Intensive Care Unit-acquired infection as a side effect of sedation

Effect of Remimazolam and Propofol on Blood Glucose and Serum Inflammatory Markers in Patients with Type 2 Diabetes: A Clinical Trial with Prospective Randomized Control

Background and Objectives: Patients with type 2 diabetes are at a higher risk of postoperative complications, such as infections, delayed wound healing, and increased mortality compared to non-diabetic patients. Materials and Methods: This prospective randomized study aims to compare the effects of two anesthetics, remimazolam and propofol, on blood glucose levels and immune function in diabetic patients undergoing surgery. Seventy-four diabetic patients undergoing general anesthesia were randomly assigned to receive either remimazolam or propofol. Plasma blood glucose levels, anti-inflammatory markers, and insulin levels were measured during the perioperative period. Results: No statistically significant differences were observed between the remimazolam and propofol groups in terms of neutrophil-to-lymphocyte ratio, anti-inflammatory markers, or glucose levels during the perioperative period (p value > 0.05). Conclusions: These results suggest that there is no difference between propofol and remimazolam in immune function deterioration that occurs due to surgical stress. This study is limited by its small sample size, and in future, larger trials could be conducted to find differences in the effects of blood sugar levels and serum inflammatory markers between the two groups.

Outcomes and factors associated with prolonged stays among patients admitted to adult intensive care unit in a resource-limited setting: a multicenter chart review

The length of stay in an intensive care unit is used as a benchmark for measuring resource consumption and quality of care and predicts a higher risk of readmission. The study aimed to assess the outcome and factors associated with prolonged intensive care unit stays among those admitted to adult intensive care units of selected public hospitals in Addis Ababa from January 1, 2022, to December 31, 2022. A multicenter retrospective chart review was conducted involving 409 adult patients. Binary logistic regression was used to assess factors associated with a prolonged stay and chi-square tests were used to assess associations and differences in outcomes for prolonged stays. The study, involving 409 of 421 individuals, revealed a predominantly male (55.0%) and the median age of study participants was 38, with an interquartile range (27, 55). Approximately 16.9% experienced prolonged stays, resulting in a 43.5% mortality rate. After adjustments for confounders, there were significant associations with prolonged stays for sedative/hypnotics, readmission, and complications. The study revealed that for every six patients admitted to the intensive care unit, one patient stayed longer, with nearly half experiencing mortality, demanding increased attention. The study emphasized the critical need for improvement in addressing associations between sedative/hypnotics, readmissions, complications, and prolonged stays.

Generalized music therapy to reduce neuroactive drug needs in critically ill patients. Study protocol for a randomized trial

BACKGROUND

Critically ill patients are exposed to several physical and emotional stressors, needing analgesic and sedative drugs to tolerate invasive procedures and the harsh intensive care unit (ICU) environment. However, this pharmacological therapy presents several side effects: guidelines suggest using a light sedation target, keeping critically ill patients calm, conscious, and cooperative. Personalized music therapy (MT) can reduce stress and anxiety, decreasing the need for drugs. The aim of the current investigation is to compare different approaches for MT in the ICU: a personalized approach, with music selected by patients/families and listened through headphones, or a generalized approach, with ambient music chosen by a music therapist and transmitted through speakers.

PRIMARY OUTCOME

number of days "free from neuroactive drugs" in the first 28 days after ICU admission.

SECONDARY OUTCOMES

total amount of neuroactive drugs (midazolam, propofol, morphine, fentanyl, haloperidol), stress during ICU stay (sleep at night, anxiety and agitation, use of physical restraints, stressors evaluated at discharge), the feasibility of generalized MT (interruptions requested by staff members and patients/families).

METHODS

Randomized, controlled trial with three groups of critically ill adults: a control group, without MT; a personalized MT group, with music for at least 2 h per day; a generalized MT group, with music for 12.5 h/day, subdivided into fifteen 50-min periods.

DISCUSSION

One hundred fifty-three patients are expected to be enrolled. This publication presents the rationale and the study methods, particularly the strategies used to build the generalized MT playlist. From a preliminary analysis, generalized MT seems feasible in the ICU and is positively received by staff members, critically ill patients, and families.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03280329. September 12, 2017.

Anti-inflammatory potential of remimazolam: A laboratory and clinical investigation

BACKGROUND

Anesthetic agents, particularly intravenous anesthetics, may affect immune function and tumorigenic factors. We herein investigated whether the anti-inflammatory effects of anesthetic agents are attributed to their antioxidant properties. The antioxidant and anti-inflammatory effects of remimazolam, a new anesthetic, remain unclear. We hypothesized that remimazolam exerts anti-inflammatory effects due to its antioxidant properties, which may affect the postoperative inflammatory response. This retrospective clinical study examined this hypothesis using laboratory and clinical approaches.

METHODS

The antioxidant effects of remimazolam and dexmedetomidine were assessed by electron spin resonance (ESR) spectroscopy, and postoperative inflammatory responses were compared in 143 patients who underwent transcatheter aortic valve replacement at Kindai University Hospital between April 2021 and December 2022. The primary endpoint was the presence or absence of the antioxidant effects of the anesthetics themselves using ESR.

RESULTS

Remimazolam at clinical concentrations exerted antioxidant effects, whereas dexmedetomidine did not. Increases in C-reactive protein (CRP) levels on POD3 from preoperative values were significantly smaller in the remimazolam group than in the dexmedetomidine group (1.33 ± 1.29 vs. 2.17 ± 1.84, p = .014).

CONCLUSIONS

Remimazolam exerted stronger anti-inflammatory effects than dexmedetomidine, and these effects were enhanced by its antioxidant properties, which may have affected postoperative CRP production.

Remi-fent 1-A pragmatic randomised controlled study to evaluate the feasibility of using remifentanil or fentanyl as sedation adjuncts in mechanically ventilated patients

Objective

To evaluate the feasibility of conducting a prospective randomised controlled trial (pRCT) comparing remifentanil and fentanyl as adjuncts to sedate mechanically ventilated patients.

Design

Single-center, open-labelled, pRCT with blinded analysis.

Setting

Australian tertiary intensive care unit (ICU).

Participants

Consecutive adults between June 2020 and August 2021 expected to receive invasive ventilation beyond the next day and requiring opioid infusion were included. Exclusion criteria were pregnant/lactating women, intubation >12 h, or study-drug hypersensitivity.

Interventions

Open-label fentanyl and remifentanil infusions per existing ICU protocols.

Outcomes

Primary outcomes were feasibility of recruiting ≥1 patient/week and >90 % compliance, namely no other opioid infusion used during the study period. Secondary outcomes included complications, ICU-, ventilator- and hospital-free days, and mortality (ICU, hospital). Blinded intention-to-treat analysis was performed concealing the allocation group.

