Daily Sedation Research Articles

Respiratory Review of 2013: Critical Care Medicine

Several papers on respiratory and critical care published from March 2012 to February 2013 were reviewed. From these, this study selected and summarized ten articles, in which the findings were notable, new, and interesting: effects of high-frequency oscillation ventilation on acute respiratory distress syndrome (ARDS); safety and efficacy of hydroxyethyl starch as a resuscitation fluid; long-term psychological impairments after ARDS; safety and efficacy of dexmedetomidine for sedation; B-type natriuretic peptide-guided fluid management during weaning from mechanical ventilation; adding of daily sedation interruptions to protocolized sedations for mechanical ventilation; unassisted tracheostomy collar of weaning from prolonged mechanical ventilations; and effects of nighttime intensivist staffing on the hospital mortality rates.

Acquired Neuromuscular Weakness and Early Mobilization in the Intensive Care Unit

Survival from critical illness has improved in recent years, leading to increased attention to the sequelae of such illness. Neuromuscular weakness in the intensive care unit (ICU) is common, persistent, and has significant public health implications. The differential diagnosis of weakness in the ICU is extensive and includes critical illness neuromyopathy. Prolonged immobility and bedrest lead to catabolism and muscle atrophy, and are associated with critical illness neuromyopathy and ICU-acquired weakness. Early mobilization therapy has been advocated as a mechanism to prevent ICU-acquired weakness. Early mobilization is safe and feasible in most ICU patients, and improves outcomes. Implementation of early mobilization therapy requires changes in ICU culture, including decreased sedation and bedrest. Various technologies exist to increase compliance with early mobilization programs. Drugs targeting muscle pathways to decrease atrophy and muscle-wasting are in development. Additional research on early mobilization in the ICU is needed.

Daily Sedation Interruption in Mechanically Ventilated Critically Ill Patients Cared for With a Sedation Protocol

Protocolized sedation and daily sedation interruption are 2 strategies to minimize sedation and reduce the duration of mechanical ventilation and intensive care unit (ICU) stay. We hypothesized that combining these strategies would augment the benefits. To compare protocolized sedation with protocolized sedation plus daily sedation interruption in critically ill patients. Randomized controlled trial of 430 critically ill, mechanically ventilated adults conducted in 16 tertiary care medical and surgical ICUs in Canada and the United States between January 2008 and July 2011. Continuous opioid and/or benzodiazepine infusions and random allocation to protocolized sedation (n = 209) (control) or to protocolized sedation plus daily sedation interruption (n = 214). Using validated scales, nurses titrated infusions to achieve light sedation. For patients receiving daily interruption, nurses resumed infusions, if indicated, at half of previous doses. Patients were assessed for delirium and for readiness for unassisted breathing. Time to successful extubation. Secondary outcomes included duration of stay, doses of sedatives and opioids, unintentional device removal, delirium, and nurse and respiratory therapist clinical workload (on a 10-point visual analog scale [VAS]). Median time to successful extubation was 7 days in both the interruption and control groups (median [IQR], 7 [4-13] vs 7 [3-12]; interruption group hazard ratio, 1.08; 95% CI, 0.86-1.35; P = .52). Duration of ICU stay (median [IQR], 10 [5-17] days vs 10 [6-20] days; P = .36) and hospital stay (median [IQR], 20 [10-36] days vs 20 [10-48] days; P = .42) did not differ between the daily interruption and control groups, respectively. Daily interruption was associated with higher mean daily doses of midazolam (102 mg/d vs 82 mg/d; P = .04) and fentanyl (median [IQR], 550 [50-1850] vs 260 [0-1400]; P < .001) and more daily boluses of benzodiazepines (mean, 0.253 vs 0.177; P = .007) and opiates (mean, 2.18 vs 1.79; P < .001). Unintentional endotracheal tube removal occurred in 10 of 214 (4.7%) vs 12 of 207 patients (5.8%) in the interruption and control groups, respectively (relative risk, 0.82; 95% CI, 0.36-1.84; P = .64). Rates of delirium were not significantly different between groups (53.3% vs 54.1%; relative risk, 0.98; 95% CI, 0.82-1.17; P = .83). Nurse workload was greater in the interruption group (VAS score, 4.22 vs 3.80; mean difference, 0.41; 95% CI, 0.17-0.66; P = .001). For mechanically ventilated adults managed with protocolized sedation, the addition of daily sedation interruption did not reduce the duration of mechanical ventilation or ICU stay. clinicaltrials.gov Identifier: NCT00675363.

