Daily Sedation Interruption Research Articles

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.

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.

Nursing Guidelines for Sedation Titration or Pausing to Facilitate Neurological Assessment.

Q Per The Joint Commission, we need clearer nursing titration/pausing guidelines to facilitate serial neurological assessments. How can we titrate or pause sedation/analgesia infusions to facilitate serial neurological assessments as well as “standard” wake-up assessments in a way that is compliant with regulatory agencies?A Richard Arbour, MSN, RN, CCRN, CNRN, CCNS, CCTC, replies:The Joint Commission (TJC) overview of sedation, analgesia, restraints, and other practices has added additional requirements to documentation, policies, and clinical review as a means to increase standardization of care and, most importantly, patient safety. In particular, TJC has closely evaluated sedation/analgesia dosing and titration.Optimal, goal-directed sedation practices are well established and include 4 components. First, validated clinical assessment tools such as the Sedation-Agitation Scale and the Richmond Agitation-Sedation Scale (RASS) are used to determine therapeutic end points for patients who are not pharmacologically paralyzed.1–3 Second, targeted clinical end points for sedative/hypnotic agents are optimally aimed at “lighter” levels of sedation (eg, a RASS score of 0 to −2 [light sedation]),1 unless higher levels are clinically necessary; patients with these “lighter” levels of sedation are best described as calm and interactive and are able to respond appropriately to stimulation.2,4 Third, sedatives/hypnotic agents should be periodically interrupted or titrated down. This component has become well established since a landmark study in which Kress et al5 identified a connection between daily interruption of sedation and a shorter duration of mechanical ventilation; in current practice, meticulous patient selection and close monitoring are paramount to protect vulnerable patients from harm. Fourth, attention must be given to sedation and analgesic needs and to clinically appropriate nonpharmacological comfort measures, and treatable causes of agitation, pain, and delirium must be addressed.2–4To achieve optimal, goal-directed therapy, all 4 of these points need to be included in a plan of care. Previously, a team may have ordered a “wake-up assessment” for a patient, and that patient’s sedation/analgesic agents may have been abruptly stopped. From a regulatory perspective that assessment order may not have constituted a complete medication order. A complete medication order for titration includes the following items: Note that TJC allows for range orders and multiple range orders, so a provider can order titration increments for a range of times and doses. A direct care nurse would then apply their knowledge and experience with the patient to select the most appropriate interval and dose from among the ordered range when necessary.Clearer titration guidelines to facilitate serial neurological evaluation would include the required order elements and specifically attend to the desired clinical goal for wakefulness or responsiveness (eg, a RASS score of 0 to −1). In addition, downward titration of central nervous system depressants should be specified in institutional policy addressing titration, which should also include a specific callout for daily spontaneous awakening trials (SATs). One such example addressing regulatory considerations is outlined below.To the specific practice question, when considering an awakening trial for neurological assessment followed by specified baseline assessment and goals of care, optimal patient selection from among the neuroscience population is necessary to establish optimal risk/benefit analysis. Documentation should include baseline dosing for any central nervous system depressant, sedation depth, and repeat assessment after each dose change. When a patient’s sedation assessment identifies elements that remain outside the provider-ordered parameters, appropriate communication with the provider and documentation are indicated. If the order does not fit the clinical situation, contact the provider, clarify the order, and document.The importance of interdisciplinary collaboration cannot be overstated: it is essential in optimal patient selection for downward titration of sedation/analgesia to allow neurological evaluation. Respiratory therapy is integral when ventilator support is being titrated as an intervention to manage agitation or ventilator dyssynchrony. In addition to assessing patients and documenting, nurses implement nonpharmacological interventions, calm the patient and family, and facilitate a healing, caring environment. Pharmacy team members offer expertise in optimizing pharmacological therapies for managing pain and agitation. Physicians and advanced care providers are accountable for the overall plan of care and multisystem support. Of particular note is how practices such as sedation/analgesia titration and interruption continue to evolve on the basis of best available evidence and in collaboration with health care regulatory bodies. This collaboration has been useful in practice and in improving patient safety.

Perceptions and practices regarding light sedation in mechanically ventilated patients: a survey on the attitudes of Brazilian critical care physicians.

To characterize the knowledge and perceived attitudes toward pharmacologic interventions for light sedation in mechanically ventilated patients and to understand the current gaps comparing current practice with the recommendations of the Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the Intensive Care Unit. This was a cross-sectional cohort study based on the application of an electronic questionnaire focused on sedation practices. A total of 303 critical care physicians provided responses to the survey. Most respondents reported routine use of a structured sedation scale (281; 92.6%). Almost half of the respondents reported performing daily interruptions of sedation (147; 48.4%), and the same percentage of participants (48.0%) agreed that patients are often over sedated. During the COVID-19 pandemic, participants reported that patients had a higher chance of receiving midazolam compared to before the pandemic (178; 58.8% versus 106; 34.0%; p = 0.05), and heavy sedation was more common during the COVID-19 pandemic (241; 79.4% versus 148; 49.0%; p = 0.01). This survey provides valuable data on the perceived attitudes of Brazilian intensive care physicians regarding sedation. Although daily interruption of sedation was a well-known concept and sedation scales were often used by the respondents, insufficient effort was put into frequent monitoring, use of protocols and systematic implementation of sedation strategies. Despite the perception of the benefits linked with light sedation, there is a need to identify improvement targets to propose educational strategies to improve current practices.

