Clinical effectiveness of a sedation protocol minimizing benzodiazepine infusions and favoring early dexmedetomidine: a before-after study

Sedation, analgesia, and delirium management in Portugal: a survey and point prevalence study

OBJECTIVE

To establish current Portuguese critical care practices regarding analgesia, sedation, and delirium based on a comparison between the activities reported and daily clinical practice.

METHODS

A national survey was conducted among physicians invited to report their practice toward analgesia, sedation, and delirium in intensive care units. A point prevalence study was performed to analyze daily practices.

RESULTS

A total of 117 physicians answered the survey, and 192 patients were included in the point prevalence study. Survey and point prevalence studies reflect a high sedation assessment (92%; 88.5%), with the Richmond Agitated Sedation Scale being the most reported and used scale (41.7%; 58.2%) and propofol being the most reported and used medication (91.4%; 58.6%). Midazolam prescribing was reported by 68.4% of responders, but a point prevalence study revealed a use of 27.6%.Although 46.4% of responders reported oversedation, this was actually documented in 32% of the patients. The survey reports the daily assessment of pain (92%) using standardized scales (71%). The same was identified in the point prevalence study, with 91.1% of analgesia assessment mainly with the Behavioral Pain Scale. In the survey, opioids were reported as the first analgesic. In clinical practice, acetaminophen was the first option (34.6%), followed by opioids. Delirium assessment was reported by 70% of physicians but was performed in less than 10% of the patients.

CONCLUSION

The results from the survey did not accurately reflect the common practices in Portuguese intensive care units, as reported in the point prevalence study. Efforts should be made specifically to avoid oversedation and to promote delirium assessment.

Different depths of sedation versus risk of delirium in adult mechanically ventilated patients: A systematic review and meta-analysis

Background

Delirium is multifactorial. This study aimed at determining the association between different depths of sedation and the risk of delirium in adult mechanically ventilated patients.

Methods

A systematic literature retrieval was conducted in databases including Cochrane Central Register of Controlled Trials, PubMed, Embase, Cumulative Index to Nursing and Allied Health Literature for publications available till December 2019 without limitation in study type, and followed by a secondary retrieval for related literature. STATA15.1 and WinBugs 14.3 were used in statistical analyses for different sedation depths as the intervention. The main endpoint was delirium occurrence. Secondary endpoints were agitation-related adverse events and mortality.

Results

We included 18 studies comprising 8001 mechanically ventilated patients. Different sedation depths were not associated with the occurrence of delirium (OR = 1.00, 95%CI: 0.64–1.58, P = 0.993). Among the 18 enrolled studies, this finding was not confounded by the dosage of benzodiazepines (OR = 0.96, 95%CI: 0.79–1.17, P = 0.717) in eight randomized controlled trials(RCTs) or the patients’ disease severity(OR 0.95, 95%CI: 0.79–1.13, P = 0.548) in 10 RCTs. However, contrasting results were found in non-RCTs. The deeper sedation group had a significantly increased risk for death(OR = 1.82, 95% CI: 1.23–2.69, P = 0.003), whereas lighter sedation seemed a potential risk for agitation-related adverse events (OR = 0.61, 95%CI: 0.45–0.84, P = 0.002).

Conclusions

It is inconclusive whether significantly different sedation depths would change the risk of delirium in adult mechanically ventilated patients.

Trial registration number

The study was registered in PROSPERO(http://www.crd.york.ac.uk/PROSPERO/) under registration number CRD42019145276.

Sedation Depth is Associated with Increased Hospital Length of Stay in Mechanically Ventilated Air Medical Transport Patients: A Cohort Study