Results

208 patients were enrolled (mean 3.7 patients/week). Compliance was 80.6 %. More patients developed complications with fentanyl than remifentanil: bradycardia (n = 44 versus n = 21; p < 0.001); hypotension (n = 78 versus n = 53; p < 0.01); delirium (n = 28 versus n = 15; p = 0.001). No differences were seen in ICU (24.3 % versus 27.6 %,p = 0.60) and hospital mortalities (26.2 % versus 30.5 %; p = 0.50). Ventilator-free days were higher with remifentanil (p = 0.01).

Conclusions

We demonstrated the feasibility of enrolling patients for a pRCT comparing remifentanil and fentanyl as sedation adjuncts in mechanically ventilated patients. We failed to attain the study-opioid compliance target, likely because of patients with complex sedative/analgesic requirements. Secondary outcomes suggest that remifentanil may reduce mechanical ventilation duration and decrease the incidence of complications. An adequately powered multicentric phase 2 study is required to evaluate these results.

Excessive Sedation as a Risk Factor for Delirium: A Comparison between Two Cohorts of ARDS Critically Ill Patients with and without COVID-19

Excessive sedation is associated with poor outcome in critically ill acute respiratory distress syndrome (ARDS) patients. Whether this prognostic effect varies among ARDS patients with and without COVID-19 has yet to be determined. We compared the prognostic value of excessive sedation—in terms of delirium, length of stay in intensive care unit (ICU-LOS) and ICU mortality—between COVID-19 and non-COVID-19 critically ill ARDS patients. This was a second analysis of prospectively collected data in four European academic centers pertaining to 101 adult critically ill ARDS patients with and without COVID-19 disease. Depth of sedation (DOS) and delirium were monitored through processed electroencephalogram (EEG) and the Confusion Assessment Method for ICU (CAM-ICU). Our main exposure was excessive sedation and how it relates to the presence of delirium, ICU-LOS and ICU mortality. The criterion for excessive sedation was met in 73 (72.3%) patients; of these, 15 (82.2%) and 58 (69.1%) were in non-COVID-19 and COVID-19 ARDS groups, respectively. The criteria of delirium were met in 44 patients (60.3%). Moreover, excessive sedation was present in 38 (86.4%) patients with delirium (p < 0.001). ICU death was ascertained in 41 out of 101 (41.0%) patients; of these, 37 (90.2%) had excessive sedation (p < 0.001). The distribution of ICU-LOS among excessive-sedated and non-sedated patients was 22 (16−27) vs. 14 (10.5−19.5) days (p < 0.001), respectively. In a multivariable framework, excessive sedation was independently associated with the development of delirium (p = 0.001), increased ICU mortality (p = 0.009) and longer ICU-LOS (p = 0.000), but only in COVID-19 ARDS patients. Independent of age and gender, excessive sedation might represent a risk factor for delirium in COVID-19 ARDS patients. Similarly, excessive sedation shows to be an independent predictor of ICU-LOS and ICU mortality. The use of continuous EEG-based depth of sedation (DOS) monitoring and delirium assessment in critically ill COVID-19 patients is warranted.

Propofol directly binds to and inhibits TLR7

Sedatives/anesthetics are important medical tools to facilitate medical care and increase patients' comfort. Increasingly, there is recognition that sedatives/anesthetics can modulate immune functions. Toll-like receptors (TLRs) are major pattern recognition receptors involved in the recognition of microbial components. TLR7 recognizes single-strand RNA virus such as influenza and SARS-CoV2 viruses and initiates interferon (IFN) responses. IFN production triggered by TLR7 stimulation is a critical anti-viral response. For example, patients with TLR7 variants including loss-of- function variants were associated with severe COVID-19. Taken together, it is important to determine if sedatives/anesthetics mitigate TLR7 function. We have previously showed that TLR7-mediated activation was not affected by volatile anesthetics. However, we found that propofol attenuated TLR7 activation among intravenous sedatives in the reporter assay. TLR7 agonist R837 stimulation increased TNF-α, IL-1β, IL-6, IL-10, and IFN-β mRNA levels in bone marrow-derived dendritic cells, while these levels were attenuated by propofol. Our murine lung slice experiments showed that propofol attenuated IFN production. R837 increased IFN-β expression in the lungs, and propofol attenuated IFN-β expression in an in vivo model of R837 intranasal instillation. We also found that propofol directly bound to and hindered its association of TLR7 with MyD88. Our analysis using fropofol, propofol derivative showed that the hydroxyl group in propofol was important for propofol-TLR7 interaction.

The complications of opioid use during and post-intensive care admission: A narrative review

Opioids are a commonly administered analgesic medication in the intensive care unit, primarily to facilitate invasive mechanical ventilation. Consensus guidelines advocate for an opioid-first strategy for the management of acute pain in ventilated patients. As a result, these patients are potentially exposed to high opioid doses for prolonged periods, increasing the risk of adverse effects. Adverse effects relevant to these critically ill patients include delirium, intensive care unit-acquired infections, acute opioid tolerance, iatrogenic withdrawal syndrome, opioid-induced hyperalgesia, persistent opioid use, and chronic post-intensive care unit pain. Consequently, there is a challenge of optimising analgesia while minimising these adverse effects. This narrative review will discuss the characteristics of opioid use in the intensive care unit, outline the potential short-term and long-term adverse effects of opioid therapy in critically ill patients, and outline a multifaceted strategy for opioid minimisation.

Epidemiology and Risk Factors of Healthcare-Associated Infections in Critically Ill Patients in a Tertiary Care Teaching Hospital in Nepal: A Prospective Cohort Study

Background:

Healthcare-associated infection (HAI) is an important public health problem, particularly in intensive care units (ICUs). We aimed to examine the epidemiology and risk factors of HAIs in our ICUs and study their microbiological profile.

Methods:

We evaluated 100 consecutive patients in 3 medical and surgical ICUs of a tertiary care teaching hospital daily starting in January 2016 using the Centers for Disease Control and Prevention definitions and methods. We determined the incidence and sites of HAIs, identified the causative microorganism, and studied their antibiotic sensitivity profiles. We investigated risk factors for the development of an HAI using a multiple logistic regression model.

Results:

Of 300 patients, 129 patients (43%) developed HAIs (55.96 HAI events per 1000 ICU-days). Pneumonia was the most common type of HAI (57, 41%). Escherichia coli was the most frequently isolated microorganism (20, 29%) and 74% of the pathogens isolated were multi-drug resistant. The presence of an invasive device (Odds Ratio, 4.29; 95% Confidence Interval, 2.52-7.51) and use of sedation (Odds Ratio, 2.24; 95% Confidence Interval, 1.31-3.87) were the statistically significant risk factors for HAIs.