The Changing Landscape of ICU Sedation

INTUBATION AND MECHANICAL VENTILATION ARE ESSENtial components of modern intensive care. However, they are also uncomfortable and often intolerable for the patient. Therefore, intensive care clinicians typically prescribe sedation for ventilated patients, hoping to ensure comfort and yet avoid excess or prolonged unconsciousness. Two decades ago, the typical approach was to provide sedation via continuous infusion, with a focus on ensuring comfort and with little awareness of the adverse effects of excessive sedative use in the intensive care unit (ICU). However, as reports emerged showing such infusions could unnecessarily prolong the duration of mechanical ventilation and intensive care, a variety of evidence-based sedation algorithms for mechanically ventilated patients evolved. Nursing-directed drug titration algorithms and daily sedation interruption (“sedation holiday”) are 2 common strategies currently used. Compared with traditional usual care, both of these strategies reduce the duration of mechanical ventilation and length of stay in the ICU and hospital. However, the 2 strategies are quite different from each other and it is unclear which is better. Two small studies reported divergent results, with one favoring daily sedative interruption and the other favoring algorithmic titration by bedside nurses. In this issue of JAMA, Mehta and colleagues present the results of a large multicenter clinical trial conducted among critically ill patients receiving mechanical ventilation in 16 tertiary care medical and surgical ICUs in Canada and the United States. The authors compared protocolized sedation (209 patients) vs protocolized sedation plus daily sedation interruption (214 patients) and used benzodiazepines (midazolam or lorazepam) for sedation and opiates (fentanyl, morphine, or hydromorphone) for analgesia. There were no significant differences between the protocolized sedation and the protocolized sedation plus daily interruption groups in time to extubation (median, 7 days) or length of ICU stay (median, 10 days) or hospital stay (median, 20 days). In addition, there were no differences in the rates of unintentional removal of medical devices, ICU delirium, diagnostic neuroimaging, or tracheostomy. Patients randomized to daily sedation interruption received more midazolam and fentanyl and had higher perceived nurse (although not respiratory therapist) workload scores. This study was conducted by experienced ICU clinical investigators in a large, multicenter format. The study design was methodologically sound, with the potential for relatively widespread applicability. Interpretation of the results of this trial requires consideration of several interrelated issues. First, the rapidly changing critical care evidence base can influence interpretation and relevance of trial results, particularly large trials that may take years to design and complete. This trial began enrolling patients in January 2008. At the time the trial was designed (presumably 2007 or earlier), the use of benzodiazepines for ICU sedation was common. The Society of Critical Care Medicine (SCCM) Sedative and Analgesia Guidelines from 2002 recommended benzodiazepines (lorazepam) for sedation of most patients; however, more recent evidence suggests that benzodiazepines may not be the optimal agents for ICU sedation. The updated 2012 Evidence-Based SCCM Guidelines for the Management of Pain, Agitation and Delirium will be published later this year. An overview of these guidelines presented at the 2012 SCCM Congress meeting included a recommendation that non-benzodiazepine sedatives (eg, propofol or dexmedetomidine) are preferable to benzodiazepines (eg, midazolam or lorazepam). Second, in the first trial of daily sedation interruption in 2000, the average daily dose for patients randomized to midazolam was 47 mg in the sedation interruption group vs 58 mg in the control group (P=.05). In contrast, in the current trial, these average daily doses were 102 mg vs 82 mg, respectively (P=.04). This is important because the average daily dose of 102 mg of midazolam for the sedation interruption group was more than twice that recorded in the original trial. In addition, the group assigned to daily sedative interruption in the current trial received significantly more midazolam than the control group did. Given the propensity for midazolam to accumulate in ICU patients receiving prolonged administration, it is possible that such higher midazolam doses may have offset the effects of sedation interruption.

