Daily Sedation Research Articles

Daily Sedation Interruption in Intubated PICU Patients

Daily Sedation Interruption in Intubated PICU Patients

Daily Sedation Interruption vs Continuous Sedation in Pediatric Patients Receiving Mechanical Ventilation

The effectiveness of daily sedation interruption (DSI, defined as temporary interruption of sedation) has yet to be demonstrated in critically ill pediatric patients. To compare the clinical outcomes of DSI vs continuous intravenous (IV) sedation in patients receiving invasive mechanical ventilation (MV) support in the pediatric intensive care unit (PICU). A systematic search for studies was conducted using predefined keywords and Medical Subject Headings in 5 major databases (PubMed, Embase, Web of Science, CINAHL [Cumulated Index to Nursing and Allied Health Literature], and Cochrane Central Register of Controlled Trials) from database inception to October 31, 2023. Retrospective and prospective observational studies, randomized clinical trials (RCTs), and systematic reviews were assessed for inclusion. Studies were eligible if they compared DSI to continuous IV sedation in patients aged 18 years or younger requiring MV in the PICU. Study characteristics, including the types of sedation, sedation protocols, and clinical outcomes, were extracted. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) reporting guideline was followed. A random-effects model was used to pool results from articles for the meta-analysis. The primary outcomes of interest were duration of MV and length of PICU stay. Secondary outcomes included total sedative dose requirement, adverse events (eg, complications associated with MV, withdrawal, and delirium), and mortality. A total of 6 RCTs with 2810 pediatric patients (1569 males [55.8%]; mean age, 26.5 [95% CI, 15.0-37.9] months) were included in the final analysis; patients had a mean PRISM (Pediatric Risk of Mortality) score of 13.68 (95% CI, 10.75-16.61). Compared with continuous IV sedation, DSI was associated with a reduction in length of PICU stay (5 studies, n = 2770; mean difference [MD], -1.45 [95% CI, -2.75 to -0.15] days; P = .03]. There was no difference in MV duration (5 studies, n = 2750; MD, -0.93 [95% CI, -1.89 to 0.04] days; P = .06), total doses of midazolam (3 studies, n = 191; MD, -1.66 [95% CI, -3.95 to 0.63] mg/kg) and morphine used (2 studies, n = 189; MD, -2.63 [95% CI, -7.01 to 1.75] mg/kg), or adverse events (risk ratio [RR], 1.03 [95% CI, 0.74-1.42]; P = .88). There was no difference in mortality between patients exposed vs not exposed to DSI (RR, 0.89 [95% CI, 0.55-1.46]; P = .65). This systematic review and meta-analysis found that use of DSI in pediatric patients was associated with reduced length of PICU stay with no increase in adverse events. Further research is needed to ascertain whether this strategy is associated with improved neurodevelopmental outcomes in PICU survivors.

Analgesia and sedation strategy for mechanically ventilated patients in the respiratory ICU

Abstract Background Mechanical ventilation is typically required for ICU patients as part of their care. This recommends the use of analgesia and sedation in a balanced strategy to alter patients’ comfort and assist synchronization with mechanical ventilation while avoiding the downsides of excessive sedation. Objective The aim of the study was to compare between deep sedation and light sedation, analgesia, and no sedation strategies and their effects on the length of mechanical ventilation, and their effects on patients’ prognosis. Patients and methods This cohort prospective pilot study was conducted at the medical respiratory ICU at Ain Shams University Hospital in Cairo, Egypt, on 54 patients separated into four groups according to the type of sedation and analgesia suited for each patient’s severity condition. Results In this study, 54 mechanically ventilated patients in respiratory ICU were recruited. The patients were divided into group 1: no sedation or analgesia, group 2: analgesia only, group 3: light sedation, and group 4: deep sedation. There was a significant difference in Acute Physiology and Chronic Health Evaluation score and severity%, although the Acute Physiology and Chronic Health Evaluation score and severity % were the highest in group 1 (25.53, 55.11%) and group 4 (23.40, 47.68%), but the prognosis was poorer in group 4 and was affected by deep sedation (100% death rate) than that in group 1 (60.0%). The average infusion rate of fentanyl and the total dose were significantly different between groups, the highest being in the deep sedation group. ICU length of stay was nonsignificant between groups but it was lower in group 4 (median: 9 days) than other groups. The average rate of dormicum infusion in the deep sedation group was 5 µg, while there was no daily vacation period; so, it can be explained that higher doses of sedation and analgesia in group 4 affected their prognosis to be poorer than other groups. Delirium occurred in 80% of group 4 patients, but only in 6.7% of subgroups, indicating a highly significant difference. Complications either metabolic, cardiac, or hematologic in the postextubation period were higher in group 4 (60%), than in group 1 (47.7%), group 2 (40%), and group 3 (15%). Conclusion Light sedation and analgesia strategies with daily sedation interruption would have a better survival outcome and cause fewer issues in patients, who were on mechanical ventilation than a heavy sedation approach.