Conclusions:

We found a high incidence of HAIs in our ICUs and a high burden of multidrug-resistant microorganisms highlighting the importance of infection control and antibiotic stewardship.

Ventilator-Associated Events: Epidemiology, Risk Factors, and Prevention

The Centers for Disease Control and Prevention shifted the focus of safety surveillance in mechanically ventilated patients from ventilator-associated pneumonia to ventilator-associated events in 2013 to increase the objectivity and reproducibility of surveillance and to encourage quality improvement programs to focus on preventing a broader array of complications. Ventilator-associated events are associated with a doubling of the risk of dying. Prospective studies have found that minimizing sedation, increasing spontaneous awakening and breathing trials, and conservative fluid management can decrease event rates and the duration of ventilation. Multifaceted interventions to enhance these practices can decrease ventilator-associated event rates.

Dexmedetomidine Protects Against Septic Liver Injury by Enhancing Autophagy Through Activation of the AMPK/SIRT1 Signaling Pathway

Background: Liver injury is one of the serious complications of sepsis. Previous studies suggested that dexmedetomidine (DEX) could alleviate cecal ligation and puncture (CLP)-induced liver injury. However, it is unclear whether the protective effect of DEX on sepsis-induced liver injury is related to autophagy.

Methods: Mice (n = 105) were randomly divided into the following groups: (i) CON group (Sham); (ii) CLP group (CLP-induced liver injury + saline); (iii) CLP + DEX group (CLP-induced liver injury + DEX). Mouse models of sepsis-induced liver injury were established using CLP. DEX or normal saline was administered by intraperitoneal injection at 0, 2, and 4 h after CLP surgery. The mortality rate within 120 h was calculated. The levels of alanine aminotransferase (ALT), aspartate aminotransferase (AST), and inflammatory cytokines were measured at 6, 12, and 24 h in each group. Hematoxylin and eosin staining assay was carried out to detect the morphological changes of mouse liver cells in each group. The levels of autophagy-associated proteins LC3II, Beclin-1, p62, and LAMP-2 were detected in three groups of mice using western blotting. The expression of LC3II was detected using immunofluorescence. Transmission electron microscopy (TEM) of liver tissue was used to observe autophagosomes and autophagosome–lysosomes. Lastly, the effect of DEX on the AMPK/SIRT1 pathway-associated protein levels were detected using western blotting. Meanwhile, we used L0-2 cells infected with mRFP-GFP-LC3 adenovirus to further analyze the role of SIRT1 in DEX-induced autophagy in liver injury model in vitro.

Results: DEX significantly improved the survival rate of septic mice at the early stage and ameliorated the pathology of sepsis-induced liver injury. The level of autophagy-associated proteins, phosphorylated (p)-AMPK/AMPK, and SIRT1 in the liver of CLP-induced sepsis mice peaked at 12 h post-CLP and decreased significantly at 24 h. In the CLP + DEX group, the levels of autophagy-associated proteins, p-AMPK/AMPK, and SIRT1 increased, whereas inflammatory cytokines decreased at 24 h. The autophagosome structure was clearly observed at different time points in the CLP + DEX group. In the in vitro hepatocyte injury model, the SIRT1 inhibitor significantly increased intracellular ROS levels and reversed the effect of DEX on autophagy flux.

Conclusion: We demonstrated a novel mechanism in which DEX protects against CLP-induced liver injury. DEX enhances autophagy, which alleviates the inflammatory responses in CLP-induced liver injury by regulating the SIRT1/AMPK pathway.

Antiviral Efficacy of the Anesthetic Propofol against Dengue Virus Infection and Cellular Inflammation

Propofol, 2,6-diisopropylphenol, is a short-acting intravenous sedative agent used in adults and children. Current studies show its various antimicrobial as well as anti-inflammatory effects. Dengue virus (DENV) is an emerging infectious pathogen transmitted by mosquitoes that causes mild dengue fever and progressive severe dengue diseases. In the absence of safe vaccines and antiviral agents, adjuvant treatments and supportive care are generally administered. This study investigated the antiviral effects of propofol against DENV infection and cellular inflammation by using an in vitro cell model. Treatment with propofol significantly inhibited DENV release 24 h postinfection in BHK-21 cells. Furthermore, it also blocked viral protein expression independent of the translational blockade. Propofol neither caused inhibitory effects on endosomal acidification nor prevented dsRNA replication. Either the proinflammatory TNF-α or the antiviral STAT1 signaling was reduced by propofol treatment. These results provide evidence to show the potential antiviral effects of the sedative propofol against DENV infection and cellular inflammation.

Evaluating the Saliva of Burn ICU Patients for Resistant Infections Harbor Metallo-β-Lactamase Genes

Pseudomonas aeruginosa and Acinetobacter baumannii are the bacteria which increasingly account for nosocomial infections. Due to high virulence, the rate of Multi-Drug Resistance (MDR) and limited availability of new agents, these infections create significant clinical burdens, making it important to identify the possible sources of their occurrence. The aim of this study was to assess non-lactose fermenting bacteria and their metallo-β-lactamase (MBLs) genes expression in the Burn Intensive Care Unit (BICU) patients' saliva samples. This cross-sectional study was conducted from 2017 to 2018 on 124 saliva samples of BICU patients. Identified isolates were evaluated for drug susceptibility by disc diffusion method. MBLs production isolates were detected by Modified Hodge test and Imipenem-EDTA Combined disk. MBLs related genes were evaluated by polymerase chain reaction (PCR). A total of 86 Gram negative non-lactose fermenting bacteria (38; A. baumannii) and (48; P. aeruginosa), were detected. All of the A. baumannii isolates were resistant to Carbapenems, while more than 90% of them were sensitive to Colistin. However, the highest sensitivity in P. aeruginosa isolates was related to Carbapenems and Colistin. More than 95% of A. baumannii and 32% of P. aeruginosa were detected MDR. MBLs production was confirmed in 9 (33.33%) P. aeruginosa and 18 (66.67%) A. baumannii isolates. The blaVIM was the most prevalent gene, while this gene was detected in all of MBLs positive strains. This study confirmed the prevalence of carbapenemase producer Gram-negative bacilli in the saliva of BICU patients. The results of the present study provide a new data set about saliva infection source that could lead to the proper antibiotic regimen and better control of drug resistance.

Risk factors for ventilator-associated events: A prospective cohort study

BACKGROUND

In January 2013, the Centers for Disease Control and Prevention released new surveillance definitions for ventilator-associated event (VAE) to replace ventilator-associated pneumonia (VAP) in adult patients. VAEs are associated with prolonged mechanical ventilation and hospital death, but little is known about their risk factors and how best to prevent them.