Daily Interruptions of Sedation: A Clinical Approach to Improve Outcomes in Critically Ill Patients

The continuous infusion of sedative agents is often necessary for critically ill patients. However, it has been associated with several disadvantages. Numerous interventions to reduce these risks have been evaluated, including the practice of interrupting sedative infusions on a daily basis. A literature search was conducted, and 7 studies were reviewed to evaluate the safety and effectiveness of daily interruption of sedative infusions and its outcomes. The implementation of daily sedation interruptions was suggested to minimize multiple complications associated with continuous sedative infusions and was not associated with intensive care-related complications or long-term psychological effects. Additional studies have revealed perceived barriers to the implementation of daily sedation interruptions. Further randomized controlled trials enrolling larger, more diverse samples are needed to provide more evidence regarding the safety and effectiveness of this intervention.

Meta-Analysis of Randomised Controlled Trials on Daily Sedation Interruption for Critically Ill Adult Patients

Sedation is often used to improve comfort, reduce anxiety and stress and to facilitate nursing care of critically ill patients in the intensive care unit. This meta-analysis examined the benefits and risks of daily sedation interruption in critically ill adult patients. A total of five randomised controlled trials, comparing daily sedation interruption with no interruption in 699 critically ill patients, from the Cochrane controlled trials register, Embase and MEDLINE databases (1966 to April 2010) were identified and subject to meta-analysis. With the limited data available, daily sedation interruption was not associated with a significant reduction in duration of mechanical ventilation, length of intensive care unit and hospital stay, or mortality. Daily sedation interruption was associated with a reduced risk of requiring tracheostomy (odds ratio 0.57, 95% confidence interval 0.35 to 0.92, P = 0.02; F = 3%) but not an increased risk of removal of the endotracheal tube by the patients (odds ratio 1.3, 95% confidence interval 0.41 to 4.10, P = 0.65; F = 49%). The current evidence suggests that daily sedation interruption appears to be safe, but the significant heterogeneity and small sample sizes of the existing studies suggest that large randomised controlled studies with long-term survival follow-up are needed before daily sedation interruption can be recommended as a standard sedation practice for critically ill adult patients.

Daily Sedation Interruption; A Glass Half Empty?

The last decade witnessed an exponential rise in the number of publications addressing management of sedation during critical illness. In 1998 Kollef and colleagues1 suggested that the use of continuous infusions of sedatives may be associated with prolonged duration of mechanical ventilation and intensive care unit (ICU) stay. This was followed by a landmark study by Kress and colleagues2 who demonstrated significant reduction in ventilation time and ICU stay with daily interruption of sedative infusions (DSI). Subsequent investigations have been consistent with the notion that strategies that reduce sedation depth such as algorithms and protocols for sedation management3-5 and the use of validated sedation scales6 can improve patient outcomes. This academic exuberance led to an endorsement of these strategies, and in particular DSI, by the UK Department of Health ( www.clean-safe-care.nhs.uk ), the Institute for Healthcare Improvement ( www.IHI.org ) and Safer Health Care Now! ( www.saferhealthcarenow.ca ).

