Abstract
Purpose: To investigate physicians' perception of patients' tolerance levels regarding sedation, which could affect sedation practice for mechanically ventilated (MV) patients.Methods: This is a questionnaire survey combined with a 24 h cross-sectional study. The physician's propensity score for light sedation (PS-LS) was estimated by his/her response to the given answers for each item of the questionnaire, which tested the levels of interviewee's desire to manage MV patient with light sedation. Thereby, the mean physicians' PS-LS of each participating ICU (ICU-meanPS-LS) was calculated. The practical measurements of all variables listed on the questionnaire were used to semi-quantitatively assess stimulus intensity of what the recruited patients suffered (i.e., semi-quantitative stimulus intensity, SSI). Sedation depth was assessed by Richmond Agitation Sedation Scale (RASS).Results: 555 of 558 (99.5%) physicians from 102 ICUs were concerned with patients' tolerance levels regarding sedation while titrating sedation depth. The physician's PS-LS was non-normally distributed with median (IQR) of 3 (0–5). ICU-meanPS-LS was calculated in 92 out of 102 ICUs participating in the cross-sectional study, which was ranged from −5 to 7 with a median (IQR) of 2.37 (0.16–4.33). A significant increasing trend in prevalence of light sedation was observed over increasing ICU-meanPS-LS quartiles (from Q1 to Q4, χ2-test for trend, p = 0.002). Moreover, odds ratio for probability of light sedation remained significant in MV patients from Q4 ICUs vs. Q1 ICUs, adjusted by APACHE II score (OR, 2.332; 95% CI: 1.463–3.717; p < 0.001) or SSI score (OR, 2.445; 95% CI: 1.468–4.074; p = 0.001). Notably, adjusted OR for mortality was significant in deeply sedated MV patients (OR, 2.034; 95% CI: 1.435–2.884; p < 0.001).Conclusions: ICU physician's individualized perception for patients' tolerance levels regarding sedation, in light sedation affected sedation practice for MV patients.
Highlights
ICU-meanPS-LS was calculated in 92 out of 102 ICUs participating in the cross-sectional study, which was ranged from −5 to 7 with a median (IQR) of 2.37 (0.16–4.33)
Odds ratio for probability of light sedation remained significant in mechanically ventilated (MV) patients from Q4 ICUs vs. Q1 ICUs, adjusted by APACHE Acute Physiology and Chronic Health Evaluation II (II) score (OR, 2.332; 95% CI: 1.463–3.717; p < 0.001) or stimulus intensity (SSI) score (OR, 2.445; 95% CI: 1.468–4.074; p = 0.001)
While deep sedation has been associated with morbidity and mortality in mechanically ventilated (MV) patients [1,2,3], increasing data suggest that targeting lighter levels of sedation (RASS −2 ∼ +1, Richmond Agitation Sedation Scale) could be beneficial to reduce ICU stay and ventilator days [4,5,6]
Summary
While deep sedation has been associated with morbidity and mortality in mechanically ventilated (MV) patients [1,2,3], increasing data suggest that targeting lighter levels of sedation (RASS −2 ∼ +1, Richmond Agitation Sedation Scale) could be beneficial to reduce ICU stay and ventilator days [4,5,6]. Recently published studies demonstrated that up to 65% MV patients continued to score deep sedation (RASS ≤ −3) [3, 10,11,12], which suggested that the recommendation for promoting lighter sedation is far from being implemented well. Agitation or agitated adverse events were observed more frequently in the arm of patients who were sedated at the lighter target than the usual care in several published randomized control trials (RCTs) [4,5,6, 20]. Evidence regarding ICU physicians’ concerns about patients’ tolerance levels in light sedation remain limited. A questionnaire survey combined with a cross-sectional study were conducted, hypothesizing that ICU physician’s perception for patient’s tolerance levels in light sedation was individualized, which impacted decision-making on implementation of minimizing sedation strategy for MV patients
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