Hemodynamic Effects of a High-Frequency Oscillatory Ventilation Open-Lung Strategy in Critically Ill Children With Acquired or Congenital Cardiac Disease.

To study the hemodynamic consequences of an open-lung high-frequency oscillatory ventilation (HFOV) strategy in patients with an underlying cardiac anomaly with or without intracardiac shunt or primary pulmonary hypertension with severe lung injury. Secondary analysis of prospectively collected data. Medical-surgical PICU. Children less than 18 years old with cardiac anomalies (± intracardiac shunt) or primary pulmonary hypertension. None. Data from 52 subjects were analyzed, of whom 39 of 52 with cardiac anomaly (23/39 with intracardiac shunt) and 13 of 52 with primary pulmonary hypertension. Fourteen patients were admitted postoperatively, and 26 patients were admitted with acute respiratory failure. Five subjects (9.6%) were canulated for ECMO (of whom four for worsening respiratory status). Ten patients (19.2%) died during PICU stay. Median conventional mechanical ventilation settings prior to HFOV were peak inspiratory pressure 30 cm H 2 O (27-33 cm H 2 O), positive end-expiratory pressure 8 cm H 2 O (6-10 cm H 2 O), and F io2 0.72 (0.56-0.94). After transitioning to HFOV, there was no negative effect on mean arterial blood pressure, central venous pressure, or arterial lactate. Heart rate decreased significantly over time ( p < 0.0001), without group differences. The percentage of subjects receiving a fluid bolus decreased over time ( p = 0.003), especially in those with primary pulmonary hypertension ( p = 0.0155) and without intracardiac shunt ( p = 0.0328). There were no significant differences in the cumulative number of daily boluses over time. Vasoactive Infusion Score did not increase over time. Pa co2 decreased ( p < 0.0002) and arterial pH significantly improved ( p < 0.0001) over time in the whole cohort. Neuromuscular blocking agents were used in all subjects switched to HFOV. Daily cumulative sedative doses were unchanged, and no clinically apparent barotrauma was found. No negative hemodynamic consequences occurred with an individualized, physiology-based open-lung HFOV approach in patients with cardiac anomalies or primary pulmonary hypertension suffering from severe lung injury.

Sedation and analgesia practices of pediatric intensivists in Saudi Arabia

Background: Sedation practices in pediatric intensive care units (PICUs) vary significantly worldwide. This study aimed to explore the current sedation and analgesia practices among paediatric intensivists in Saudi Arabia. Methods: This web-based survey was conducted among pediatric intensive care physicians in Saudi Arabia. The survey investigated the participating PICUs, physicians' demographic data, and sedation/analgesia practices. Results: Of the 160 physicians included, the response rate was 67% (n = 108). Of the 100 participants who provided location information, 51% (n = 51) were from the central region of Saudi Arabia. Approximately two-thirds of the participants were consultants, and 48.1% had >10 years of experience. Most respondents practised in general PICUs and routinely assessed sedation and analgesia levels. The COMFORT-Behavior and Face, Legs, Activity, Cry, and Consolability scales were popular (42.6%). More than half of the respondents (52/98) did not practice daily sedation interruption. Furthermore, 78.3% of the respondents assessed patients for withdrawal, whereas only 25% used delirium screening scores. Infusions were preferred over interrupted doses to provide comfort for mechanically ventilated patients. The first-choice infusions were midazolam for sedation and fentanyl for analgesia. Dexmedetomidine was preferred when a third agent was required. Sedation protocols were used by 41.2% of the respondents and were mainly physician-led (75.2%). Various nonpharmacological measures were used to provide patient comfort, and parents often participated in their application. Conclusions: The practice of sedation varies significantly between pediatric intensivists, and formal assessment for delirium is infrequently done in PICUs in Saudi Arabia.