Effect of Daily Sedative Interruption on Sleep Stages of Mechanically Ventilated Patients Receiving Midazolam by Infusion

Daily sedative interruption (DSI) may reduce excessive sedation and shorten the duration of mechanical ventilation. It is not clear, however, how DSI affects sleep characteristics. For patients receiving mechanical ventilation, we compared the effect on sleep quality of DSI and continuous sedation (CS). Twenty-two mechanically ventilated patients who were receiving midazolam by infusion were randomly assigned to two groups, DSI (n = 11) or CS (n = 11). In the DSI group, sedatives were interrupted until the patients awoke and expressed discomfort, after which midazolam or opioids were administered intermittently as needed during the daytime (0600 to 2100 hours); during the night (2100 to 0600) midazolam was administered intravenously to maintain Ramsay sedation scale 4 to 5. In the CS group, the sedatives were titrated to obtain Ramsay sedation scale 4 to 5 throughout the day. The polysomnography of each patient was recorded continuously over a 24 hour period. Sleep stages were analysed using Rechtschaffen and Kales criteria. In the DSI group, the amount of stage 3 and 4 non-rapid eye movement sleep (slow wave sleep) was longer (6 vs 0 minutes, P = 0.04) and rapid eye movement sleep was longer than in CS (54 vs 0 minutes, P = 0.02). In the CS group, total sleep time during night-time was longer (8.7 vs 7.3 hours, P = 0.047) and frequency of arousal was lower (2.2 vs 4.4 event/hour, P = 0.03) than those in the DSI group. All mechanically ventilated patients demonstrated abnormal sleep architecture, but, compared with CS, DSI increased the amount of slow wave sleep and rapid eye movement sleep.

The complex interplay between delirium, sedation, and early mobility during critical illness: applications in the trauma unit.

Critically ill patients are prescribed sedatives and analgesics to decrease pain and anxiety, improve patient-ventilator dyssynchrony and ensure patient safety. These medications may themselves lead to delirium and ICU-acquired weakness, which are associated with worse clinical outcomes. This review will focus on the epidemiology of these two disease processes and discuss strategies aimed at reducing these devastating complications of critical illness. Delirium and ICU-acquired weakness are associated with longer hospital stay, increased cost and decreased quality of life after discharge from the ICU. Delirium has also shown to be associated with increased mortality. Strategies aimed at reducing sedative exposure through protocols and coordination of daily sedation and ventilator cessation trials, avoiding benzodiazepines in favor of alternative sedative regimens and early mobilization of patients have all shown to significantly improve patient outcomes. Delirium and ICU-acquired weakness are complications of critical illness associated with worse clinical outcomes and functional decline in survivors. An evidence-based approach based on the following tenets - minimization of sedative medication, particularly benzodiazepines, delirium monitoring and management and early mobilization may mitigate these complications.

Change in hypnotic sedative choice over time as a surrogate marker of improved performance

Daily sedation holds, particularly when combined with protocolised spontaneous breathing trials, are one of the only strategies available to intensivists that produce an outcome benefit [1]. This evidence has also provoked a renewed interest in the choice of both hypnotic and analgesic agents. Midazolam is known to produce unpredictable awakening and may prolong time to extubation when infusions continue longer than 48 to 72 hours. In contrast, propofol may enhance the benefit to critically ill patients of the daily sedation hold due to its pharmacokinetic properties [2]. This study examines the hypothesis that the ratio of propofol/midazolam use can be used as a surrogate marker of good practice and utilises the potential of the pharmacy procurement database.

Feasibility of physical and occupational therapy beginning from initiation of mechanical ventilation*

Physical and occupational therapy are possible immediately after intubation in mechanically ventilated medical intensive care unit patients. The objective of this study was to describe a protocol of daily sedative interruption and early physical and occupational therapy and to specify details of intensive care unit-based therapy, including neurocognitive state, potential barriers, and adverse events related to this intervention. Detailed descriptive study of the intervention arm of a trial of mechanically ventilated patients receiving early physical and occupational therapy. Two tertiary care academic medical centers participating in a randomized controlled trial. Patients underwent daily sedative interruption followed by physical and occupational therapy every hospital day until achieving independent functional status. Therapy began with active range of motion and progressed to activities of daily living, sitting, standing, and walking as tolerated. Forty-nine mechanically ventilated patients received early physical and occupational therapy occurring a median of 1.5 days (range, 1.0-2.1 days) after intubation. Therapy was provided on 90% of MICU days during mechanical ventilation. While endotracheally intubated, subjects sat at the edge of the bed in 69% of all physical and occupational therapy sessions, transferred from bed to chair in 33%, stood in 33%, and ambulated during 15% (n = 26 of 168) of all physical and occupational therapy sessions (median distance of 15 feet; range, 15-20 feet). At least one potential barrier to mobilization during mechanical ventilation (acute lung injury, vasoactive medication administration, delirium, renal replacement therapy, or body mass index ≥ 30 kg/m) was present in 89% of patient encounters. Therapy was interrupted prematurely in 4% of all sessions, most commonly for patient-ventilator asynchrony and agitation. Early physical and occupational therapy is feasible from the onset of mechanical ventilation despite high illness acuity and presence of life support devices. Adverse events are uncommon, even in this high-risk group.