Background: Analgesics, sedatives, and neuromuscular blockers are commonly used medications for mechanically ventilated air medical transport patients. Prior research in the emergency department (ED) and intensive care unit (ICU) has demonstrated that depth of sedation is associated with increased mechanical ventilation duration, delirium, increased hospital length-of-stay (LOS), and decreased survival. The objectives of this study were to evaluate current sedation practices in the prehospital setting and to determine the impact on clinical outcomes. Methods: A retrospective cohort study of mechanically ventilated patients transferred by air ambulance to a single 812-bed Midwestern academic medical center from July 2013 to May 2018 was conducted. Prehospital sedation medications and depth of sedation [Richmond Agitation-Sedation Scale score (RASS)] were measured. Primary outcome was hospital LOS. Secondary outcomes were delirium, length of mechanical ventilation, in-hospital mortality, and need for neurosurgical procedures. Univariate analyses were used to measure the association between sedatives, sedation depth, and clinical outcomes. Multivariable models adjusted for potentially confounding covariates to measure the impact of predictors on clinical outcomes. Results: Three hundred twenty-seven patients were included. Among those patients, 79.2% of patients received sedatives, with 41% of these patients achieving deep sedation (RASS = -4). Among patients receiving sedation, 58.3% received at least one dose of benzodiazepines. Moderate and deep sedation was associated with an increase in LOS of 59% (aRR: 1.59; 95% CI: 1.40-1.81) and 24% (aRR: 1.24; 95% CI: 1.10-1.40), respectively. Benzodiazepines were associated with a mean increase of 2.9 days in the hospital (95% CI, 0.7-5.1). No association existed between either specific medications or depth of sedation and the development of delirium. Conclusions: Prehospital moderate and deep sedation, as well as benzodiazepine administration, is associated with increased hospital LOS. Our findings point toward sedation being a modifiable risk factor and suggest an important need for further research of sedation practices in the prehospital setting.

A Non-Comparative Prospective Pilot Study of Ketamine for Sedation in Adult Septic Shock

Introduction

Sedation and analgesia in the intensive care unit (ICU) for patients with sepsis can be challenging. Opioids and benzodiazepines can lower blood pressure and decrease respiratory drive. Ketamine is an N-methyl-D-aspartate (NMDA) receptor antagonist that provides both amnesia and analgesia without depressing respiratory drive or blood pressure. The purpose of this pilot study was to assess the effect of ketamine on the vasopressor requirement in adult patients with septic shock requiring mechanical ventilation.

Materials and Methods

We conducted a two-phase study in a multi-disciplinary adult ICU at a tertiary medical center. The first phase was a retrospective chart review of patients admitted with septic shock between July 2010 and July 2011; 29 patients were identified for a historical control group. The second phase was a prospective, non-randomized, open-label pilot study. Patients were eligible for inclusion if they were 18-89 yr of age with a diagnosis of septic shock, who also required mechanical ventilation for at least 24 h, concomitant sedation, and vasopressor therapy. Pregnant patients, patients in the peri-operative timeframe, and patients with acute coronary syndrome were excluded. Patients enrolled in the phase two pilot study received ketamine as the primary sedative. Ketamine was administered as a 1-2 mg/kg IV bolus, then as a continuous infusion starting at 5 mcg/kg/min, titrated 2 mcg/kg/min every 30 min as needed to obtain a Richmond Agitation Sedation Scale (RASS) goal of -1 to -2. If continuous sedation was still required after 48 h, patients were transitioned off ketamine and sedative strategy reverted to usual ICU sedation protocol. The primary outcome was the dose of vasopressor required at 24, 48, 72 and 96 h after enrollment. Secondary outcomes included cumulative ketamine dose, additional sedative and analgesics used, cumulative sedative and analgesic dosing at all time periods, corticosteroid use, days of mechanical ventilation, ICU LOS, hospital LOS, and mortality. Contiguous data were analyzed with unpaired t-tests and categorical data were analyzed with two-tailed, Fisher's exact test. This study was approved by our Institutional Review Board.

Results

From January 2012 to April 2015, a total of 17 patients were enrolled. Patient characteristics were similar in the control and study group. Ketamine was discontinued in one patient due to agitation at 36 h. There was a trend towards decreased norepinephrine and vasopressin use in the study group at all time periods. Regarding secondary outcomes, the study group received less additional analgesia with fentanyl at 24 and 48 h (p < 0.001), and less additional sedation with lorazepam, midazolam or dexmedetomidine at 24 h (p = 0.015).

Conclusion

This pilot study demonstrated a trend towards decreased vasopressor dose, and decreased benzodiazepine and opiate use when ketamine is used as the sole sedative. The limitations to our study include a small sample size and those inherent in using a retrospective control group. Our findings should be further explored in a large, randomized prospective study.