METHODS

We compared VAE cases with non-VAE cases with regard to demographics, comorbidities, sedative exposures, opioids exposures, paralytic exposures, routes of nutrition, blood products, gastric retention, and fluid balance. Patients mechanically ventilated for ≥4 days between January 1, 2017, and December 31, 2017, in 2 adult intensive care units of a tertiary care teaching hospital in China were included.

RESULTS

On multivariable logistic regression, significant risk factors for VAEs were positive daily fluid balances of ≥ 50 mL between day of intubation and the fourth day of mechanical ventilation (relative risk [RR], 8.39; 95% confidence interval [CI], 2.99-23.50), sedative administered between the first day and the fourth day of invasive mechanical ventilation (RR, 15.69; 95% CI, 1.62-152.06), and daily gastric retention of ≥200 mL between day of intubation and the fourth day of mechanical ventilation (RR, 9.27; 95% CI, 1.89-45.47).

CONCLUSIONS

Positive daily fluid balances of ≥50 mL, sedatives administered, and gastric retention of ≥200 mL are risk factors for VAEs. Intervention studies are needed to determine if targeting these risk factors can lower VAE rates.

Enteral versus intravenous approach for the sedation of critically ill patients: a randomized and controlled trial

Background

ICU patients must be kept conscious, calm, and cooperative even during the critical phases of illness. Enteral administration of sedative drugs might avoid over sedation, and would be as adequate as intravenous administration in patients who are awake, with fewer side effects and lower costs. This study compares two sedation strategies, for early achievement and maintenance of the target light sedation.

Methods

This was a multicenter, single-blind, randomized and controlled trial carried out in 12 Italian ICUs, involving patients with expected mechanical ventilation duration > 72 h at ICU admission and predicted mortality > 12% (Simplified Acute Physiology Score II > 32 points) during the first 24 h on ICU. Patients were randomly assigned to receive intravenous (midazolam, propofol) or enteral (hydroxyzine, lorazepam, and melatonin) sedation. The primary outcome was percentage of work shifts with the patient having an observed Richmond Agitation-Sedation Scale (RASS) = target RASS ±1. Secondary outcomes were feasibility, delirium-free and coma-free days, costs of drugs, length of ICU and hospital stay, and ICU, hospital, and one-year mortality.

Results

There were 348 patients enrolled. There were no differences in the primary outcome: enteral 89.8% (74.1–100), intravenous 94.4% (78–100), p = 0.20. Enteral-treated patients had more protocol violations: n = 81 (46.6%) vs 7 (4.2%), p < 0.01; more self-extubations: n = 14 (8.1%) vs 4 (2.4%), p = 0.03; a lighter sedative target (RASS = 0): 93% (71–100) vs 83% (61–100), p < 0.01; and lower total drug costs: 2.39 (0.75–9.78) vs 4.15 (1.20–20.19) €/day with mechanical ventilation (p = 0.01).

Conclusions

Although enteral sedation of critically ill patients is cheaper and permits a lighter sedation target, it is not superior to intravenous sedation for reaching the RASS target.

Trial registration

ClinicalTrials.gov, NCT01360346. Registered on 25 March 2011.

Electronic supplementary material

The online version of this article (10.1186/s13054-018-2280-x) contains supplementary material, which is available to authorized users.

Is intra-abdominal hypertension a risk factor for ventilator-associated pneumonia?

In the last years, there has been a significant amount of research about the impact of intra-abdominal hypertension (IAH) on the outcomes of critical care patients. IAH is increasingly recognized as potential complication in intensive care unit (ICU) patients. IAH affects all body systems, most notably the cardiac, respiratory, renal, and neurologic systems. IAH affects blood flow to various organs and plays a significant role in the prognosis of the patients. Recognition of IAH, its risk factors and clinical signs can reduce the morbidity and mortality associated. Moreover, knowledge of the pathophysiology may help rationalize the therapeutic approach. On the other hand, ICU patients present frequently ventilator- associated respiratory infections. Ventilator-associated pneumonia (VAP) is the most common healthcare-associated infection (HAI) in adult critical care units. It is associated with increased ICU stay, patient ventilator days and mortality. This paper reviews the relationship between IAH and VAP. Despite animal experimentation and physiological studies on humans, in favor of the impact of IAH to VAP, there is no definitive clinical data that IAH is associated with VAP. Microaspirations form the gastrointestinal track is a pathophysiological mechanism for VAP. This review provides data suggesting that under IAH conditions bacterial translocation might be an additional responsible mechanism for VAP in those patients that merits further investigation in the future.

Intra-Abdominal Hypertension is a Risk Factor for Increased VAP Incidence: A Prospective Cohort Study in the ICU of a Tertiary Hospital

BACKGROUND

Ventilator-associated pneumonia (VAP) might be increased in cases with intra-abdominal hypertension (IAH). However, despite animal experimentation and physiological studies on humans in favor of this hypothesis, there is no definitive clinical data that IAH is associated with VAP. We therefore aimed to study whether IAH is a risk factor for increased incidence of VAP in critical care patients. This 1-center prospective observational cohort study was conducted in the intensive care unit of the University Hospital of Larissa, Greece, during 2013 to 2015. Consecutive patients were recruited if they presented risk factors for IAH at admission and were evaluated systematically for IAH and VAP for a 28-day period.

RESULTS

Forty-five (36.6%) of 123 patients presented IAH and 45 (36.6%) presented VAP; 24 patients presented VAP following IAH. Cox regression analysis showed that VAP was independently associated with IAH (1.06 [1.01-1.11]; P = .053), while there was an indication for an independent association between VAP and abdominal surgery (1.62 [0.87-3.03]; P = .11] and chronic obstructive pulmonary disease (1.79 [0.96-3.37]; P = .06).

CONCLUSIONS

Intra-abdominal hypertension is an independent risk factor for increased VAP incidence in critically ill patients who present risk factors for IAH at admission to the ICU.

Point prevalence & risk factor assessment for hospital-acquired infections in a tertiary care hospital in Pune, India

Background & objectives:

Hospital-acquired infections (HAIs) are a major challenge to patient safety and have serious public health implications by changing the quality of life of patients and sometimes causing disability or even death. The true burden of HAI remains unknown, particularly in developing countries. The objective of this study was to estimate point prevalence of HAI and study the associated risk factors in a tertiary care hospital in Pune, India.

Methods:

A series of four cross-sectional point prevalence surveys were carried out between March and August 2014. Data of each patient admitted were collected using a structured data entry form. Centers for Disease Control and Prevention guidelines were used to identify and diagnose patients with HAI.