The association of brainstem and motor recovery with awakening after out-of-hospital cardiac arrest

BackgroundComa is common following resuscitation from cardiac arrest. Few data describe the trajectory of recovery the first days following resuscitation. The objective of this study is to describe the evolution in neurological examination during the first 5 days after resuscitation and test if subjects who go on to awaken have different patterns of early recovery. MethodsProspective study of adult subjects resuscitated from out-of-hospital cardiac arrest. We abstracted demographic information and trained clinicians completed daily neurologic examinations using the Glasgow Coma Scale (GCS) and Full Outline of UnResponsiveness brainstem (FOUR-B) and motor (FOUR-M) scores during daily sedation interruption. The change in scores between Day 1 and Day 5 was analyzed using the Kruskal-Wallis Test and logistic regression models. The relationship of FOUR-B, FOUR-M, and GCS with time to death was estimated by fitting cox proportional hazard models. ResultsFOUR-M and GCS did not differ over time (p = 0.10; p = 0.07). FOUR B increased over time (p < 0.01). Time to recovery of brainstem or motor function differed between those treated at 33 °C and 36 °C (p = 0.0023 and p = 0.0032, respectively). FOUR-B, FOUR-M, and GCS differed between survivors and non-survivors (p < 0.01). Time to recovery of brainstem and motor function differed between survivors and non-survivors. FOUR-M and FOUR-B differed between those with good outcome and poor outcome. ConclusionsThe brainstem clinical examination improved during the first 5 days following resuscitation. Brainstem recovery was common in entire cohort and did not differentiate between survivors and non-survivors. Recovery of motor function, however, was associated with survival.

ABCDE and ABCDEF care bundles: A systematic review of the implementation process in intensive care units.

Background:The ABCDE (Awakening and Breathing Coordination of daily sedation and ventilator removal trials, Delirium monitoring and management, and Early mobility and exercise) and ABCDEF (Assessment, prevent and manage pain, Both spontaneous awakening and spontaneous breathing trials, Choice of analgesia and sedation, assess, prevent and manage Delirium, Early mobility and exercise, Family engagement) care bundles consist of small sets of evidence-based interventions and are part of the science behind Intensive Care Unit (ICU) liberation. This review sought to analyse the process of implementation of ABCDE and ABCDEF care bundles in ICUs, identifying barriers, facilitators and changes in perception and attitudes of healthcare professionals; and to estimate care bundle effectiveness and safety.Methods:We selected qualitative and quantitative studies addressing the implementation of ABCDE and ABCDEF bundles in the ICU, identified on MEDLINE, Embase, CINAHL, The Cochrane Library, Web of Science, Epistemonikos, PsycINFO, Virtual Health Library and Open Grey, without restriction on language or date of publication, up to June 2018. The outcomes measured were ICU and hospital length of stay; mechanical ventilation time; incidence and prevalence of delirium or coma; level of agitation and sedation; early mobilization; mortality in ICU and hospital; change in perception, attitude or behaviour of the stakeholders; and change in knowledge of health professionals. Two reviewers independently selected the studies, performed data extraction, and assessed risk of bias and methodological quality. A meta-analysis of random effects was performed.Results:Twenty studies were included, 13 of which had a predominantly qualitative and 7 a quantitative design (31,604 participants). The implementation strategies were categorized according to the taxonomy developed by the Cochrane Effective Practice and Organization of Care Group and eighty strategies were identified. The meta-analysis results showed that implementation of the bundles may reduce length of ICU stay, mechanical ventilation time, delirium, ICU and hospital mortality, and promoted early mobilization in critically-ill patients.Conclusions: This study can contribute to the planning and execution of the implementation process of ABCDE and ABCDEF care bundles in ICUs. However, the effectiveness and safety of these bundles need to be corroborated by further studies with greater methodological rigor.Protocol registration:PROSPERO CRD42019121307.