Is It Time for an Expanded Role of Dexmedetomidine in Contemporary Anesthesia Practice? - A Clinician's Perspective

Since its approval by US Food and Drug Administration in 1999 the clinical use of dexmedetomidine has been gaining in popularity. The indications and clinical applications of this drug have been expanded significantly. In this paper we reviewed its pharmacokinetics, pharmacodynamics, mechanisms of action and mainly focused on its clinical uses and outcomes. Common clinical uses of dexmedetomidine include pre-operative anxiolysis, heart rate control during intubation, treatment of bronchospasm, prevention of laryngospasm and avoiding opioid-induced post-operative respiratory depression and nausea and vomiting. Avoiding opioid induced respiratory depression has been especially beneficial in patients with sleep apnea syndrome. Other problems that can be prevented with dexmedetomidine are tachydysrhythmias, myocardial ischemia, delirium and acute kidney injury. Dexmedetomidine is an excellent sedative drug for intubated patients and it greatly facilitates neurological evaluation. It has been used successfully as a patient-controlled anesthesia drug and to prevent shivering. It is also used as an adjuvant to local anesthetics. It has been suggested that dexmedetomidine is a drug that has many beneficial effects and should be used more frequently by anesthesia care providers to prevent common problems in the peri-operative period. With judicious titration to effect during the intravenous administration of this drug the occurrence of side effects can be minimized. It is very likely that this drug will ascend to take a much more prominent role in future anesthesia practice.

A National Multicenter Survey on Management of Pain, Agitation, and Delirium in Intensive Care Units in China

Background:

The management of pain, agitation, and delirium (PAD) in Intensive Care Unit (ICU) is beneficial for patients and makes it widely applied in clinical practice. Previous studies showed that the clinical practice of PAD in ICU was improving; yet relatively little information is available in China. This study aimed to investigate the practice of PAD in ICUs in China.

Methods:

A multicenter, nationwide survey was conducted using a clinician-directed questionnaire from September 19 to December 18, 2016. The questionnaire focused on the assessment and management of PAD by the clinicians in ICUs. The practice of PAD was compared among the four regions of China (North, Southeast, Northwest, and Southwest). The data were expressed as percentage and frequency. The Chi-square test, Fisher's exact test, and line-row Chi-square test were used.

Results:

Of the 1011 valid questionnaire forms, the response rate was 80.37%. The clinicians came from 704 hospitals across 158 cities of China. The rate of PAD assessment was 75.77%, 90.21%, and 66.77%, respectively. The rates of PAD scores were 45.8%, 68.94%, and 34.03%, respectively. The visual analog scale, Richmond agitation-sedation scale, and confusion assessment method for the ICU were the first choices of scales for PAD assessment. Fentanyl, midazolam, and dexmedetomidine were the first choices of agents for analgesic, sedation, and delirium treatment. While choosing analgesics and sedatives, the clinicians put the pharmacological characteristics of drugs in the first place (66.07% and 76.36%). Daily interruption for sedation was carried out by 67.26% clinicians. Most of the clinicians (87.24%) used analgesics while using sedatives. Of the 738 (73%) clinicians titrating the sedatives on the basis of the proposed target sedation level, 268 (26.61%) clinicians just depended on their clinical experience. Totally, 519 (51.34%) clinicians never used other nondrug strategies for PAD. The working time of clinicians was an important factor in the management of analgesia and sedation rather than their titles and educational background. The ratios of pain score and sedation score in the Southwest China were the highest and the North China were the lowest. The ratios of delirium assessment and score were the same in the four regions of China. Moreover, the first choices of scales for PAD in the four regions were the same. However, the top three choices of agents in PAD treatment in the four regions were not the same.

Conclusions:

The practice of PAD in China follows the international guidelines; however, the pain assessment should be improved. The PAD practice is a little different across the four regions of China; however, the trend is consistent.

Trial Registration:

The study is registered at http://www.clinicaltrials.gov (No. ChiCTR-OOC-16009014, www.chictr.org.cn/index.aspx.).

Avaliação metabólica e hemodinâmica de dois protocolos de sedação prolongada em cães

RESUMO Objetivou-se determinar a viabilidade de dois protocolos de sedação para ventilação prolongada em cães e seus efeitos hemodinâmicos e metabólicos. Doze cães, alocados aleatoriamente em dois grupos (n=6), receberam infusão contínua de midazolam (0,5mg/kg/h), fentanil (10µg/kg/h) e propofol (18mg/kg/h) no GMF ou cetamina (0,6mg/kg/h), morfina (0,26mg/kg/h) e propofol (18mg/kg/h) no GCM, durante 24 horas. Os cães foram ventilados mecanicamente com FiO2 de 40%, mantendo-se a normocapnia. A FC diminuiu 32% no GMF e 34% no GCM ao longo do tempo, reduzindo o IC em 24% no GMF e em 29% no GCM. A CaO2, o CvmO2, a DO2 e o VO2 diminuíram no GCM (5%, 16%, 31% e 7%) e no GMF (4%, 19%, 26% e 15%), respectivamente. A TEO2 aumentou 32% no GMF e 36% no GCM, sem diferenças entre grupos, porém a calorimetria indireta demonstrou diminuição do VO2, minimizando a redução da DO2. Não houve diferença entre os tempos para extubação, deambulação e recuperação total, com médias globais (minutos) de 33,8±15,9, 134,8±60,7 e 208±77,5, respectivamente. Conclui-se que ambos os protocolos permitiram a ventilação mecânica, com redução do IC e da DO2, porém sem prejuízos hemodinâmicos e metabólicos, podendo ser utilizados com segurança em cães hígidos.