Results:

Overall prevalence of HAI was 3.76 per cent. Surgical Intensive Care Unit (ICU) (25%), medical ICU (20%), burns ward (20%) and paediatric ward (12.17%) were identified to have significant association with HAI. Prolonged hospital stay [odds ratio (OR=2.81), mechanical ventilation (OR=18.57), use of urinary catheter (OR=7.89) and exposure to central air-conditioning (OR=8.59) had higher odds of acquiring HAI (P<0.05).

Interpretation & conclusions:

HAI prevalence showed a progressive reduction over successive rounds of survey. Conscious effort needs to be taken by all concerned to reduce the duration of hospital stay. Use of medical devices should be minimized and used judiciously. Healthcare infection control should be a priority of every healthcare provider. Such surveys should be done in different healthcare settings to plan a response to reducing HAI.

Ventilator-Associated Events and Their Prevention

The Centers for Disease Control and Prevention shifted the focus of safety surveillance in mechanically ventilated patients from ventilator-associated pneumonia to ventilator-associated events (VAEs) in 2013. The shift was designed to increase the objectivity and reproducibility of surveillance and to encourage quality-improvement programs to tackle a broader array of complications in mechanically ventilated patients. Prospective intervention studies have found that minimizing sedation, increasing the use of spontaneous awakening and breathing trials, and conservative fluid management can lower VAE rates and decrease duration of mechanical ventilation. Additional strategies to prevent VAEs include early mobility programs, low tidal volume ventilation, and restrictive transfusion thresholds.

The Benefit of Benzodiazepine Reduction: Improving Sedation in Surgical Intensive Care

Aims:

Sedation, as it is often required in critical care, is associated with immobilization, prolonged ventilation, and increased morbidity. Most sedation protocols are based on benzodiazepines. The presented study analyzes the benefit of benzodiazepine-free sedation.

Methods:

In 2008, 134 patients were treated according to a protocol using benzodiazepine and propofol (Group 1). In 2009, we introduced a new sedation strategy based on sufentanil, nonsteroidal anti-inflammatory drugs, neuroleptics, and antidepressants, which was applied in 140 consecutive patients (Group 2). Depth of sedation, duration of mechanical ventilation, duration of Intensive Care Unit, and hospital stay were analyzed.

Results:

Group 1 had both a longer duration of deep sedation (18.7 ± 2.5 days vs. 12.6 ± 1.85 days, P = 0.031) and a longer duration of controlled ventilation (311, 35 ± 32.69 vs. 143, 96 ± 20.76 h, P < 0.0001) than Group 2. Ventilator days were more frequent in Group 1 (653, 66 ± 98.37 h vs. 478, 89 ± 68.92 h, P = 0.128).

Conclusions:

The benzodiazepine-free sedation protocol has been shown to significantly reduce depth of sedation and controlled ventilation. Additional evidence is needed to ascertain reduction of ventilator days which would not only be of benefit for the patient but also for the hospital Management.

The Relationship Between Sedatives, Sedative Strategy, and Healthcare-Associated Infection: A Systematic Review

BACKGROUND Healthcare-associated infections (HAIs) cause significant morbidity in critically ill patients. An underappreciated but potentially modifiable risk factor for infection is sedation strategy. Recent trials suggest that choice of sedative agent, depth of sedation, and sedative management can influence HAI risk in mechanically ventilated patients. OBJECTIVE To better characterize the relationships between sedation strategies and infection. METHODS Systematic literature review. RESULTS We found 500 articles and accepted 70 for review. The 3 most common sedatives for mechanically ventilated patients (benzodiazepines, propofol, and dexmedetomidine) have different pharmacologic and immunomodulatory effects that may impact infection risk. Clinical data are limited but retrospective observational series have found associations between sedative use and pneumonia whereas prospective studies of sedative interruptions have reported possible decreases in bloodstream infections, pneumonia, and ventilator-associated events. CONCLUSION Infection rates appear to be highest with benzodiazepines, intermediate with propofol, and lowest with dexmedetomidine. More data are needed but studies thus far suggest that a better understanding of sedation practices and infection risk may help hospital epidemiologists and critical care practitioners find new ways to mitigate infection risk in critically ill patients. Infect Control Hosp Epidemiol 2016;1-9.

Potential Strategies to Prevent Ventilator-associated Events

The Centers for Disease Control and Prevention (CDC) released ventilator-associated event (VAE) definitions in 2013. The new definitions were designed to track episodes of sustained respiratory deterioration in mechanically ventilated patients after a period of stability or improvement. More than 2,000 U.S. hospitals have reported their VAE rates to the CDC, but there has been little guidance to date on how to prevent VAEs. Existing ventilator-associated pneumonia prevention bundles are unlikely to be optimal insofar as pneumonia accounts for only a minority of VAEs. This review proposes a framework and potential intervention set to prevent VAEs on the basis of studies of VAE epidemiology, risk factors, and prevention. Work to date suggests that the majority of VAEs are caused by four conditions: pneumonia, fluid overload, atelectasis, and acute respiratory distress syndrome. Interventions that minimize ventilator exposure and target one or more of these conditions may therefore prevent VAEs. Potential strategies include avoiding intubation, minimizing sedation, paired daily spontaneous awakening and breathing trials, early exercise and mobility, low tidal volume ventilation, conservative fluid management, and conservative blood transfusion thresholds. Interventional studies have thus far affirmed that minimized sedation, paired daily spontaneous awakening and breathing trials, and conservative fluid management can reduce VAE rates and improve patient-centered outcomes. Further studies are needed to evaluate the impact of the other proposed interventions, to identify additional modifiable risk factors for VAEs, and to measure whether combining strategies into VAE prevention bundles confers additional benefits over implementing one or more of these interventions in isolation.

Epidemiology, associated factors and outcomes of ICU-acquired infections caused by Gram-negative bacteria in critically ill patients: an observational, retrospective study

BACKGROUND

Gram-negative bacteria are increasingly responsible for nosocomial infections, including ICU-acquired infections. Due to high virulence, rate of multi-drug resistance and limited availability of new agents, these infections create cumbersome clinical burdens, making it important to reduce the risk of their occurrence. The aim of the study was to assess epidemiology-related factors and outcomes of Gram-negative, ICU-acquired infections in a cohort of medical-surgical patients.

METHODS

A retrospective survey was conducted on all patients admitted to a mixed ICU from January 2012 to December 2013. 'ICU-acquired infections' were defined as new infections acquired no less than 48 h after ICU admission. Diagnosis was made according to the Centers for Disease Control and Prevention National Healthcare Safety Network (CDC/NHSN) criteria. Differences across patients who did and did not acquire a Gram-negative infection were tested regarding age, sex, body mass index, medical or surgical admission, cardiovascular comorbidities, chronic obstructive pulmonary disease, diabetes, end-stage renal failure, co-existing tumours and prophylactic anti-fungal treatment. Multivariate analysis was used to assess the independency of these associations. Finally, differences in ICU-mortality, ICU-length of stay and duration of mechanical ventilation were tested across patients with and without new, ICU-acquired, Gram-negative infections.

