Children on Mechanical Ventilation

BACKGROUND

To evaluate the efficacy and safety of fentanyl for sedation therapy in mechanically ventilated children.

METHODS

This was a double-blind, randomized controlled trial of mechanically ventilated patients between 2 months and 18 years of age. Patients were randomly divided into two groups; the control group with midazolam alone, and the combination group with both fentanyl and midazolam. The sedation level was evaluated using the Comfort Behavior Scale (CBS), and the infusion rates were adjusted according to the difference between the measured and the target CBS score.

RESULTS

Forty-four patients were recruited and randomly allocated, with 22 patients in both groups. The time ratio of cumulative hours with a difference in CBS score (measured CBS-target CBS) of ≥ 4 points (i.e., under-sedation) was lower in the combination group (median, 0.06; interquartile range [IQR], 0-0.2) than in the control group (median, 0.15; IQR, 0.04-0.29) (P < 0.001). The time ratio of cumulative hours with a difference in CBS score of ≥ 8 points (serious under-sedation) was also lower in the combination group (P < 0.001). The cumulative amount of midazolam used in the control group (0.11 mg/kg/hr; 0.07-0.14 mg/kg/hr) was greater than in the combination group (0.07 mg/kg/hr; 0.06-0.11 mg/kg/hr) (P < 0.001). Two cases of hypotension in each group were detected but coma and ileus, the major known adverse reactions to fentanyl, did not occur.

CONCLUSION

Fentanyl combined with midazolam is safe and more effective than midazolam alone for sedation therapy in mechanically ventilated children.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02172014.

Analgesic and sedative agents used in the intensive care unit: A review

Pain is a common experience for most patients in the intensive care unit (ICU). In the current study, the advantages and disadvantages of analgesic and sedative drugs used in the ICU are reviewed. An ideal sedative and analgesic agent should have features such as rapid onset of action, rapid recovery after discontinuation, predictability, minimal accumulation of the agent and metabolites in the body, and lack of toxicity. None of the sedative and analgesic agents have all of these desired characteristics; nevertheless, clinicians must be familiar with these classes of drugs to optimize pharmacotherapy and ensure as few side-effects as possible for ICU patients.

Models for Nociception Stimulation and Memory Effects in Awake and Aware Healthy Individuals

OBJECTIVE

This paper introduces a primer in the health care practice, namely a mathematical model and methodology for detecting and analysing nociceptor stimulation followed by related tissue memory effects.

METHODS

Noninvasive nociceptor stimulus protocol and prototype device for measuring bioimpedance is provided. Various time instants, sensor location, and stimulus train have been analysed.

RESULTS

The method and model indicate that nociceptor stimulation perceived as pain in awake healthy volunteers is noninvasively detected. The existence of a memory effect is proven from data. Sensor location had minimal effect on detection level, while day-to-day variability was observed without being significant.

CONCLUSION

Following the experimental study, the model enables a comprehensive management of chronic pain patients, and possibly other analgesia, or pain related regulatory loops.

SIGNIFICANCE

A device and methodology for noninvasive for detecting nociception stimulation have been developed. The proposed method and models have been validated on healthy volunteers.

Propofol Associated with a Shorter Duration of Mechanical Ventilation than Scheduled Intermittent Lorazepam: A Database Analysis Using Project Impact

Background:

While one prospective controlled study in medical intensive care unit (ICU) patients demonstrated that sedation with propofol leads to a shorter duration of mechanical ventilation compared with scheduled intermittent intravenous lorazepam, its conclusions may not be applicable to surgical ICU patients and institutions not using daily sedation interruption.

Objective:

To compare the duration of mechanical ventilation between medical and surgical ICU patients receiving propofol versus scheduled intermittent lorazepam in routine clinical practice.

Methods:

Retrospective data (January 2001–December 2005) were obtained from the Project IMPACT database for medical and surgical ICU patients at Tufts-New England Medical Center, a 450 bed academic hospital. These patients had been mechanically ventilated for 24 hours or more and had received 24 hours or more of either propofol or scheduled intermittent lorazepam as the sole sedative. Clinically relevant variables were identified a priori, and their influence on duration of mechanical ventilation was evaluated. Differences in these variables between propofol and scheduled intermittent lorazepam groups within the ICU cohorts were then measured.

Results:

Of 4608 database patients, 287 met criteria. Factors associated with a prolonged duration of mechanical ventilation for the medical ICU cohort included sedation use for 5 or more days (OR 13.8; 95% CI 8.3 to 19.4), narcotic use (OR 7.6; 95% CI 2.3 to 13), and scheduled intermittent lorazepam use (OR 7.0; 95% CI 0.4 to 13.7). For the surgical ICU cohort, these factors included sedation use for 5 or more days (OR 15; 95% CI 11.4 to 19.4), APACHE II (Acute Physiology and Chronic Health Evaluation II) score equal to or greater than 18 (OR 4.1; 95% CI 0.4 to 7.8), and scheduled intermittent lorazepam use (OR 4.0; 95% CI 0.2 to 7.7). Duration of mechanical ventilation was the only variable that differed significantly between propofol and scheduled intermittent lorazepam in both the medical ICU, with a median (range) of 6 (3–12) versus 11 (5–25; p = 0.03), and surgical ICU, with a median of 4 (2–15) versus 9 (4–20; p = 0.001), groups.

Conclusions:

Sedation with propofol in the naturalistic setting appears to be associated with a shorter duration of mechanical ventilation compared with scheduled intermittent lorazepam in both medial and surgical ICU patients when only one sedative drug is used. Data from this uncontrolled observational study are consistent with findings from a randomized clinical trial.

Pharmacokinetics cannot explain the increased effective dose requirement for morphine and midazolam in rats during their extended administration alone or in combination

Objectives

Chronic administration of morphine and midazolam, alone or in combination, can induce tolerance to their effects. Data showed that co-administration of morphine and midazolam increased effective dose requirement of morphine, exceeding that observed with morphine alone.