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.

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.

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

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 ASSOCIATION BETWEEN COMA, DAYS ON MECHANICAL VENTILATION, AND 28-DAY MORTALITY FOR ADULTS MANAGED WITH ANALGESIA-FIRST SEDATION OR TRADITIONAL SEDATION METHODS

SESSION TITLE: Late-breaking Abstract Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: October 18-21, 2020 PURPOSE: A recent RCT of 86 adults requiring mechanical ventilation (MV) > 48 hours and continuous sedation compared analgesia-first sedation (AFS), protocolized sedation (PS), and both daily sedation interruption (DSI) and PS and found a lack of difference between the three groups for days free of coma [Richmond Agitation Sedation Score (RASS) <-4] [ AFS (15.1), PS (17.6), PS+DSI (13.4); p=0.01] or mechanical ventilation (24, 24, 24; p=0.62) at 28 days or mortality at 28 days [AFS 30%, PS 21%, PS+DSI 13%; p=0.29]. We sought to evaluate the association between coma and days of mechanical ventilation and mortality at 28 days. METHODS: This post-doc cohort analysis included all 86 patients from the RCT. We adjusted for age, gender, baseline APACHE II score, medical (vs. surgical) admission, daily opioid dose, daily sedative dose, and study allocation (i.e., AFS vs. PS. vs DSI+PS) in each regression model. The level of sedation was assessed using the Richmond Agitation–Sedation Scale (RASS); coma was considered for a RASS − 5. RESULTS: 86 patients were analyzed. The mean age was 65±5 years, 55.8% male, an average APACHE II was 24±8. Eighty-one percent of the admissions were medical vs 29% were surgical admissions. A Regression model analysis demonstrated that coma was independently associated with more days of mechanical ventilation in the 28 days after randomization (1.65 days; 95% CI 1.25–3.07, p=0.02) and greater 28-day mortality rate (OR 5.06; 95% CI 1.2–21.2.7, p=0.03). Coma was associated with a higher likelihood of unsuccessful spontaneous breathing trial (SBT) (OR 0.106; 95% CI 0.01–0.8, p=0.03) and longer hospital length of stay (6.9 days; 95% CI 0.17–13.5, p=0.045). CONCLUSIONS: Coma is independently associated with greater days spent mechanically ventilated and higher 28-day mortality regardless of whether patients are managed with AFS, PS, or both DSI+ PS. CLINICAL IMPLICATIONS: Clinicians should adhere to PADIS guidelines on recommendations for sedation goals and avoid deep sedation or coma whenever clinically appropriate. DISCLOSURES: No relevant relationships by Antonio Beltran, source=Web Response No relevant relationships by John Devlin, source=Web Response No relevant relationships by Quang Le, source=Web Response No relevant relationships by Huan Mark Nguyen, source=Web Response No relevant relationships by Hyunsoon Park, source=Web Response No relevant relationships by Ramy Sidhom, source=Web Response No relevant relationships by Maged Tanios, source=Web Response No relevant relationships by Fady Youssef, source=Web Response

Vanquishing Ventilator Associated Events by Re-emphasizing Evidence Based Practices

<h3>Background</h3> Patients on mechanical ventilation are at a high risk for a variety of serious complications, including infections that can increase the duration of ventilation, length of hospital stay and morbidity and mortality. In early 2019, our facility noted a significant increase in ventilator-associated events (VAEs) with a total of four (4) events in all of 2018 to seven (7) events in the first six months of 2019. <h3>Methods</h3> A multidisciplinary work group was formed and an evidence-based quality improvement (EBQI) project was implemented to ensure the Society of Healthcare Epidemiology of America (SHEA) guidelines for prevention of ventilator-associated pneumonia practices were being followed. Collaboration by respiratory therapists (RT) and registered nurses (RN) was determined to be a priority in order to ensure daily interruption of sedation (DIS) and spontaneous breathing trials (SBTs) were completed. Respiratory therapists played a critical role in ensuring positive end-expiratory pressures (PEEP) were set appropriately for the patient's body mass index. Staff re-education on the best practices of DIS, SBT, oral care and changing of oral care kits at a specified time was carried out. The Infection Preventionist performed daily audits of ventilated patients and practices. The goal was to reduce the number of VAEs by 50% in the last six months of 2019. Confounding variables were determined to be existing co-morbidities prior to mechanical ventilation and admitting diagnosis. <h3>Results</h3> To date, data from June 2019 to mid-November 2019 has demonstrated a significant decrease in VAEs. Only one VAE, a ventilator-associated condition (VAC), occurred in early November 2019. Since June 2019, our VAEs have decreased by 85% since implementation of the EBQI project. <h3>Conclusions</h3> Going back to the basics and evidence-based guidelines through a multidisciplinary work group and EBQI project which stressed staff education, RT and RN collaboration and appropriate ventilator settings has helped significantly reduce our VAE rate.