RESULTS

Of 494 patients admitted to the ICU, 46 (9.3 %) acquired an infection 48 or more hours after admittance. In 30/46 patients (65.2 %) the isolated bacterium was Gram-negative. Univariate analysis showed that clinical factors associated with new ICU-acquired Gram-negative infections were medical admission (p < 0.001, 95 % CI 0.59 - 0.29, OR = 0.13), chronic kidney disease (p = 0.018, 95 % CI 1.20 - 7.34, OR = 2.98) and prophylactic antifungal therapy (p < 0.001, 95 % CI 1.91 - 9.79, OR = 4.33). At multivariate analysis, only medical admission and prophylactic antifungal therapy were significantly associated with ICU-acquired Gram-negative infections. Higher ICU-length of stay and longer duration of mechanical ventilation were associated with these infections while ICU-mortality did not significantly differ.

CONCLUSIONS

ICU-acquired Gram-negative infections were common in a cohort of mixed medical-surgical patients. Only medical admission and anti-fungal prophylaxis were found to be independently associated with these infections; they were not found to have a significant effect on ICU-mortality.

The contribution of opiate analgesics to the development of infectious complications in trauma patients

Trauma-related pain is a natural consequence of injury and its surgical management; however, the relationship between opiates and complications in trauma patients is unknown. To study this a retrospective chart review of selected subjects following traumatic injury with admission to the SICU for > 3 days was performed, and opiate administration data was collected for the first 3 days of admission. Associated data from each subject's chart was also collected. Analysis of the data revealed that increased opiate intake after admission to the SICU was associated with significantly increased SICU and hospital LOS independent of injury severity. This increase in LOS was independent of mechanical ventilation in the moderate ISS group. Infectious complications were also more prevalent in the moderate ISS group with higher opiate use. These findings suggest that increased doses of opiate analgesics in trauma patients may contribute to an increased overall LOS and associated infectious complications. Analgesic regimes that minimize opiate intake, while still providing adequate pain relief, may be advantageous in reducing LOS, complications and reduce hospitalization costs.

The preventability of ventilator-associated events. The CDC Prevention Epicenters Wake Up and Breathe Collaborative

RATIONALE

The CDC introduced ventilator-associated event (VAE) definitions in January 2013. Little is known about VAE prevention. We hypothesized that daily, coordinated spontaneous awakening trials (SATs) and spontaneous breathing trials (SBTs) might prevent VAEs.

OBJECTIVES

To assess the preventability of VAEs.

METHODS

We nested a multicenter quality improvement collaborative within a prospective study of VAE surveillance among 20 intensive care units between November 2011 and May 2013. Twelve units joined the collaborative and implemented an opt-out protocol for nurses and respiratory therapists to perform paired daily SATs and SBTs. The remaining eight units conducted surveillance alone. We measured temporal trends in VAEs using generalized mixed effects regression models adjusted for patient-level unit, age, sex, reason for intubation, Sequential Organ Failure Assessment score, and comorbidity index.

MEASUREMENTS AND MAIN RESULTS

We tracked 5,164 consecutive episodes of mechanical ventilation: 3,425 in collaborative units and 1,739 in surveillance-only units. Within collaborative units, significant increases in SATs, SBTs, and percentage of SBTs performed without sedation were mirrored by significant decreases in duration of mechanical ventilation and hospital length-of-stay. There was no change in VAE risk per ventilator day but significant decreases in VAE risk per episode of mechanical ventilation (odds ratio [OR], 0.63; 95% confidence interval [CI], 0.42-0.97) and infection-related ventilator-associated complications (OR, 0.35; 95% CI, 0.17-0.71) but not pneumonias (OR, 0.51; 95% CI, 0.19-1.3). Within surveillance-only units, there were no significant changes in SAT, SBT, or VAE rates.

CONCLUSIONS

Enhanced performance of paired, daily SATs and SBTs is associated with lower VAE rates. Clinical trial registered with www.clinicaltrials.gov (NCT 01583413).

Risk factors for ventilator-associated events: a case-control multivariable analysis

OBJECTIVES

The Centers for Disease Control and Prevention recently released new surveillance definitions for ventilator-associated events, including the new entities of ventilator-associated conditions and infection-related ventilator-associated complications. Both ventilator-associated conditions and infection-related ventilator-associated complications are associated with prolonged mechanical ventilation and hospital death, but little is known about their risk factors and how best to prevent them. We sought to identify risk factors for ventilator-associated conditions and infection-related ventilator-associated complications.

DESIGN

Retrospective case-control study.

SETTING

Medical, surgical, cardiac, and neuroscience units of a tertiary care teaching hospital.

PATIENTS

Hundred ten patients with ventilator-associated conditions matched to 110 controls without ventilator-associated conditions on the basis of age, sex, ICU type, comorbidities, and duration of mechanical ventilation prior to ventilator-associated conditions.

INTERVENTIONS

None.

MEASUREMENTS

We compared cases with controls with regard to demographics, comorbidities, ventilator bundle adherence rates, sedative exposures, routes of nutrition, blood products, fluid balance, and modes of ventilatory support. We repeated the analysis for the subset of patients with infection-related ventilator-associated complications and their controls.

MAIN RESULTS

Case and control patients were well matched on baseline characteristics. On multivariable logistic regression, significant risk factors for ventilator-associated conditions were mandatory modes of ventilation (odds ratio, 3.4; 95% CI, 1.6-8.0) and positive fluid balances (odds ratio, 1.2 per L positive; 95% CI, 1.0-1.4). Possible risk factors for infection-related ventilator-associated complications were starting benzodiazepines prior to intubation (odds ratio, 5.0; 95% CI, 1.3-29), total opioid exposures (odds ratio, 3.3 per 100 μg fentanyl equivalent/kg; 95% CI, 0.90-16), and paralytic medications (odds ratio, 2.3; 95% CI, 0.79-80). Traditional ventilator bundle elements, including semirecumbent positioning, oral care with chlorhexidine, venous thromboembolism prophylaxis, stress ulcer prophylaxis, daily spontaneous breathing trials, and sedative interruptions, were not associated with ventilator-associated conditions or infection-related ventilator-associated complications.

CONCLUSIONS

Mandatory modes of ventilation and positive fluid balance are risk factors for ventilator-associated conditions. Benzodiazepines, opioids, and paralytic medications are possible risk factors for infection-related ventilator-associated complications. Prospective studies are needed to determine if targeting these risk factors can lower ventilator-associated condition and infection-related ventilator-associated complication rates.