Methods

To elucidate the pharmacokinetic component to the tolerance, we administered midazolam (2 mg/kg) and morphine (10 mg/kg) alone or their combination daily to rats for 12 days followed by a pharmacokinetic study on day 13. On the study day, each animal received a single bolus dose of 5 mg/kg morphine, and 2 mg/kg of midazolam 30 s later. Multiple blood samples were obtained for 6 h. Plasma drug concentrations were assayed by mass spectrometry optimized for small samples.

Key findings

Mean morphine clearance was as follows: 22.2, 27.2, 26.0 and 23.4 l/h per kg in the saline–saline, saline–midazolam, saline–morphine and midazolam–morphine groups, respectively. Corresponding midazolam clearances were 32.8, 23.0, 22.2 and 31.1 l/h per kg. ANOVA indicated no significant differences among the four groups in the clearances, half-lives, and volumes of distribution. Morphine and midazolam clearances were significantly correlated (R2 = 0.48, P &lt; 0.001).

Conclusions

This animal model suggests that altered pharmacokinetics cannot explain tolerance evidenced as increased dose requirement for morphine or midazolam, when administered alone or combination, for extended periods.

Acquired Muscle Weakness in the Surgical Intensive Care Unit

Muscle weakness is common in the surgical intensive care unit (ICU). Low muscle mass at ICU admission is a significant predictor of adverse outcomes. The consequences of ICU-acquired muscle weakness depend on the underlying mechanism. Temporary drug-induced weakness when properly managed may not affect outcome. Severe perioperative acquired weakness that is associated with adverse outcomes (prolonged mechanical ventilation, increases in ICU length of stay, and mortality) occurs with persistent (time frame: days) activation of protein degradation pathways, decreases in the drive to the skeletal muscle, and impaired muscular homeostasis. ICU-acquired muscle weakness can be prevented by early treatment of the underlying disease, goal-directed therapy, restrictive use of immobilizing medications, optimal nutrition, activating ventilatory modes, early rehabilitation, and preventive drug therapy. In this article, the authors review the nosology, epidemiology, diagnosis, and prevention of ICU-acquired weakness in surgical ICU patients.

Clonidine for sedation in the critically ill: a systematic review and meta-analysis (protocol)

BACKGROUND

Management and choice of sedation is important during critical illness in order to reduce patient suffering and to facilitate the delivery of care. Unfortunately, medications traditionally used for sedation in the intensive care unit (ICU) such as benzodiazepines and propofol are associated with significant unwanted effects. Clonidine is an alpha-2 selective adrenergic agonist that may have a role in optimizing current sedation practices in the pediatric and adult critically ill populations by potentially minimizing exposure to other sedative agents.

METHODS/DESIGN

We will search MEDLINE, EMBASE, CINAHL, ACPJC, the Cochrane trial registry, World Health Organization International Clinical Trials Registry Platform (WHO ICTRP), and clinicaltrials.gov for eligible observational studies and randomized controlled trials investigating the use of clonidine as an adjunctive or stand-alone sedative agent in patients requiring invasive mechanical ventilation. Our primary outcome is the duration of mechanical ventilation. Secondary outcomes include the following, listed by priority: duration of sedation infusions, dose of sedation used, level of sedation, incidence of withdrawal from other sedatives, delirium incidence, ICU and hospital length of stay, use and duration of non-invasive ventilation, and all-cause ICU and hospital mortality. We will also capture unwanted effects potentially associated with clonidine administration such as clinically significant hypotension or bradycardia, clonidine withdrawal, self-extubation, and the accidental removal of central intravenous lines and arterial lines. We will not apply any publication date, language, or journal restrictions. Two reviewers will independently screen and identify eligible studies using predefined eligibility criteria and then review full reports of all potentially relevant citations. A third reviewer will resolve disagreements if consensus cannot be achieved. We will use Review Manager (RevMan) to pool effect estimates from included studies across outcomes. We will present the results as relative risk (RR) with 95 % confidence intervals (CI) for dichotomous outcomes and as mean difference (MD) or standardized mean difference (SMD) for continuous outcomes with 95 % CI. We will assess the quality of evidence using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach.

DISCUSSION

The aim of this systematic review is to summarize the evidence on the efficacy and safety of clonidine as a sedative agent in the critically ill population.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42015019365.

Nursing diagnosis in intensive care unit: the Turkey experience

PURPOSE

The purpose of this study was to determine intensive care unit nurses diagnostic abilities and diagnoses that they provide.

METHODS AND SUBJECT

A vignette study was performed. The vignette contained a patient's history, treatment, and signs/symptoms of 18 nursing diagnoses based on NANDA-I as the criterion standard. Turkish intensive care unit nurses (N = 45) stated nursing diagnoses described by patient data in the vignette. The resulting nursing diagnoses were grouped into Gordon's Functional Health Patterns, and descriptive analyses were performed. One-way analysis of variance was used to detect possible differences in diagnostic abilities based on nurses' education levels.

RESULTS AND CONCLUSIONS

Nurses identified 14 nursing diagnoses. Four of the predetermined psychosocial nursing diagnoses were not identified. The highest percentage of diagnoses was risk for impaired skin integrity (62.2%) and impaired oral mucous membrane (60.0%). The lowest number of diagnoses was impaired verbal communication (2.2%). A statistically significant difference was found between the educational level of nurses and their abilities to determine nursing diagnoses (P < .05). The findings are important for nursing education. They demonstrate the need to focus on patients as complete human beings, covering not only biological aspects but also cultural and social values, as well as emotional and spiritual care needs.

Relationship of tidal volume to peak flow, breath rate, I: E and plateau time: mock study

BACKGROUND

The purpose of this study was to determine the functional relationship between tidal volume (VT) and 4 other ventilator parameters.

METHODS

The following parameters were collected from an AVEA ventilator operating in the volume-controlled ventilation mode: VT (in L), peak flow (Vmax, in L/min), breath rate (f, in bpm), inspiratory-to-expiratory time ratio (I:E) and plateau time (TP, in s). The relationship between VT and each of the other variables was determined.