Nursing Care at End of Life in Pediatric Intensive Care Unit Patients Requiring Mechanical Ventilation.

Parents' perceptions of critical care during the final days of their child's life shape their grief for decades. Little is known about nursing care needs of children actively dying in the pediatric intensive care unit (PICU). To examine associations between patient characteristics, circumstances of death, and nursing care requirements for children who died in the PICU. A secondary analysis of the data set from the Randomized Evaluation of Sedation Titration for Respiratory Failure trial was conducted. This analysis included 104 children; 67 died after withdrawal of life-sustaining treatments; 21, after failed resuscitation; and 16, after brain death. Patients had a median age of 7.5 years, were cognitively appropriate, and were intubated for acute respiratory failure. Daily pain and sedation scores indicated patients' comfort was well managed (mean pain scores: modal, 0; peak, 2; mean sedation scores: modal, -2; peak, -1). Patients with longer PICU stays more often experienced pain and agitation on the day of death. Illness trajectory (acute, complex chronic condition, or cancer) was associated with pain scores (P = .04). Specifically, children with cancer had higher pain scores than children with acute illness trajectories (P = .01). Many patients (62%) had no change in critical care devices in their last days of life (median, 5 devices). Patterns of pain, sedation, comfort medications, and nursing care requirements did not differ by circumstances of death. Children with cancer and longer PICU stays may need comprehensive comfort management. Invasive devices left in place during withdrawal of life support may have inhibited parents' ability to connect with their child. Future research should incorporate parents' perspectives.

Application of an Automatic Medical Information System to Implement Bundle Care for the Prevention of Ventilator-Associated Pneumonia.

Ventilator-associated pneumonia is a common hospital-acquired infection. It causes patients to stay longer in the hospital and increases medical costs. This study explores the effect of applying an automatic medical information system to implement five-item prevention care bundles on the prevention of ventilator-related pneumonia. This study was a retrospective cohort study. This study was conducted from October 2017 to February 2018 and collected data from the intensive care unit of a medical center in southern Taiwan from January 2013 to May 2016. The control group (enrolled from January 2013 to June 2014) received oral hygiene. The experimental group (enrolled from July 2014 to December 2015) received five-item ventilator-associated pneumonia prevention care bundles, which consisted of (1) elevation of the head of the bed to 30–45°; (2) daily oral care with 0.12−0.2% chlorhexidine twice daily; (3) daily assessment of readiness to extubate; (4) daily sedative interruption; and (5) emptying water from the respirator tube. Results showed the incidence of ventilator-associated pneumonia in the bundle group was significantly less than the oral hygiene group (p = 0.029). The factors that significantly affected the incidence of ventilator-associated pneumonia were ventilator-associated pneumonia care bundle, ventilator-days, and intensive care unit length of stay. A significant reduction in ventilator-associated pneumonia rate in the bundle group compared to the oral hygiene group (OR = 0.366, 95% CI = 0.159–0.840) was observed, with 63.4% effectiveness. Application of an automatic medical information system to implement bundle care can significantly reduce the incidence of ventilator-associated pneumonia.

Sedation in critically ill patients: will the vaporiser replace the syringe?

Critically ill patients in intensive care units (ICUs) often need sedation to treat anxiety, pain, and confusion, and for diagnostic procedures and interventions. One such intervention is invasive ventilation. Protocolised sedation with daily sedative interruption could prevent oversedation, delayed emergence, and belated extubation, but comes with challenges because of the altered pharmacology and frequent drug interactions in invasively ventilated patients in the ICU.