A Novel Porcine Model of Ventilator-associated Pneumonia Caused by Oropharyngeal Challenge with Pseudomonas aeruginosa

Background:

Animal models of ventilator-associated pneumonia (VAP) in primates, sheep, and pigs differ in the underlying pulmonary injury, etiology, bacterial inoculation methods, and time to onset. The most common ovine and porcine models do not reproduce the primary pathogenic mechanism of the disease, through the aspiration of oropharyngeal pathogens, or the most prevalent human etiology. Herein the authors characterize a novel porcine model of VAP due to aspiration of oropharyngeal secretions colonized by Pseudomonas aeruginosa.

Methods:

Ten healthy pigs were intubated, positioned in anti-Trendelenburg, and mechanically ventilated for 72 h. Three animals did not receive bacterial challenge, whereas in seven animals, a P. aeruginosa suspension was instilled into the oropharynx. Tracheal aspirates were cultured and respiratory mechanics were recorded. On autopsy, lobar samples were obtained to corroborate VAP through microbiological and histological studies.

Results:

In animals not challenged, diverse bacterial colonization of the airways was found and monolobar VAP rarely developed. In animals with P. aeruginosa challenge, colonization of tracheal secretion increased up to 6.39 ± 0.34 log colony-forming unit (cfu)/ml (P &lt; 0.001). VAP was confirmed in six of seven pigs, in 78% of the cases developed in the dependent lung segments (right medium and lower lobes, P = 0.032). The static respiratory system elastance worsened to 41.5 ± 5.8 cm H2O/l (P = 0.001).

Conclusions:

The authors devised a VAP model caused by aspiration of oropharyngeal P. aeruginosa, a frequent causative pathogen of human VAP. The model also overcomes the practical and legislative limitations associated with the use of primates. The authors’ model could be employed to study pathophysiologic mechanisms, as well as novel diagnostic/preventive strategies.

Optimal care and design of the tracheal cuff in the critically ill patient

Despite the increasing use of non-invasive ventilation and high-flow nasal-oxygen therapy, intubation is still performed in a large proportion of critically ill patients. The aim of this narrative review is to discuss recent data on long-term intubation-related complications, such as microaspiration, and tracheal ischemic lesions. These complications are common in critically ill patients, and are associated with substantial morbidity and mortality. Recent data suggest beneficial effects of tapered cuffed tracheal tubes in reducing aspiration. However, clinical data are needed in critically ill patients to confirm this hypothesis. Polyurethane-cuffed tracheal tubes and continuous control of cuff pressure could be beneficial in preventing microaspiration and ventilator-associated pneumonia (VAP). However, large multicenter studies are needed before recommending their routine use. Cuff pressure should be maintained between 20 and 30 cmH₂O to prevent intubation-related complications. Tracheal ischemia could be prevented by manual or continuous control of cuff pressure.

Risk factors for the first episode of Klebsiella pneumoniae resistant to carbapenems infection in critically ill patients: a prospective study

Objective. To identify risk factors for the first episode of Klebsiella Pneumonia resistant to carbapenems (KPRC) infection in critically ill patients. Design, Setting, and Methods. This prospective cohort study was conducted in a 12-bed general Intensive Care Unit (ICU) in a University Hospital on ICU patients who required mechanical ventilation (MV) for >48 hours during a 12-month period. Clinical and microbiologic data were studied. Characteristics of KPRC patients were compared with those of critically ill patients who presented nonmultidrug resistant (MDR) bacterial infections or no documented infection at all. Results. Twenty-five patients presented KPRC infection, 18 presented non-MDR bacterial infection, and 39 patients presented no infection. Compared to patients without documented infection or infected by non MDR bacteria, patients with KPRC infection had received more frequently or for longer duration antibiotics against Gram-negative bacteria (carbapenems, colistin P < 0.05). Duration of colistin administration prior to KPRC isolation was independently associated with increased frequency of KPRC infection (odds ratio, 1.156 per day; 95% confidence interval, 1.010 to 1.312; P = 0.025). KPRC patients stayed longer in the ICU and received mechanical ventilation and sedation for longer periods and presented increased mortality (P < 0.05). Conclusion. KPRC infection is an emerging problem which might be more common in patients with previous use of antibiotics and especially colistin.

A retrospective analysis of determinants of self-extubation in a tertiary care intensive care unit

Background:

Self-extubation is a common event in intensive care units (ICUs) world-wide. The most common factor attributed in various studies is lack of optimal sedation. However, the factors that lead to this inadequacy of sedation are not analyzed.

Aims:

The present study aimed to evaluate the determinants of factors leading to self-extubation in our ICU. Relation of patient profile, nature of sedation and any diurnal variation in extubation frequency was analyzed

Materials and Methods

Retrospective explorative analysis was carried out for patients admitted to ICU from January 2011 to January 2012. Information from medical records for the above parameters was extracted and descriptive statistics was used for assessing the outcomes.

Results:

In the present study, there was a higher incidence of self-extubation in ventilated ICU patients during the changeover periods of the ICU staff. There was no relation of frequency of self-extubation with the medications used for sedation once the sedation was titrated to a common endpoint. A higher incidence of self-extubation was seen in the surgical and younger age group of patients.

Conclusions:

It is recommended that the duty shift finishing time of ICU staff (medical and paramedical) staff should be staggered and should have minimal overlap to prevent self-extubation. A continuous reassessment of level of sedation of patients independent of the type sedative medication should be carried out.

Sedation and paralysis

Sedation is used almost universally in the care of critically ill patients, especially in those who require mechanical ventilatory support or other life-saving invasive procedures. This review will focus on the sedation strategies for critically ill patients and the pharmacology of commonly used sedative agents. The role of neuromuscular blocking agents in the ICU will be examined and the pharmacology of commonly used agents is reviewed. Finally a strategy for rational use of these sedative and neuromuscular blocking agents in critically ill patients will be proposed.

A review of the practice of sedation with inhalational anaesthetics in the intensive care unit with the AnaConDa(®) device

The intensive care unit (ICU) environment is often perceived to be hostile and frightening by patients due to unfamiliar surroundings coupled with presence of numerous personnel, monitors and other equipments as well as a loss of perception of time. Mechanical ventilation and multiple painful procedures that often need to be carried out in these critically ill patients add to their overall anxiety. Sedation is therefore required not only to allay the stress and anxiety, but also to allow for mechanical ventilation and other invasive therapeutic and diagnostic procedures to be performed. The conventional intravenous sedative agents used in ICUs suffer from problems of over sedation, tachyphylaxis, drug accumulation, organ specific elimination and often lead to patient agitation on withdrawal. All this tend to prolong the ventilatory as well as ICU and hospital discharge time, which increase the risk for infection and add to the overall increase in morbidity, mortality and hospital costs. In 2005, the anaesthetic conserving device (AnaConDa(®)) was marketed for ICU sedation with volatile anaesthetic agents. A number of trials have shown the effectiveness of using volatile anaesthetic agents for ICU sedation with the AnaConDa device. Compared with intravenous sedatives, use of volatile anaesthetic agents have resulted in shorter wake up and extubation time, lesser duration of mechanical ventilation and faster discharge from hospitals. This review shall focus on the benefits, technical pre-requisites and status of sedation with volatile anaesthetic agents in ICUs with the AnaConDa(®) device.