RESULTS

When the other parameters were held constant, VT was positively correlated with Vmax and I:E, but negatively correlated with f and TP. When the velocity versus time curve was a 50% linearly decreasing wave, the functional relationship among the 5 parameters was governed by the equation: VT = 180 Vmax (60f - 60f [1 + I:E] - TP).

CONCLUSIONS

The functional relationship among the 5 parameters for the AVEA ventilator in the volume-controlled ventilation mode was determined. The parameters should be controlled in accordance with the patient's pathophysiological needs.

Propofol is associated with favorable outcomes compared with benzodiazepines in ventilated intensive care unit patients

RATIONALE

Mechanically ventilated intensive care unit (ICU) patients are frequently managed using a continuous-infusion sedative. Although recent guidelines suggest avoiding benzodiazepines for sedation, this class of drugs is still widely used. There are limited data comparing sedative agents in terms of clinical outcomes in an ICU setting.

OBJECTIVES

Comparison of propofol to midazolam and lorazepam in adult ICU patients.

METHODS

Data were obtained from a multicenter ICU database (2003-2009). Patient selection criteria included age greater than or equal to 18 years, single ICU admission with single ventilation event (>48 h), and treatment with continuously infused sedation (propofol, midazolam, or lorazepam). Propensity score analysis (1:1) was used and mortality measured. Cumulative incidence and competing risk methodology were used to examine time to ICU discharge and ventilator removal.

MEASUREMENTS AND MAIN RESULTS

There were 2,250 propofol-midazolam and 1,054 propofol-lorazepam matched patients. Hospital mortality was statistically lower in propofol-treated patients as compared with midazolam- or lorazepam-treated patients (risk ratio, 0.76; 95% confidence interval [CI], 0.69-0.82 and risk ratio, 0.78; 95% CI, 0.68-0.89, respectively). Competing risk analysis for 28-day ICU time period showed that propofol-treated patients had a statistically higher probability for ICU discharge (78.9% vs. 69.5%; 79.2% vs. 71.9%; P < 0.001) and earlier removal from the ventilator (84.4% vs. 75.1%; 84.3% vs. 78.8%; P < 0.001) when compared with midazolam- and lorazepam-treated patients, respectively.

CONCLUSIONS

In this large, propensity-matched ICU population, patients treated with propofol had a reduced risk of mortality and had both an increased likelihood of earlier ICU discharge and earlier discontinuation of mechanical ventilation.

Ventilator-Associated Pneumonia Bundle

The ventilator-associated pneumonia (VAP) bundle is a focus of many health care institutions. Many hospitals are conducting process-improvement projects in an attempt to improve VAP rates by implementing the bundle. However, this bundle is controversial in the literature, because the evidence supporting the VAP interventions is weak. In addition, definitions used for surveillance are interpreted differently than definitions used for clinical diagnosis. The variance in definitions has led to lower reported VAP rates, which may not be accurate. Because of the variance in definitions, the Centers for Disease Control and Prevention developed a ventilator-associated event algorithm. Health care institutions are under pressure to reduce the VAP infection rate, but correctly identifying VAP can be very challenging. This article reviews the current evidence related to VAP and provides insight into implementing a suggested revision of the care of patients being treated with mechanical ventilation.

ABCDEs of ICU: Awakening

Critically ill patients in the intensive care unit (ICU) who require mechanical ventilation often require continuous sedation infusions. These 2 interventions are associated with adverse outcomes such as increased duration of mechanical ventilation, increased length of stay in both the ICU and the hospital, and significant physiological and psychological complications. Daily sedation interruption (DSI) can reduce these adverse effects thereby improving long-term outcomes after critical illness.

CONCLUSION

DSI is safe, practical, cost-effective, and results in positive outcomes for patients; however, there are barriers to implementing and incorporating DSI into daily practice. Further research is required to provide additional evidence and promote more widespread utilization.

Monitoring sedation for bronchoscopy in mechanically ventilated patients by using the Ramsay sedation scale versus auditory-evoked potentials

BACKGROUND

Appropriate sedation benefits patients by reducing the stress response, but it requires an appropriate method of assessment to adjust the dosage of sedatives. The aim of this study was to compare the difference in the sedation of mechanically ventilated patients undergoing flexible bronchoscopy (FB) monitored by auditory-evoked potentials (AEPs) or the Ramsay sedation scale (RSS).

METHODS

In a prospective, randomized, controlled study, all patients who underwent FB with propofol sedation were monitored and their sedation adjusted. During FB, one group was monitored by AEP and another group was monitored by RSS. The propofol dosage was adjusted by the nursing staff during examination to maintain the Alaris AEP index (AAI) value between 25 and 40 in the AEP group and the RSS at 5 or 6 in the RSS group. Before FB and during FB, the AAI, heart rate (HR), and mean arterial pressure (MAP) were recorded every 5 min. The percentages of time at the sedation target and the propofol dosages were calculated.

RESULTS

Nineteen patients received AEP monitoring and 18 patients received RSS monitoring. The percentage of time at the sedation target during FB was significantly higher in the AEP monitoring group (51.3%; interquartile range [IQR], 47.0-63.5%) than in the RSS group (15.4%; IQR, 9.5-23.4%), (P < 0.001). During FB, the RSS group had a significantly higher AAI (P = 0.011), HR (P < 0.001), and MAP (P < 0.001) than the AEP group.

CONCLUSIONS

In mechanically ventilated patients undergoing FB, AEP monitoring resulted in less variation in AAI, HR, and MAP, and a higher percentage of time at the sedation target than RSS monitoring.

The influence of the time of day on midazolam pharmacokinetics and pharmacodynamics in rabbits

BACKGROUND

This study evaluates the time-of-day effect on midazolam and 1-OH midazolam pharmacokinetics, and on the sedative pharmacodynamic response in rabbits. Also, circadian fluctuations in rabbits' vital signs, such as the blood pressure, heart rate and body temperature were examined. The water intake was measured in order to confirm the presence of the animals' diurnal activity. The secondary aim involved the comparison of two methods of data analysis: a noncompartmental and a population modeling approach.

