986: HOW ARE WE OVERSEDATING OUR MECHANICALLY VENTILATED PATIENTS IN THE MICU AT A TERTIARY CARE CENTER?

Abstract

Introduction: Endotracheal intubation and invasive mechanical ventilation are distressing interventions in the Medical Intensive care Unit (MICU). Mechanically ventilated patients often receive analgesic and sedative medications to reduce agitation and pain. According to recommendations in the Society of Critical Care (SCC) PADIS guidelines, sedatives should be used only when pain and delirium have been addressed with specific pharmacologic and non-pharmacologic strategies. Despite this, we observe that many mechanically ventilated MICU patients are sedated on a routine basis without any clear indication. Methods: We performed a retrospective medical chart review of patients above 18 years of age who were intubated for more than 24 hours between January 2020 till October 2021. We analyzed indications for intubation and excluded patients requiring a deep level of sedation from the final study sample. We analyzed the type and number of sedatives initiated in the first 24 hours of intubation, associated RASS parameters set for sedation titration and its monitoring frequency by nurses, and the effect of our practices on intubation and hospitalization outcomes. Statistical analysis was performed using SPSS and SAS. Results: Of the 281 patients, 83% received fentanyl, 66% received propofol or dexmedetomidine, and 33% received midazolam in the first 24 hours. About 53% and 11% of patients were simultaneously started on a 2- and 3-agents sedative regimen in the first 24 hours, respectively. The most common upper and lower RASS limits for sedation titration were set at 0 and -3, respectively. The average frequency of nurses’ RASS documentation was once every 10 hours. There was a positive correlation between the number of sedative agents used in the first 24 hours and the associated length of intubation, hospitalization, and extubation failure. Furthermore, the use of benzodiazepine led to a higher rate of extubation failure, length of intubation, and hospitalization. Conclusions: In the absence of clear medical indication for deep sedation and appropriate sedation administration and titration parameter protocol, the indiscriminate use of sedatives leads to poor patient outcomes. There is a dire need to implement sedation protocols in institutions to standardize practices and improve sedation performance metric.