Physical Therapy and Sedation While on Extracorporeal Membrane Oxygenation for COVID-19–Associated Acute Respiratory Distress Syndrome

ObjectivesThis study aimed to determine whether patients on extracorporeal membrane oxygenation (ECMO) with coronavirus disease 2019 (COVID-19) achieved lower rates of physical therapy participation and required more sedation than those on ECMO without COVID-19.DesignRetrospective, observational, matched-cohort study.SettingBicenter academic quaternary medical centers.ParticipantsAll adults on ECMO for severe COVID-19-associated acute respiratory distress syndrome (ARDS) during 2020 and matched (matched 1:1 based on age ± 15 years and medical center) adults on ECMO for ARDS not associated with COVID-19.InterventionsObservational only.Measurements and Main ResultsMeasurements were collected retrospectively during the first 20 days of ECMO support and included daily levels of physical therapy activity, number of daily sedation infusions and doses, and level of sedation and agitation (Richmond Agitation and Sedation Score). During the first 20 days of ECMO support, the 22 patients who were on ECMO for COVID-19–associated ARDS achieved a similar proportion of days with active physical therapy participation while on ECMO compared to matched patients on ECMO for non-COVID-19 ARDS (22.5% v 7.5%, respectively; p value 0.43), a similar proportion of days with Richmond Agitation and Sedation Score ≥-2 while on ECMO (47.5% v 27.5%, respectively; p value 0.065), and a similar proportion of days with chemical paralysis while on ECMO (8.4% v 18.0%, respectively; p value 0.35).ConclusionsThe results of this matched cohort study supported that sedation requirements were not dramatically greater and did not significantly limit early physical therapy for patients who had COVID-19–associated ARDS and were on venovenous extracorporeal membrane oxygenation (VV-ECMO) versus those without COVID-19–associated ARDS who were on VV-ECMO.

Effects of daily sedation interruption in intensive care unit patients undergoing mechanical ventilation: A meta-analysis of randomized controlled trials.

This study aimed to assess the effects of daily sedation interruption on the mechanical ventilation duration and relevant outcomes in mechanically ventilated patients in the intensive care unit (ICU). Previously, three meta-analyses on the association of daily sedation interruption with the mechanical ventilation duration have reported conflicting findings, and these did not support current guideline recommendations that daily sedation interruption can be routinely used in mechanically ventilated adult ICU patients. This was a systematic review and meta-analysis of randomized controlled studies. Data were from PubMed, Embase, Cochrane Library, CINAHL, ProQuest dissertation and theses, Airiti Library, China National Knowledge Infrastructure, Wanfang Data Chinese, Science Direct and PsycINFO databases. Two reviewers independently assessed, extracted and appraised the included studies. Then, pooled estimates were calculated using a random-effects model. In total, 45 studies involving 5493 participants were included. Compared with controls, daily sedation interruption significantly reduced the mechanical ventilation duration, ICU stay length, sedation duration, and tracheostomy and ventilator-associated pneumonia risks (all p ≤ 0.001). Moreover, the Acute Physiology and Chronic Health Evaluation II score and study quality were significant moderators. Daily sedation interruption could substantially reduce the duration of mechanical ventilation, particularly when it was applied to patients with high disease severity.

Long-Term Cognitive Outcomes and Sleep in Adults After Extracorporeal Life Support