METHODS

Twelve rabbits were sedated with intravenous midazolam 0.35 mg/kg at four local times: 09.00, 14.00, 18.00 and 22.00 h. Each rabbit served as its own control by being given a single infusion at the four different times of the day on four separate occasions. The values of the monitored physiological parameters were recorded during the experiment and arterial blood samples were collected for midazolam assay. The pedal withdrawal reflex was used as the measurement of the sedation response. Two and one compartmental models were successfully used to describe midazolam and 1-OH midazolam pharmacokinetics. The categorical pharmacodynamic data were described with a logistic model.

RESULTS AND CONCLUSIONS

We did not find any time-of-day effects for the pharmacokinetic and pharmacodynamics parameters of midazolam. For 1-OH midazolam, statistically significant time-of-day differences in the apparent volume of distribution and clearance were noticed. They corresponded well with the rabbits' water intake. The noncompartmental and model-based parameters were essentially similar. However, more information can be obtained from the population model and this method should be preferred in chronopharmacokinetic and chronopharmacodynamic studies.

Reflexology: its effects on physiological anxiety signs and sedation needs

To investigate whether reflexology has an effect on the physiological signs of anxiety and level of sedation in patients receiving mechanically ventilated support, a single blinded, randomized controlled design with repeated measures was used in the intensive care unit of a university hospital in Turkey. Patients (n = 60) aged between 18 and 70 years and were hospitalized in the intensive care unit and receiving mechanically ventilated support. Participants were randomized to a control group or an intervention group. The latter received 30 minutes of reflexology therapy on their feet, hands, and ears for 5 days. Subjects had vital signs taken immediately before the intervention and at the 10th, 20th, and 30th minutes of the intervention. In the collection of the data, "American Association of Critical-Care Nurses Sedation Assessment Scale" was used. The reflexology therapy group had a significantly lower heart rate, systolic blood pressure, diastolic blood pressure, and respiratory rate than the control group. A statistically significant difference was found between the averages of the scores that the patients included in the experimental and control groups received from the agitation, anxiety, sleep, and patient-ventilator synchrony subscales of the American Association of Critical-Care Nurses Sedation Assessment Scale. Reflexology can serve as an effective method of decreasing the physiological signs of anxiety and the required level of sedation in patients receiving mechanically ventilated support. Nurses who have appropriate training and certification may include reflexology in routine care to reduce the physiological signs of anxiety of patients receiving mechanical ventilation.

Assessing circadian rhythms during prolonged midazolam infusion in the pediatric intensive care unit (PICU) children

BACKGROUND

This study evaluates possible circadian rhythms during prolonged midazolam infusion in 27 pediatric intensive care unit (PICU) children under mechanical ventilation.

METHODS

Blood samples for midazolam and 1-OH-midazolam assay were collected throughout the infusion at different times of the day. The blood pressure, heart rate and body temperature were recorded every hour for the rhythms analysis. Population nonlinear mixed-effect modeling with NONMEM was used for data analysis.

RESULTS

A two-compartment model for midazolam pharmacokinetics and a one-compartment model for midazolam metabolite adequately described the data. The 24 h profiles of all monitored physiological parameters were greatly disturbed/abolished in comparison with the well-known 24 h rhythmic patterns in healthy subjects. There was no significant circadian rhythm detected with respect to midazolam pharmacokinetics, its active metabolite pharmacokinetics and all monitored parameters.

CONCLUSIONS

We concluded that the light-dark cycle did not influence midazolam pharmacokinetics in intensive care units children. Also, endogenous rhythms in critically ill and sedated children are severely disturbed and desynchronized. Our results confirmed that it is necessary to adjust the dose of midazolam to the patient's body weight. The low value of midazolam clearances observed in our study was probably caused by mechanical ventilation, which was shown to decrease the cardiac output.

Comparative effects of flurbiprofen and fentanyl on natural killer cell cytotoxicity, lymphocyte subsets and cytokine concentrations in post-surgical intensive care unit patients: prospective, randomized study

PURPOSE

The purpose of this study was to compare the effect of the long-term administration of flurbiprofen and fentanyl in the intensive care unit on natural killer cell cytotoxicity (NKCC), lymphocyte subsets and cytokine levels.

METHODS

In this prospective study, patients scheduled for at least 48 h sedation after neck surgery were randomly assigned to two groups called group N and group F. Group N patients were sedated with propofol and flurbiprofen after surgery (n = 12), while group F patients were sedated with propofol and fentanyl (n = 13). The NKCC, lymphocyte subsets, and plasma levels of tumor necrosis factor (TNF)-α, interleukin (IL)-1β, IL-6, and IL-10 were measured before and at the end of surgery, on postoperative day (POD) 1 and POD2.

RESULTS

The NKCC was significantly higher on POD1 in group N than in group F (14.5 ± 11.2 versus 6.3 ± 4.1%, p < 0.05), the difference between the groups disappearing on POD2. Lymphocyte subsets and plasma levels of cytokines were not significantly different between the two groups during the study period.

CONCLUSIONS

Transient suppressive effects on NKCC were observed in the fentanyl group as compared to the flurbiprofen group. This suggests that when choosing postoperative analgesics, physicians should bear in mind the potential immunosuppressive effects of these agents in patients requiring prolonged sedation in the intensive care unit.

Reliability and validity of shortened state trait anxiety inventory in Spanish patients receiving mechanical ventilation

BACKGROUND

In order to measure anxiety in physically and cognitively debilitated patients, such as patients receiving invasive mechanical ventilation, the use of reliable and valid instruments is recommended; however, these instruments should be short.

OBJECTIVE

To analyze the reliability and validity of a short version of the state subscale from the Spielberger State-Trait Anxiety Inventory, developed by Chlan and colleagues and translated into Spanish (STAI-E6), in patients receiving invasive mechanical ventilation.

METHODS

An instrumental study was conducted of 80 patients receiving invasive mechanical ventilation in the intensive care unit at the Hospital of Alicante (Spain). The patients completed the 6-item STAI-E6 scale. Before the patients completed the scale, the interviewers indicated their impression of each patient's level of anxiety by using a linear scale. Internal consistency, construct validity, and convergent validity of the scale were analyzed.

