596 ICU Sedation Practices for Mechanically Ventilated Burn Patients Following Guideline Implementation

Abstract

Abstract Introduction Our American Burn Association verified regional burn center has approximately 700 admissions for burn injury per year, 200 of which are admitted to the burn intensive care unit (BICU). Sedation practices during acute burn resuscitations remain variable. In order to standardize our sedation practices, we developed a Background Pain and Anxiety Decision Tree for Mechanically Intubated Adults in March 2017. Concern over hypotension led to the removal of propofol as the sedative of choice. The new protocol made midazolam the primary choice and recommended the use of adjunct analgesics, including acetaminophen, for background pain. It uses the Richmond Agitation Sedation Scale (RASS) to determine whether patients were oversedated (RASS< 0) or anxious (RASS >1+). Methods We conducted a single center retrospective chart review on intubated patients admitted to the BICU from November 2017 through November 2018. Data collection focused primarily on sedation practices during this time to determine whether our protocol had the desired effects. Highest and lowest RASS were collected, and the difference between the two (delta RASS) was used to determine changes in patient agitation and sedation. Results Thirty three adult patients requiring mechanical ventilation were admitted to the BICU between November 2017 and November 2018. Of these patients, 21 (66%) received propofol on hospital day one, and 12 (38%) received propofol on hospital day two. Eleven patients received both propofol and midazolam on hospital day one. Of these patients, the average propofol dose was 511 micrograms per day and the average midazolam dose was 13.3mg per day (p=0.02). Eighteen (56%) and twenty five (78%) patients received acetaminophen on hospital days one and two, respectively. Twenty four patients had a RASS recorded during their first hospital day. The average highest RASS recorded was 1.3 and the average lowest recorded RASS was -3.2. Patients who received both propofol and midazolam had a higher peak RASS (2.4) and a lower minimum RASS (3.4), creating a larger delta RASS for this group. Conclusions Despite eliminating propofol from our sedation guidelines, its use remains the predominant mode of sedation for burn patients throughout the first forty eight hours of hospitalization. There is also room for improvement for administration of non-opioid analgesics, including acetaminophen. Finally, our ventilated patients tend to be more oversedated than undersedated, and a combination of midazolam and propofol creates the largest swings in patients’ sedation and agitation status. Applicability of Research to Practice Changing sedation and pain management practices in the ICU is a multifactorial process that requires more than ICU guideline implementation. The use of two sedatives during the first hospital day can result in larger swings in RASS as opposed to use of a single agent.