Recall of intensive care unit stay in patients managed with a sedation protocol or a sedation protocol with daily sedative interruption: A pilot study

Purpose Analgesics and sedatives are integral for the relief of pain and anxiety in critically ill patients. However, these agents may contribute to amnesia for intensive care unit (ICU) events; which has been associated with development of posttraumatic stress disorder. Drug administration strategies that minimize sedative use have been associated with less amnesia. The objective of this pilot study was to evaluate recall of ICU stay in patients managed with 2 sedation strategies: a sedation protocol or a combination of sedation protocol and daily sedative/analgesic interruption. Methods A questionnaire was administered on day 3 following ICU discharge to evaluate patients' recollections of pain, anxiety, fear, and sleep, as well as memories for specific ICU procedures. Participants were ICU survivors who had been enrolled in SLEAP - a randomized pilot trial comparing two sedation strategies, at 3 university-affiliated medical/surgical ICUs. Results Twenty-one patients who regained orientation within 72 hours of ICU discharge completed the questionnaire. More than 50% of patients recalled experiencing pain, anxiety, and fear to a moderate or extreme extent; and 57% reported inadequate sleep while in the ICU. Of the 21 patients, 48%, 33%, and 29% had no memories of endotracheal tube suctioning, being on a “breathing machine,” and being bathed, respectively. Conclusion A notable percentage of patients discharged from the ICU report moderate to extreme pain, anxiety, and fear, and inability to sleep during their ICU stay; and 29% to 48% have no recall of specific ICU events.

Case Report: Use of a nanocrystalline silver dressing and vacuum‐assisted closure in a severely burned dog

AbstractObjective – To describe the first veterinary use of a nanocrystalline silver dressing (NSD) and use of vacuum‐assisted closure (VAC) to treat a severely burned dog.Case or Series Summary – A 1‐year‐old female intact American Staffordshire Terrier with 50% total body surface area burned was referred for definitive care approximately 18–24 hours post injury. The dog was treated with crystalloid fluids, hydroxyethyl starch, and antimicrobials based on culture and sensitivity results of wound cultures, fresh frozen plasma, human serum albumin, and packed red cells. Wound care initially consisted of daily debridement under anesthesia with silver sulfadiazine application and bandaging. Because of the extent and the location of the wounds and morbid state of the patient, early wound grafting was not an option. Because of its reported improvement in granulation tissue formation and decreased tissue edema, VAC was used once the majority of burned tissue was manually debrided. Because of the pain caused by VAC and traditional bandaging techniques with this extent of injury, an NSD was utilized. This strategy was chosen due to the antimicrobial properties of NSD and the reduced necessity for daily bandage changes, which was reduced to only every 3 days. This protocol reduced the need for daily sedation or anesthesia.New or Unique Information Provided – VAC and NSD were used successfully for the treatment of a severe burn injury in a dog. The use of NSD decreased the cost of therapy by reducing the need for daily bandage changes, thereby reducing the anesthetic and analgesic costs and allowing the patient to be managed on an outpatient basis.