RESULTS

The scale did not present a floor/ceiling effect, the Cronbach α was 0.79, and the single-factor structure of the original scale was maintained. Scores on the scale correlated positively with the subjective assessment of the health professional. Significant differences were found only between anxiety level and duration of intubation.

CONCLUSIONS

The 6-item version of the state subscale from the STAI-E6 shows satisfactory reliability and validity for Spanish patients receiving invasive mechanical ventilation.

Sedation for critically ill or injured adults in the intensive care unit: a shifting paradigm

As most critically ill or injured patients will require some degree of sedation, the goal of this paper was to comprehensively review the literature associated with use of sedative agents in the intensive care unit (ICU). The first and selected latter portions of this article present a narrative overview of the shifting paradigm in ICU sedation practices, indications for uninterrupted or prolonged ICU sedation, and the pharmacology of sedative agents. In the second portion, we conducted a structured, although not entirely systematic, review of the available evidence associated with use of alternative sedative agents in critically ill or injured adults. Data sources for this review were derived by searching OVID MEDLINE and PubMed from their first available date until May 2012 for relevant randomized controlled trials (RCTs), systematic reviews and/or meta-analyses and economic evaluations. Advances in the technology of mechanical ventilation have permitted clinicians to limit the use of sedation among the critically ill through daily sedative interruptions or other means. These practices have been reported to result in improved mortality, a decreased length of ICU and hospital stay and a lower risk of drug-associated delirium. However, in some cases, prolonged or uninterrupted sedation may still be indicated, such as when patients develop intracranial hypertension following traumatic brain injury. The pharmacokinetics of sedative agents have clinical importance and may be altered by critical illness or injury, co-morbid conditions and/or drug-drug interactions. Although use of validated sedation scales to monitor depth of sedation is likely to reduce adverse events, they have no utility for patients receiving neuromuscular receptor blocking agents. Depth of sedation monitoring devices such as the Bispectral Index (BIS©) also have limitations. Among existing RCTs, no sedative agent has been reported to improve the risk of mortality among the critically ill or injured. Moreover, although propofol may be associated with a shorter time to tracheal extubation and recovery from sedation than midazolam, the risk of hypertriglyceridaemia and hypotension is higher with propofol. Despite dexmedetomidine being linked with a lower risk of drug-associated delirium than alternative sedative agents, this drug increases risk of bradycardia and hypotension. Among adults with severe traumatic brain injury, there are insufficient data to suggest that any single sedative agent decreases the risk of subsequent poor neurological outcomes or mortality. The lack of examination of confounders, including the type of healthcare system in which the investigation was conducted, is a major limitation of existing pharmacoeconomic analyses, which likely limits generalizability of their results.

Occurrence and predictors of dexmedetomidine infusion intolerance and failure

BACKGROUND

Dexmedetomidine, a selective α2 adrenergic receptor agonist, exhibits sedative, analgesic, anxiolytic, and sympatholytic effects, and may aid in controlling agitation in the intensive care unit (ICU). At our hospital (Barnes-Jewish Hospital, St. Louis, MO), dexmedetomidine is commonly used as a sedative in the medical ICU. Predictors of dexmedetomidine intolerance or failure have not yet been defined.

OBJECTIVE

Describe the rate of dexmedetomidine infusion intolerance/failure and identify patient predictors of intolerance/failure.

METHODS

This retrospective single-center cohort study evaluated 75 mechanically ventilated adults who received dexmedetomidine infusion. Patients were included in the study if they were aged ≥ 18 years; mechanically ventilated for > 24 hours; received dexmedetomidine infusion for ≥ 1 hour following > 24 hours of continuous infusions of midazolam, fentanyl, or propofol; and were admitted to our medical ICU between August 1, 2009 and August 1, 2010. Multivariate logistic regression analysis was performed to identify independent predictors of intolerance/failure.

RESULTS

A total of 85 episodes of dexmedetomidine infusion were analyzed (75 total patients). Eighteen episodes (21%) met the criteria for intolerance/failure and 67 episodes (79%) met the criteria for tolerance/success. The median duration of mechanical ventilation, total dexmedetomidine infusion time, and ICU length of stay did not differ between groups. Nonblack race was the only variable independently associated with treatment failure or intolerance in the logistic regression analysis.

CONCLUSION

Twenty-one percent of dexmedetomidine infusion episodes met the criteria for intolerance/failure. No predictors of intolerance/failure were found to be clinically significant.

Protocolized and target-based sedation and analgesia in the ICU

Protocolized target-based sedation and analgesia is central to effective management of sedation. Important components include identifying goals and specific targets,using valid and reliable tools to measure pain, agitation, and sedation, and titrating a logically selected combination of sedatives and analgesics to defined end-points.A variety of approaches to structured management have been tested in controlled trials with major categories of (1) sedation algorithms and protocols and (2) daily interruption of sedation. Although not all studies that compare new interventions to “usual care” document dramatic improvements, many studies show that by reducing oversedation, using a structured approach, faster recovery from respiratory failure may ensue. The somewhat discrepant results illustrate, however, that various approaches,such as DIS, may not be optimal for all patients. Further research will be necessary to define these patients and examine alternative strategies. Finally, implementation of structured approaches to sedation management is a challenging, time-consuming process for clinicians that must be supported with sufficient resources to be successful.

A novel technique of differential lung ventilation in the critical care setting

Background

Differential lung ventilation (DLV) is used to salvage ventilatory support in severe unilateral lung disease in the critical care setting. However, DLV with a double-lumen tube is associated with serious complications such as tube displacement during ventilatory management. Thus, long-term ventilatory management with this method may be associated with high risk of respiratory incidents in the critical care setting.