Replacement of fentanyl infusion by enteral methadone decreases the weaning time from mechanical ventilation: a randomized controlled trial

INTRODUCTION

Patients undergoing mechanical ventilation (MV) are frequently administered prolonged and/or high doses of opioids which when removed can cause a withdrawal syndrome and difficulty in weaning from MV. We tested the hypothesis that the introduction of enteral methadone during weaning from sedation and analgesia in critically ill adult patients on MV would decrease the weaning time from MV.

METHODS

A double-blind randomized controlled trial was conducted in the adult intensive care units (ICUs) of four general hospitals in Brazil. The 75 patients, who met the criteria for weaning from MV and had been using fentanyl for more than five consecutive days, were randomized to the methadone (MG) or control group (CG). Within the first 24 hours after study enrollment, both groups received 80% of the original dose of fentanyl, the MG received enteral methadone and the CG received an enteral placebo. After the first 24 hours, the MG received an intravenous (IV) saline solution (placebo), while the CG received IV fentanyl. For both groups, the IV solution was reduced by 20% every 24 hours. The groups were compared by evaluating the MV weaning time and the duration of MV, as well as the ICU stay and the hospital stay.

RESULTS

Of the 75 patients randomized, seven were excluded and 68 were analyzed: 37 from the MG and 31 from the CG. There was a higher probability of early extubation in the MG, but the difference was not significant (hazard ratio: 1.52 (95% confidence interval (CI) 0.87 to 2.64; P = 0.11). The probability of successful weaning by the fifth day was significantly higher in the MG (hazard ratio: 2.64 (95% CI: 1.22 to 5.69; P < 0.02). Among the 54 patients who were successfully weaned (29 from the MG and 25 from the CG), the MV weaning time was significantly lower in the MG (hazard ratio: 2.06; 95% CI 1.17 to 3.63; P < 0.004).

CONCLUSIONS

The introduction of enteral methadone during weaning from sedation and analgesia in mechanically ventilated patients resulted in a decrease in the weaning time from MV.

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.

Sedation in adults receiving mechanical ventilation: physiological and comfort outcomes

OBJECTIVE

To describe the relationships among sedation, stability in physiological status, and comfort during a 24-hour period in patients receiving mechanical ventilation.

METHODS

Data from 169 patients monitored continuously for 24 hours were recorded at least every 12 seconds, including sedation levels, physiological status (heart rate, respiratory rate, oxygen saturation by pulse oximetry), and comfort (movement of arms and legs as measured by actigraphy). Generalized linear mixed-effect models were used to estimate the distribution of time spent at various heart and respiratory rates and oxygen saturation and actigraphy intervals overall and as a function of level of sedation and to compare the percentage of time in these intervals between the sedation states.

RESULTS

Patients were from various intensive care units: medical respiratory (52%), surgical trauma (35%), and cardiac surgery (13%). They spent 42% of the time in deep sedation, 38% in mild/moderate sedation, and 20% awake/alert. Distributions of physiological measures did not differ during levels of sedation (deep, mild/moderate, or awake/alert: heart rate, P = .44; respirations, P = .32; oxygen saturation, P = .51). Actigraphy findings differed with level of sedation (arm, P < .001; leg, P = .01), with less movement associated with greater levels of sedation, even though patients spent the vast majority of time with no arm movement or leg movement.

CONCLUSIONS

Level of sedation most likely does not affect the stability of physiological status but does have an effect on comfort.

Analgosedation: A Paradigm Shift in Intensive Care Unit Sedation Practice

Objective:

To critically evaluate the use of analgosedation in the management of agitation in critically ill mechanically ventilated patients.

Data Sources:

Literature was accessed through MEDLINE (1948-November 2011) and Cochrane Library (2011, issue 1) using the terms analgosedation, analgosedation, or analgesia-based sedation alone or in combination with intensive care unit or critically ill. Reference lists of related publications were also reviewed.

Study Selection and Data Extraction:

All articles published in English were evaluated. Randomized controlled trials examining critically ill mechanically ventilated patients older than 18 years were included.

Data Synthesis:

Limitations of current sedation practices include serious adverse drug events, prolonged mechanical ventilation time, and intensive care unit (ICU) length of stay. Studies have demonstrated that analgosedation, a strategy that manages patient pain and discomfort first, before providing sedative therapy, results in improved patient outcomes compared to standard sedative-hypnotic regimens. Nine randomized controlled trials comparing remifentanil-based analgosedation to other commonly used agents (fentanyl, midazolam, morphine, and propofol) for ICU sedation and 1 trial comparing morphine to daily sedation interruption with propofol or midazolam were reviewed. Remifentanil is an ideal agent for analgosedation due to its easy titratability and organ-in dependent metabolism. When compared to sedative-hypnotic regimens, remifentanil-based regimens were associated with shorter duration of mechanical ventilation, more rapid weaning from the ventilator, and shorter ICU length of stay. Compared to fentanyl-based regimens, remifentanil had similar efficacy with the exception of increased pain requirements upon remifentanil discontinuation. Analgosedation was well tolerated, with no significant differences in hemodynamic stability compared to sedative-hypnotic regimens.

Conclusions:

Analgosedation is an efficacious and well-tolerated approach to management of ICU sedation with improved patient outcomes compared to sedative-hypnotic approaches. Additional well-designed trials are warranted to clarify the role of analgosedation in the management of ICU sedation, including trials with nonopioid analgesics.

Strategies in the prevention of ventilator-associated pneumonia

Ventilator-associated pneumonia (VAP) remains a significant problem in the hospital setting, with very high morbidity, mortality, and cost. We performed an evidence-based review of the literature focusing on clinically relevant pharmacological and nonpharmacological interventions to prevent VAP. Owing to the importance of this condition the implementation of preventive measures is paramount in the care of mechanically ventilated patients. There is evidence that these measures decrease the incidence of VAP and improve outcomes in the intensive care unit. A multidisciplinary approach, continued education, and ventilator protocols ensure the implementation of these measures. Future research will continue to investigate cost/benefit relationships, antibiotic resistance, as well as newer technologies to prevent contamination and aspiration in mechanically ventilated patients.