Objectives:To assess differences in cognitive outcomes and sleep in adult survivors of critical illness, managed with venovenous extracorporeal membrane oxygenation as compared to conventional mechanical ventilation only.Design:Retrospective cohort study linked with data from the COGnitive outcomes and WELLness study.Setting:A multisite study from five adult medical/surgical ICUs in Toronto.Patients:Thirty-three ICU survivors including adult patients who received venovenous extracorporeal membrane oxygenation (n = 11) matched with patients who received mechanical ventilation only (n = 22) using specified covariates (e.g., age).Interventions:None.Measurements and Main Results:Baseline demographics and admission diagnoses were collected at enrollment. Cognitive outcome was evaluated using the Repeatable Battery for the Assessment of Neuropsychologic Status (global cognitive function) and Trail Making Test B (executive function), and sleep variables were estimated using actigraphy. Assessments occurred at 7 days post ICU discharge and again at 6- and 12-month follow-up. No statistically significant difference was seen between patients treated with or without venovenous extracorporeal membrane oxygenation in the mean daily Riker Sedation Agitation Score; however, patients in the venovenous extracorporeal membrane oxygenation group received greater amounts of fentanyl over their ICU stay as compared to patients receiving conventional mechanical ventilation only (p < 0.001). No significant differences were found in performance on either of the cognitive assessment tools, between survivors treated or not with venovenous extracorporeal membrane oxygenation at any of the time points assessed. Total sleep time estimated by actigraphy increased from approximately 6.5 hours in hospital to 7.5 hours at 6-month follow-up in all patients, regardless of treatment type. Total sleep time remained consistent in both groups from 6 to 12 months post ICU discharge.Conclusions:In this small retrospective case series, no significant differences were found in sleep or cognitive outcomes between extracorporeal life support and non–extracorporeal life support survivors. Further, in this hypothesis-generating study, differences in administered sedative doses during the ICU stay seen between the two groups did not impact 6- or 12-month cognitive performance or actigraphy-estimated sleep time.

Effect of daily sedation interruption and the patient’s outcome who are under mechanical ventilation: A mini systematic review

Continuous administration of sedatives to the intensive care unit may increase the duration of mechanical ventilation, extend the patient's stay in the intensive care unit, and, subsequently, to the hospital. The objective was to improve the outcome of intubated patients in terms of the total duration of mechanical ventilation, the stay of these patients in the intensive care unit (ICU), and their mortality. This systematic review was conducted using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The literature search was conducted in October 2020. Articles were searched in the PubMed and Cochrane Library online databases. Data were extracted from all included research studies and analyzed thematically. The search duration was between 2008 and 2018. The studies do not document statistically significant differences with the parameters under study (total duration of mechanical ventilation, the total length of stay in the intensive care unit (ICU), and mortality), for a better outcome of intubated patients. The application of the daily sedation interruption (DSI) did not appear to affect the duration of Mechanical Ventilation, the length of stay in the ICU, and mortality in intubated patients.&#x0D; Keywords: Daily sedation interruption, intubated patients

Effect of Nursing Care Protocol daily Interruption of Sedation on Mechanical Ventilated Patients 'Outcome

Nursing care protocol daily sedation is very important to optimize sedation for patients on mechanical ventilators, these requires nursing staff is very crucial in this aspect to avoid complication of sedation and earlier extubation. Aim: This study was aimed to identify impact nursing care protocol for daily interruption sedation on mechanical ventilation patients outcome. Design: a quasi-experimental design. Setting: Carried at ICU at Assiut university hospital. Subjects: A purposive sample of 70 adults patients. Sample was assigned to two equal groups (study and control). Tools: Four tools were utilized to collect data of study, tool I: Patient assessment sheet. Tool II: Interruption and infusion sedation assessment scales tool. Tool III: Intensive Care Delirium Screening Checklist. Tool IV:patients outcome tool. Results: the present study revealed that there was a statistical significant differences (P<0.001**) between study and control groups in relation to sedative complication, Delirium , ICU stay, and Duration of mechanical ventilation. Conclusion: Patient who received nursing care protocol during daily interruption of sedation leading to improve outcome and reduce complication. Recommendation: Provide in service education and training program for critical care nurses regarding applying daily interruption of sedation and how managed these patients

Impact of Each Component of a Ventilator Bundle on Preventing Ventilator-Associated Pneumonia and Lower Respiratory Infection