Findings

We devised a novel DLV technique using two single-lumen tubes and applied it to five patients, two with severe unilateral pneumonia and three with thoracic trauma, in a critical care setting. In this novel technique, we perform the usual tracheotomy and insert two single-lumen tubes under bronchoscopic guidance into the main bronchus of each lung. We tie the two single-lumen tubes together and suture them directly to the skin. The described technique was successfully performed in all five patients. Pulmonary oxygenation improved rapidly after DLV induction in all cases, and the three patients with thoracic trauma were managed by DLV without undergoing surgery. Tube displacement was not observed during DLV management. No airway complications occured in either the acute or late phase regardless of the length of DLV management (range 2-23 days).

Conclusions

This novel DLV technique appears to be efficacious and safe in the critical care setting.

Understanding, recognizing, and managing chronic critical illness syndrome

PURPOSE

No evidence-based guidelines exist for the care of patients with chronic critical illness syndrome (CCIS), a growing population of patients being cared for by nurse practitioners (NPs). The purpose of this article is to provide NPs with a beginning physiological framework, allostasis, to guide their understanding and management of patients with CCIS.

DATA SOURCES

Scientific publications, related clinical guidelines.

CONCLUSIONS

Patients with CCIS are a distinct group of critically ill patients whose care needs are different from those of patients who are acutely critically ill. These patients demonstrate widespread tissue and organ damage. The widespread tissue and organ damage results in a syndrome of interrelated elements, which include neuroendocrine problems, severe malnutrition, wounds, infections, bone loss, polyneuropathy and myopathy, delirium and depression, and suffering.

IMPLICATIONS FOR PRACTICE

In caring for patients with CCIS, NPs need to focus on treating the elements of the syndrome as a cohort of interrelated elements and on re-establishing normalcy for the patient.

Prolonged propofol use in a critically ill pregnant patient

OBJECTIVE

To describe the prolonged use of propofol for sedation of a critically ill pregnant patient in her second trimester.

CASE SUMMARY

A 20-year-old pregnant woman at 14 weeks' gestation with non-Hodgkin's lymphoma required intubation and mechanical ventilation secondary to tumor-related airway obstruction. Immediately after intubation, propofol was initiated for sedation and maintained for 51 days with only one 5-day interruption in therapy. Over the course of the patient's stay in the intensive care unit, systemic chemotherapy was administered, resulting in a reduction in tumor burden and allowing for successful extubation. Ultimately, the fetus was deemed nonviable and the pregnancy was terminated.

DISCUSSION

Propofol is an intravenous anesthetic agent commonly used for the sedation of mechanically ventilated patients and is the only sedative agent that carries a pregnancy category B rating. Fetal outcomes following long-term use of propofol during the first trimester have not been formally evaluated and few reports of propofol use outside of early pregnancy termination, outpatient procedures, or parturition exist in the medical literature. Our patient required early termination of pregnancy; however, we were unable to determine whether fetal loss was a result of propofol use, chemotherapy administration, the use of other pharmacologic agents, or perhaps a combined effect.

CONCLUSIONS

Despite propofol's pregnancy category B rating, data are lacking in humans regarding its safe use during pregnancy and long-term developmental outcomes in children after exposure to propofol in utero. The safety of propofol as a sedative agent for critically ill pregnant patients remains unknown.

Validity and reliability of an intuitive conscious sedation scoring tool: the nursing instrument for the communication of sedation

OBJECTIVE

To develop a symmetrical 7-level scale (+3, "dangerously agitated" to -3, "deeply sedated") that is both intuitive and easy to use, the Nursing Instrument for the Communication of Sedation (NICS).

DESIGN

Prospective cohort study.

SETTING

University medical center.

PATIENTS

Mixed surgical, medical intensive care unit (ICU) population.

INTERVENTIONS

Patient assessment.

MEASUREMENTS AND MAIN RESULTS

Criterion, construct, face validity, and interrater reliability of NICS over time and comparison of ease of use and nursing preference between NICS and four common intensive care unit sedation scales. A total of 395 observations were performed in 104 patients (20 intubated [INT], 84 non intubated) by 59 intensive care unit providers. Criterion validity was tested comparing NICS WITH the 8-point level of arousal scale, demonstrating excellent correlation (rs = .96 overall, .95 non intubated, 0.85 intubated, all p < .001). Construct validity was confirmed by comparing NICS with the Richmond Agitation-Sedation Scale, demonstrating excellent correlation (rs = .98, p < .001). Face validity was determined in a blinded survey of 53 intensive care unit nurses evaluating NICS and four other sedation scales. NICS was highly rated as easy to score, intuitive, and a clinically relevant measure of sedation, and agitation and was preferred overall (74% NICS, 17% Richmond Agitation-Sedation Scale, 11% Other, p < .001 NICS vs. Richmond Agitation-Sedation Scale). Interrater reliability was assessed, using the five scales at three timed intervals, during which 37% of patients received sedative medication. The mean NICS score consistently correlated with each of the other scales over time with an rs of >.9. Using the intraclass correlation coefficient as a measure of Interrater reliability, NICS scored as high, or higher than Richmond Agitation-Sedation Scale, Riker Sedation-Agitation Scale, Motor Activity Assessment Scale, or Ramsay over the three time periods.

CONCLUSION

NICS is a valid and reliable sedation scale for use in a mixed population of intensive care unit patients. NICS ranked highest in nursing preference and ease of communication and may thus permit more effective and interactive management of sedation.

Sedation practice in three Norwegian ICUs: a survey of intensive care nurses' perceptions of personal and unit practice

OBJECTIVES

To describe intensive care nurses' perceptions of unit and personal sedation practice in the context of nursing and medical treatment of adult intensive care patients sedated and ventilated for more than 24 hours.

METHODS

Self-administered questionnaire.

SETTING

Three general ICUs in three university hospitals in Norway.

RESULTS

Eighty-six questionnaires were returned (response rate 47%). Continuous infusions of fentanyl and midazolam were perceived as most common and nurses often gave both analgesics and sedatives prior to care. Daily interruption of sedation or analgesia-based sedation was not perceived as practice in the units. MAAS was most commonly used, whilst protocols or objective scoring systems were not. Documentation of sedation levels was fairly routine, whereas documentation of patient needs was not perceived as important. Collaboration with physicians was viewed as most important, whilst no significance was assigned to collaboration with relatives.