Early Physical Medicine and Rehabilitation for Patients With Acute Respiratory Failure: A Quality Improvement Project

Needham DM, Korupolu R, Zanni JM, Pradhan P, Colantuoni E, Palmer JB, Brower RG, Fan E. Early physical medicine and rehabilitation for patients with acute respiratory failure: a quality improvement project. Objectives To (1) reduce deep sedation and delirium to permit mobilization, (2) increase the frequency of rehabilitation consultations and treatments to improve patients' functional mobility, and (3) evaluate effects on length of stay. Design Seven-month prospective before/after quality improvement project. Setting Sixteen-bed medical intensive care unit (MICU) in academic hospital. Participants 57 patients mechanically ventilated 4 days or longer. Intervention A multidisciplinary team focused on reducing heavy sedation and increasing MICU staffing to include full-time physical and occupational therapists with new consultation guidelines. Main Outcome Measures Sedation and delirium status, rehabilitation treatments, functional mobility. Results Compared with before the quality improvement project, benzodiazepine use decreased markedly (proportion of MICU days that patients received benzodiazepines [50% vs 25%, P=.002]), with lower median daily sedative doses (47 vs 15mg midazolam equivalents [ P=.09] and 71 vs 24 mg morphine equivalents [ P=.01]). Patients had improved sedation and delirium status (MICU days alert [30% vs 67%, P<.001] and not delirious [21% vs 53%, P=.003]). There were a greater median number of rehabilitation treatments per patient (1 vs 7, P<.001) with a higher level of functional mobility (treatments involving sitting or greater mobility, 56% vs 78%, P=.03). Hospital administrative data demonstrated that across all MICU patients, there was a decrease in intensive care unit and hospital length of stay by 2.1 (95% confidence interval: 0.4–3.8) and 3.1 (0.3–5.9) days, respectively, and a 20% increase in MICU admissions compared with the same period in the prior year. Conclusions Using a quality improvement process, intensive care unit delirium, physical rehabilitation, and functional mobility were markedly improved and associated with decreased length of stay.

Transtorno de estresse pós-traumático em pacientes de unidade de terapia intensiva

Post-traumatic stress disorder has been detected in patients after treatment in intensive care unit. The main goal of this study is to review the psychological aspects and therapeutic interventions on those patients after their treatment on intensive care unit. Thirty eight articles have been included. The prevalence of post-traumatic stress disorder has varied from 17% up to 30% and the incidence from 14% to 24%. The risk factors were: previous anxiety historic, depression or panic, having delusional traumatic memories (derived from psychic formations as dreams and delirium), belief effects, depressive behavior, stressing experiences and mechanical ventilation. High doses of opiates, symptoms caused by sedation or analgesia reduction and the use of lorazepam were related with the increase of delirium and delusional memory. The disorder sintomatology can be reduced with hydrocortisone administration, with daily sedation interruption. No other effectiveness psychological intervention study was found.

Evaluation of the Impact of a tele-ICU Pharmacist on the Management of Sedation in Critically III Mechanically Ventilated Patients

An organized and uniform approach to managing sedation in critically ill patients has been associated with improved outcomes, but the most effective means of optimizing sedative medication use in clinical practice has not been fully determined. Pharmacist interventions directed at improving sedation guideline compliance have been shown to reduce the duration of mechanical ventilation. To determine the impact that pharmacy staffing configurations that include a tele-ICU pharmacist have on compliance with an intensive care unit (ICU) sedation guideline in critically ill mechanically ventilated patients requiring continuous-infusion sedative medications. Compliance with an established ICU sedation guideline, the performance of daily sedative interruptions, and the number of sedative medication-related interventions were evaluated before and after expansion of the ICU pharmacist staffing model to include comprehensive off-hours pharmacist coverage supported with established tele-ICU resources. In both groups, sedation was managed by the primary ICU team. In the intervention group, a pharmacist working in the tele-ICU center performed electronic record audits and made sedative medication recommendations to the primary team. The addition of third shift tele-ICU pharmacist support was associated with a significant increase in the percentage of patients who received a daily sedative interruption (45% vs 54%; p < 0.0001). This occurred in the context of significant increases in the total number of ICU pharmacist interventions (36 vs 49.4 per 100 patient days, p < 0.0001), the number of therapeutic interventions (20.4 vs 26.1 per 100 patient days, p < 0.001), and the number of sedative-related interventions (0.9 vs 4.4 per 100 patient days, p < 0.0001). Tele-ICU resources can be utilized to increase compliance with an established ICU sedation guideline and extend the benefits that daytime ICU clinical pharmacy services provide. Increased ICU pharmacist availability may have additional benefits not measured in this study.