Background: Ventilator-associated lower respiratory infections (LRIs) and pneumonia (VAP) are important healthcare-associated infections and are among the leading causes of death worldwide. Prevention of these infections are often based on care bundles. We investigated the incidence of VAP+LRI and the preventive efficacy of each component of our ventilator bundle. Methods: Our ventilator bundle includes 6 components that are daily checked by an infection control practitioner. These 6 evidence-based practices were implemented in 3 ICUs from a general tertiary-care private hospital in Belo Horizonte City (Brazil): (1) daily oral care with chlorhexidine; (2) elevate the head of the bed to between 30 and 45; (3) avoid scheduled ventilator circuit change; (4) monitor cuff pressure; (5) use subglottic secretion drainage; and (6) daily sedation interruption and daily assessment of readiness to extubate. VAP and ventilator-LRI definitions were obtained from the CDC NHSN. The impact of adherence rate to items in the ventilator bundle (%) on the incidence rate of VAP+LRI was assessed using linear regression and scatterplot analyses. Results: Between January 2018 and April 2019, 1,888 ventilator days were observed in the 3 ICUs, with 42 VAP and LRI events, an overall incidence rate of 22.2 cases per 1,000 ventilator days. After September 2018, the infection control service started a campaign to increase the ventilator bundle compliance (Fig. 1). Adherence rates to all 6 bundle components increased between January–August 2018 and September 2018–April 2019 from 25% to 55% for daily oral care, from 34% to 79% for elevating the head of the bed, 28% to 86% for avoiding scheduled ventilator circuit change, from 32% to 83% for cuff pressure monitoring, from 32% to 83% for subglottic secretion drainage, and from 33% to 85% for daily sedation interruption. PAV and LRI incidence decreased from 41 to 16 in ICU A, from 22 to 14 in ICU B and from 24 to 18 in ICU C. The impact of each bundle component was identified by linear regression, calculating the percentage of PAV+LRI incidence rate that is explained by bundle item adherence (r2) and correlation coefficient (r): daily sedation interruption (r2 = 48%; r = 0.69; P = .004) (Fig. 2), cuff pressure monitorization (r2 = 0.3721; r = 0.61; P = .016), subglottic secretion drainage (r2 = 36%; r = 0.60; P = .017), avoidance of scheduled ventilator circuit change (r2 = 34%; r = 0.58; P = .023), daily oral care (r2 = 25%; r = 0.50; P = .050), and elevate the head of the bed (r2 = 25%; r = 0.48; P = .067). Conclusions: The impact of each bundle component on preventing PAV+LRI was identified by the study. An educational intervention performed by the infection control service increased the adherence to the ventilator bundle, and the PAV and LRI incidence decreased.Funding: NoneDisclosures: None

The effects of sedation cessation within the first four hours of intensive care unit admission in mechanically ventilated critically ill patients - a quality improvement study.

BackgroundEarly deep sedation in mechanically ventilated patients during the first 48 h of intensive care unit (ICU) admission can be associated with adverse outcomes. We hypothesised that moving the ‘daily sedation break’ process forwards, might allow earlier titration of sedation to target levels – an ‘early sedation cessation’ (ESC).MethodsWe commenced a quality improvement project with the primary outcome being to stop sedation completely, within 4 h of ICU admission, in 95% of eligible patients. This was done by small, step-wise tests of change. No ethical approval was required.FindingsBetween 1 February 2014 and 31 January 2018, 1787 intubated patients were included. 1052 received an ‘ESC’ within 4 h (‘Yes’), 545 were excluded (‘Excluded’), and 190 were inadvertently omitted from ‘ESC’ (‘No’). The primary aim was achieved for the first time after 12 months. Compared to the ‘Yes’ group, the ‘Excluded’ group received 38% more propofol in the first 48 h of admission (IRR 1.38 (1.31–1.47), p<0.001), while the ‘No’ group received 32% more (IRR 1.32 (1.22–1.43), p<0.001). At four hours, 19·6% (12·9–27·9) of the ‘Yes’ group had attained a target RASS of -1, 0 or 1, compared to 13·6% (8·0–21·0) of those in the ‘No’ group. This proportion increased to 55·6% (46·1–64·9) at 24 h compared with 44·9% (35·6–54·4) in the ‘No’ group.InterpretationCeasing sedative infusions as soon as possible, is safe and feasible, in both medical and surgical patients, and can be implemented into ‘real life’ with no additional staffing.