CONCLUSION

The study shows that a focus on analgesia-based sedation and continual control of the sedation level should be considered in order to decrease the risk of oversedation. Inclusion of relatives' opinions, increased collaboration between nurses and physicians, and implementation of sedation tools, may contribute to even better patient outcome and should be focus in further studies.

The Richmond Agitation-Sedation Scale: translation and reliability testing in a Swedish intensive care unit

BACKGROUND

Awareness about adequate sedation in mechanically ventilated patients has increased in recent years. The use of a sedation scale to continually evaluate the patient's response to sedation may promote earlier extubation and may subsequently have a positive effect on the length of stay in the intensive care unit (ICU). The Richmond Agitation-Sedation Scale (RASS) provides 10 well-defined levels divided into two different segments, including criteria for levels of sedation and agitation. Previous studies of the RASS have shown it to have strong reliability and validity. The aim of this study was to translate the RASS into Swedish and to test the inter-rater reliability of the scale in a Swedish ICU.

METHODS

A translation of the RASS from English into Swedish was carried out, including back-translation, critical review and pilot testing. The inter-rater reliability testing was conducted in a general ICU at a university hospital in the south of Sweden, including 15 patients mechanically ventilated and sedated. Forty in-pair assessments using the Swedish version of the RASS were performed and the inter-rater reliability was tested using weighted kappa statistics (linear weighting).

RESULT

The translation of the RASS was successful and the Swedish version was found to be satisfactory and applicable in the ICU. When tested for inter-rater reliability, the weighed kappa value was 0.86.

CONCLUSION

This study indicates that the Swedish version of the RASS is applicable with good inter-rater reliability, suggesting that the RASS can be useful for sedation assessment of patients mechanically ventilated in Swedish general ICUs.

Care of the intubated emergency department patient

BACKGROUND

Emergency physicians perform tracheal intubation and initiate mechanical ventilation for critically ill patients on a daily basis. With the current national challenges of intensive care unit bed availability, intubated patients now often remain in the emergency department (ED) for exceedingly long periods of time. As a result, care of the intubated patient falls to the emergency physician (EP). Given the potential for significant morbidity and mortality, it is crucial for the EP to possess the most current, up-to-date information pertaining to the care of intubated patients.

DISCUSSION

This article discusses critical aspects in the ED management of intubated and mechanically ventilated patients. Specifically, emphasis is placed on providing adequate sedation and analgesia, limiting the use of neuromuscular blocking agents, correctly setting and adjusting the mechanical ventilator, utilizing appropriate monitoring modalities, and providing key supportive measures. Despite these measures, inevitably, some patients deteriorate while receiving mechanical ventilation. The article concludes with a discussion outlining a step-wise approach to evaluating the intubated patient who develops respiratory distress or circulatory compromise. With this information, the EP can more effectively care for ventilated patients while minimizing morbidity, and ultimately, improving outcome.

CONCLUSION

Essential components of the care of intubated ED patients includes administering adequate sedative and analgesic medications, using lung-protective ventilator settings with attention to minimizing ventilator-induced lung injury, elevating the head of the bed in the absence of contraindications, early placement of an orogastric tube, and providing prophylaxis for stress-related mucosal injury and deep venous thrombosis when indicated.

[Sedation in neurointensive care unit]

The objectives for using sedation in neurointensive care unit (neuroICU) are somewhat different from those used for patients without severe brain injuries. One goal is to clinically reassess the neurological function following the initial brain insult in order to define subsequent strategies for diagnosis and treatment. Another goal is to prevent severely injured brain from additional aggravation of cerebral blood perfusion and intracranial pressure. Depending on these situations is the choice of sedatives and analgesics: short-term agents, e.g., remifentanil, if a timely neurological reassessment is required, long-term agents, e.g., midazolam and sufentanil, as part of the treatment for elevated intracranial pressure. In that situation, a multimodal monitoring is needed to overcome the lack of clinical monitoring, including repeated measurements of intracranial pressure, blood flow velocities (transcranial Doppler), cerebral oxygenation (brain tissue oxygen tension), and brain imaging. The ultimate stop of neurosedation can distinguish between no consciousness and an alteration of arousing in brain-injured patients. During this period, an elevation of intracranial pressure is usual, and should not always result in reintroducing the neurosedation.

[Analysis of 4 sedation rating scales in the critical patient]

BACKGROUND

This study aimed to verify the relationship between different Sedation Rating Scales (SRSs) for critical patients on mechanical ventilation and to know the relationship between the SRSs, clinical information and the dose of sedative and analgesia drugs (SAD).

MATERIAL AND METHODS

A longitudinal, prospective analytic pilot study conducted in a Medical-Surgical Intensive Care Unit of a tertiary hospital from October-December 2006. The sample included patients who required administration of SAP and mechanical ventilation. The following biological parameters and scales were evaluated: patient's demographics, RAMSAY, Sedation Agitation Scale (SAS), Richmond Agitation Sedation Scale (RASS), Motor Activity Assessment Scale (MASS), SAD dose, mean blood pressure, cardiac rate, pupil diameter and respiratory frequency. Spearman coefficient of interrelation was used to compare the relationship between the different scales.

RESULTS

A total of 2.412 measurements were made for each variable: SRS, clinical information and SAD dose in 30 patients with different diseases, 63 % males, age 52 +/- 19 years, APACHEII 24 +/- 8, SAPSII 44 +/- 16, with an ICU mortality UCI 34 %. Median and IQ range of stay in ICU 15.5 and 20 days, of mechanical ventilation 9 and 14 days, of SAD 6 and 5.5 days and of paralyzing drugs (PD) 2 and 5 days, respectively. Interrelation was detected between all the SRSs, with p < 0.0001. The relationship between SAS, RASS and MASS was direct, whereas these were related inversely to RAMSAY. No evidence of interrelation was found between the SRSs, the clinical information and the SAD doses.