The effect of daily repeated sedation using ketamine or ketamine combined with medetomidine on physiology and anesthetic characteristics in Rhesus Macaques

Non-human primates are frequently sedated to permit handling that can alter physiological values. The purpose of this study was to identify the effects of daily serial sedation using ketamine (K) or ketamine combined with medetomidine (KM). We hypothesized KM would reduce observed effects of repeated sedation. Eight rhesus macaques were anesthetized for three consecutive days. Physiological data were recorded daily at 5-minute intervals. Time intervals from injection to ataxia, recumbency, first movement and recovery were recorded. Depth of anesthesia was evaluated. Data showed an 11.7% increased heart rate at 5 minutes between the first and third day of injection with K and 17.9% with KM. Time from injection to ataxia increased 13.7% with K and 14.3% with KM. Time to recumbency increased 34.7% with K and 37.1% with KM. These findings demonstrate repeated anesthesia with ketamine can initiate changes suggesting a tolerance effect.

Intensive Care Unit Core Measures Improve Infectious Complications in Burn Patients

There are no data on the effects of the Joint Commission on the Accreditation of Healthcare Organizations intensive care unit (ICU) core measures for outcomes in the burn population. The impact of the ICU core measures on patients admitted to burn center was studied. The prospective outcomes measured were hospital length of stay, ventilator-associated pneumonia (VAP), catheter-related bloodstream infection (BSI) rates, and mortality for all burn patients admitted to the ICU. Protocols for the ICU core measures of deep venous thrombosis prophylaxis, stress ulcer prophylaxis, and daily weaning parameters, were in place before the start of the study period in 2005. Head-of-bed up at 30 degrees and glucose control, although variably practiced, were formally instituted in 2005. Enforcement of daily weaning parameters and sedation holidays were also implemented after 2005. The time period before institution of the core measures was 2003 to 2004 (pregroup), which was compared with the study time period of 2006 to 2008 (postgroup). There were no differences in the mean burn size, percent of inhalation injuries, or age between the two time periods. The VAP rate fell from 42/1000 to 13/1000 ventilator days, P = .0001. The BSI rate also declined from 12/1000 to 4/1000 line days, P = .05. Hospital and ICU lengths of stay and ventilator days did not change significantly between the periods. Risk-adjusted mortality for ICU patients improved from 13 to 7% (P = 0.01, odds ratio = 0.5 [0.29-0.85]). Although not specifically designed for the burn population, implementation of the proposed Joint Commission on the Accreditation of Healthcare Organizations ICU core measures for burn patients was associated with improvements in VAP and BSI rates, as well as a lower mortality.

Liberation and animation for ventilated ICU patients: the ABCDE bundle for the back-end of critical care

Critically ill patients are frequently prescribed sedatives and analgesics to ensure patient safety, to relieve pain and anxiety, to reduce stress and oxygen consumption, and to prevent patient ventilator dysynchrony. Recent studies have revealed that these medications themselves contribute to worsening clinical outcomes. An evidence-based organizational approach referred to as the ABCDE bundle (Awakening and Breathing Coordination of daily sedation and ventilator removal trials; Choice of sedative or analgesic exposure; Delirium monitoring and management; and Early mobility and Exercise) is presented in this commentary.

Safety and efficacy of a nurse-driven sedation protocol with daily sedation interruption in the ICU

Sedation algorithms have been shown to reduce the duration of mechanical ventilation in the ICU. We evaluated the effect of the implementation of a nurse-driven sedation protocol with daily sedation interruption in our ICU.