Dexmedetomidine: Current Role in Burn ICU

Dexmedetomidine (DEX) is a relativelyrecent a₂-adrenergic agonist which provides sedation, anxiolysis and analgesia with much less respiratory depression than other sedatives. These characteristics have implemented the use of the drug in the ICUs in order to achieve the target of a "arousable sedation", thanks to its significant manageability. Its sedative-analgesic properties are also particularly suitable for use in burn ICUs, both adult and pediatric, which is why the current Guidelines have recognized a central role in the management of these categories of patients. Finally, DEX has showed significant anti-inflammatory effect both in animal models and in preliminary clinical trials, reducing vasopressor requirements and main mediators levels of the systemic inflammatory response involved in sepsis and similar processes, suggesting its use for improved outcome in ICU septic patients.

Experienced Use of Dexmedetomidine in the Intensive Care Unit: A Report of a Structured Consensus

Objective

Management of pain, agitation and delirium (PAD) remains to be a true challenge in critically ill patients. The pharmacological proprieties of dexmedetomidine (DEX) make it an ideal candidate drug for light and cooperative sedation, but many practical questions remain unanswered. This structured consensus from 17 intensivists well experienced on PAD management and DEX use provides indications for the appropriate use of DEX in clinical practice.

Methods

A modified RAND/UCLA appropriateness method was used. In four predefined patient populations, the clinical scenarios do not properly cope by the current recommended pharmacological strategies (except DEX), and the possible advantages of DEX use were identified and voted for agreement, after reviewing literature data.

Results

Three scenarios in medical patients, five scenarios in patients with acute respiratory failure undergoing non-invasive ventilation, three scenarios in patients with cardiac surgery in the early postoperative period and three scenarios in patients with overt delirium were identified as challenging with the current PAD strategies. In these scenarios, the use of DEX was voted as potentially useful by most of the panellists owing to its specific pharmacological characteristics, such as conservation of cognitive function, lack of effects on the respiratory drive, low induction of delirium and analgesia effects.

Conclusion

DEX might be considered as a first-line sedative in different scenarios even though conclusive data on its benefits are still lacking.

Treatment of Severe Alcohol Withdrawal

OBJECTIVE

Approximately 50% of patients with alcohol dependence experience alcohol withdrawal. Severe alcohol withdrawal is characterized by seizures and/or delirium tremens, often refractory to standard doses of benzodiazepines, and requires aggressive treatment. This review aims to summarize the literature pertaining to the pharmacotherapy of severe alcohol withdrawal.

DATA SOURCES

PubMed (January 1960 to October 2015) was searched using the search termsalcohol withdrawal, delirium tremens, intensive care, andrefractory Supplemental references were generated through review of identified literature citations.

STUDY SELECTION AND DATA EXTRACTION

Available English language articles assessing pharmacotherapy options for adult patients with severe alcohol withdrawal were included.

DATA SYNTHESIS

A PubMed search yielded 739 articles for evaluation, of which 27 were included. The number of randomized controlled trials was limited, so many of these are retrospective analyses and case reports. Benzodiazepines remain the treatment of choice, with diazepam having the most favorable pharmacokinetic profile. Protocolized escalation of benzodiazepines as an alternative to a symptom-triggered approach may decrease the need for mechanical ventilation and intensive care unit (ICU) length of stay. Propofol is appropriate for patients refractory to benzodiazepines; however, the roles of phenobarbital, dexmedetomidine, and ketamine remain unclear.

CONCLUSIONS

Severe alcohol withdrawal is not clearly defined, and limited data regarding management are available. Protocolized administration of benzodiazepines, in combination with phenobarbital, may reduce the need for mechanical ventilation and lead to shorter ICU stays. Propofol is a viable alternative for patients refractory to benzodiazepines; however, the role of other agents remains unclear. Randomized, prospective studies are needed to clearly define effective treatment strategies.