CONCLUSION

The RAMSAY scale that has not been validated in ICU patients has a strong interrelation with the other already validated SRSs. SRSs are subjective and do not correlate with the clinical information and the SAD doses, probably due to the sample's small size and heterogeneity.

Clinical meaning of early oxygenation improvement in severe acute respiratory distress syndrome under prolonged prone positioning

BACKGROUND/AIMS

Ventilating patients with acute respiratory distress syndrome (ARDS) in the prone position has been shown to improve arterial oxygenation, but prolonged prone positioning frequently requires continuous deep sedation, which may be harmful to patients. We evaluated the meaning of early gas exchange in patients with severe ARDS under prolonged (> or = 12 hours) prone positioning.

METHODS

We retrospectively studied 96 patients (mean age, 60.1 +/- 15.6 years; 75% men) with severe ARDS (PaO(2)/FiO2 < or = 150 mmHg) admitted to a medical intensive care unit (MICU). The terms "PaO2 response" and "PaCO2 response" represented responses that resulted in increases in the PaO2/FiO2 ratio of > or = 20 mmHg and decreases in PaCO2 of > or = 1 mmHg, respectively, 8 to 12 hours after first placement in the prone position.

RESULTS

The mean duration of prone positioning was 78.5 +/- 61.2 hours, and the 28-day mortality rate after MICU admission was 56.3%. No significant difference in clinical characteristics was observed between PaO2 and PaCO2 responders and non-responders. The PaO2 responders after prone positioning showed an improved 28-day outcome, compared with non-responders by Kaplan-Meier survival estimates (p < 0.05 by the log-rank test), but the PaCO12 responders did not.

CONCLUSIONS

Our results suggest that the early oxygenation improvement after prone positioning might be associated with an improved 28-day outcome and may be an indicator to maintain prolonged prone positioning in patients with severe ARDS.

The Effect of Dexmedetomidine on Agitation during Weaning of Mechanical Ventilation in Critically ill Patients

Ventilated patients receiving opioids and/or benzodiazepines are at high risk of developing agitation, particularly upon weaning towards extubation. This is often associated with an increased intubation time and length of stay in the intensive care unit and may cause long-term morbidity. Anxiety, fear and agitation are amongst the most common non-pulmonary causes of failure to liberate from mechanical ventilation. This prospective, open-label observational study examined 28 ventilated adult patients in the intensive care unit (30 episodes) requiring opioids and/or sedatives for >24 hours, who developed agitation and/or delirium upon weaning from sedation and failed to achieve successful extubation with conventional management. Patients were ventilated for a median (interquartile range) of 115 [87 to 263] hours prior to enrolment, Dexmedetomidine infusion was commenced at 0.4 μg/kg/hour for two hours, after which concurrent sedative therapy was preferentially weaned and titrated to obtain target Motor Activity Assessment Score score of 2 to 4. The median (range) maximum dose and infusion time of dexmedetomidine was 0.7 μg/kg/hour (0.4 to 1.0) and 62 hours (24 to 252) respectively. The number of episodes at target Motor Activity Assessment Score score at zero, six and 12 hours after commencement of dexmedetomidine were 7/30 (23.3%), 28/30 (93.3%) and 26/30 (86.7%), respectively (P <0.001 for 6 and 12 vs 0 hours). Excluding unrelated clinical deterioration, 22 episodes (73.3%) achieved successful weaning from ventilation with a median (interquartile range) ventilation time of 70 (28 to 96) hours after dexmedetomidine infusion. Dexmedetomidine achieved rapid resolution of agitation and facilitated ventilatory weaning after failure of conventional therapy. Its role as first-line therapy in ventilated, agitated patients warrants further investigation.

Scales for evaluating self-perceived anxiety levels in patients admitted to intensive care units: a review

OBJECTIVE

To review studies of anxiety in critically ill patients admitted to an intensive care unit to describe the level of anxiety and synthesize the psychometric properties of the instruments used to measure anxiety.

METHODS

The CUIDEN, IME, ISOC, CINAHL, MEDLINE, and PSYCINFO databases for 1995 to 2005 were searched. The search focused on 3 concepts: anxiety, intensive care, and mechanical ventilation for the English-language databases and ansiedad, cuidados intensivos, and ventilación mecánica for the Spanish-language databases. Information was extracted from 18 selected articles on the level of anxiety experienced by patients and the psychometric properties of the instruments used to measure anxiety.

RESULTS

Moderate levels of anxiety were reported. Levels were higher in women than in men, and higher in patients undergoing positive pressure ventilation regardless of sex. Most multi-item instruments had high coefficients of internal consistency. The reliability of instruments with only a single item was not demonstrated, even though the instruments had moderate-to-high correlations with other measurements.

CONCLUSION

Midlength scales, such the anxiety subscale of the Brief Symptom Inventory or the shortened state version of the State-Trait Anxiety Inventory are best for measuring anxiety in critical care patients.

Protocolized and target-based sedation and analgesia in the ICU

Administering sedative and analgesic medications is a cornerstone of optimizing patient comfort and minimizing distress, yet may lead to unintended consequences including delayed recovery from critical illness and slower liberation from mechanical ventilation. The use of structured approaches to sedation management, including guidelines, protocols, and algorithms can promote evidence-based care, reduce variation in clinical practice, and systematically reduce the likelihood of excessive and/or prolonged sedation. Patient-focused sedation algorithms are multidisciplinary, including physician, nurse, and pharmacist development and implementation. Key components of sedation algorithms include identification of goals and specific targets, use of valid and reliable tools to assess analgesia, agitation, and sedation, and incorporation of logical medication selection. Sedation protocols generally focus on a) algorithms that incorporate treating sedation and analgesia based upon escalation, de-escalation, or changing medications according to specific targets, or b) daily interruption of sedative and opioid analgesic infusions. Many published sedation protocols have been tested in controlled clinical trials, often demonstrating benefit such as shorter duration of mechanical ventilation, reduced ICU length of stay, and/or superior sedation management compared to usual care. Implementation of sedation algorithms in ICUs is a challenging process for which sufficient resources must be allocated.