Practices related to assessment of sedation, analgesia and delirium among critical care pediatricians in Brazil.

ABSTRACTObjective To understand the use of tools, protocols and comfort measures related to sedation/analgesia, and to screen the occurrence of delirium in pediatric intensive care units.Methods A survey with 14 questions was distributed by e-mail to Brazilian critical care pediatricians. Eight questions addressed physician and hospital demographics, and six inquired practices to assess sedation, analgesia, and delirium in pediatric intensive care units.Results Of 373 questionnaires sent, 61 were answered (16.3%). The majority of physicians were practicing in the Southeast region (57.2%). Of these, 46.5% worked at public hospitals, 28.6% of which under direct state administration. Of respondents, 57.1% used formal protocols for sedation and analgesia, and the Ramsay scale was the most frequently employed (52.5%). Delirium screening scores were not used by 48.2% of physicians. The Cornell Assessment of Pediatric Delirium was the score most often used (23.2%). The majority (85.7%) of physicians did not practice daily sedation interruption, and only 23.2% used non-pharmacological measures for patient comfort frequently, with varied participation of parents in the process.Conclusion This study highlights the heterogeneity of practices for assessment of sedation/analgesia and lack of detection of delirium among critical care pediatricians in Brazil.

Daily sedation interruption versus routine sedation in critically ill children: A systematic review and meta-analysis

ABSTRACTBackground: Strategies aiming lighter sedation have demonstrated promising results in adults. This review was designed to evaluate the efficacy and safety of daily sedation interruption (DSI) versus sedation protocols in mechanically ventilated children.Methods: This was a systematic review and meta-analysis. We searched MEDLINE, Scopus, Cochrane Library and Web of Science from 1980 to August 2018 for randomized control trials comparing the two forms of sedation in question, with outcomes that included duration of mechanical ventilation, length of stay in the pediatric intensive care unit, total midazolam doses and adverse events.Results: Three studies were included in the review and meta-analysis after fulfilling the inclusion criteria. One was a multicenter trial and two were single-center trials, with a total of 261 patients. There was a shorter duration of both mechanical ventilation and intensive care stay, but with marked heterogeneity. All the results were in favor of DSI except adverse events which were higher in the DSI group.Conclusion: On comparison of DSI to routine sedation, we found evidence of benefit as regards, duration of mechanical ventilation, length of intensive care unit stay and midazolam doses. However, there was some evidence of harm with more adverse events.

Bispectral Index for Titrating Sedation in ARDS Patients During Neuromuscular Blockade.

Despite a lack of data from intensive care patients, bispectral index monitors are often used to measure the depth of sedation for critically ill patients with acute respiratory distress syndrome (ARDS) who require continuous neuromuscular blocking agents. To evaluate differences in the effectiveness and safety of monitoring sedation by using bispectral index or traditional methods in patients with ARDS who are receiving continuous neuromuscular blocking agents. This noninterventional, single-center, retrospective cohort study included adult patients with ARDS who are receiving a neuromuscular blocking agent. Daily sedation and analgesia while a neuromuscular blocking agent was being administered were compared between patients with and patients without orders for titration based on bispectral index values. Clinical outcomes also were evaluated. Overall, sedation and analgesia did not differ between patients with and patients without titration based on bispectral index. Compared with patients without such titration, patients with bispectral index-based titration experienced more dose adjustments for the sedation agent (median [interquartile range], 7 [4-11] vs 1 [0-5], respectively, P < .001) and the analgesic (1 [0-2] vs 0 [0-1], respectively; P = .003) during the first 24 hours of neuromuscular blockade, but this was not associated with any difference in clinical outcomes. Titration based on bispectral index did not result in a significant difference in sedation or analgesia exposure, or clinical outcomes, from that achieved with traditional sedation monitoring in patients with ARDS who were receiving a neuromuscular blocking agent, despite more dose adjustments during the first 24 hours of receiving the neuromuscular blocking agent.