Should Sedation Be Eliminated for Mechanically Ventilated Patients in Intensive Care

Daily interruption of sedation — rather than continuous sedation — became an intensive care unit (ICU) standard 20 years ago, after researchers

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.

Associação entre nível de sedação e mortalidade de pacientes em ventilação mecânica em terapia intensiva

To associate the sedation level, criteria for daily interruption of sedation and mortality of patients on mechanical ventilation in an Intensive Care Unit. Prospective, longitudinal and quantitative study conducted with patients by using the Richmond Agitation-Sedation Scale (RASS) and the Sepsis-related Organ Failure Assessment (SOFA) score, through a care protocol managed by a nurse at the unit for the daily interruption of sedation once a day. The Chi Square test was used to check the association between variables and the T test for independent analyzes. Participation of 204 patients. Most were male, surgical, aged between 40 and 60 years, in sedoanalgesia with fentanyl, midazolam and propofol, with sedation time of one to five days and average stay of 10.7 days. They were in moderate sedation and at high risk for mortality. There was a statistical correlation between death in patients in deep sedation, and sensitivity in relation to discharge from the Intensive Care Unit of those who underwent daily interruption of sedation and were reassessed daily. Daily interruption of sedation guided by the Richmond Agitation-Sedation Scale assists in the control of sedation, which favors the treatment and recovery of patients and guides nurses' decision making. However, in this study, it was not configured as an independent factor for predicting mortality in intensive care.

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.

Effects of sedation on clinical, gasometric, and respiratory muscle parameters in critically ill chronic obstructive pulmonary disease patients

BackgroundSevere chronic obstructive pulmonary disease (COPD) exacerbation requiring mechanical ventilation is commonly encountered in the ICU. Sedation is necessary to facilitate mechanical ventilation. The effect of no-sedation strategy on different patient parameters on the ventilator has not yet been well studied. The aim of this study was to test the efficacy of no-sedation protocol in controlling COPD patient’s gasometric and clinical parameters during mechanical ventilation.Patients and methodsPatients with COPD who required mechanical ventilation were randomized to either: sedated with daily interruption (control group) (n=50) or nonsedated group (n=47). The change in the partial pressure of arterial CO2 (PaCO2) was the primary outcome measure. Secondary outcome measures included: changes in pH, heart rate (HR), mean arterial blood pressure (MAP), respiratory rate, airway occlusion pressure (P0.1), and negative inspiratory force (NIF). Recordings for arterial blood gases, HR, MAP, and respiratory rate were performed as baseline at intubation, 1, 2, 12, 24, and 48h after intubation. NIF and P0.1 were recorded 48 h after intubation.ResultsNo significant difference was found in baseline recordings of PaCO2, pH, HR, MAP, and respiratory rate between the sedated and nonsedated groups. Further recordings of PaCO2 (P_1, P_2, P_3, and P_4<0.001, P_5=0.005), HR (P<0.001), and respiratory rate (P<0.001) were significantly higher in the nonsedated group. The rate of correction of pH from acidosis was faster among the sedated patients. MAP was significantly higher in nonsedated patients in recordings 2, 12, and 48 h after intubation (P_1=0.9, P_2<0.001, P_3<0.001, P_4=0.87, P_5<0.001). No significant difference was found in NIF or P0.1 between the two groups (P=0.8 and 0.1, respectively).ConclusionCOPD patients managed by no-sedation strategy had higher PaCO2, HR, MAP, and respiratory rate. No-sedation had no significant effect on respiratory muscle function when compared with daily interruption of sedation.

Analgesia-first sedation in critically ill adults: A U.S. pilot, randomized controlled trial

PurposeTo determine the feasibility of conducting a multicenter ICU RCT of AFS compared to either protocol-directed sedation (PDS) or both PDS and daily sedation interruption (DSI) in North America. Materials and methodsThis single-center RCT compared AFS [fentanyl (bolus ± infusions) to reach CPOT ≤2; if RASS ≥1, CPOT ≤2 and additional fentanyl failed to reach RASS goal (−2 to 0), low-dose propofol (up to 6 h) was given] with either PDS or both PDS and DSI daily in adults mechanically ventilated (MV) ≥48 h. Relevant feasibility, safety, and clinical outcomes were defined and evaluated. Results90 of 160 eligible patients were enrolled [AFS = 27; PDS = 28; PDS + DSI = 31]; rate = 3/month. Time from intubation to randomization was 17.5 ± 11.6 h. Study days fully adherent to the study intervention [AFS = 95%; PDS = 99%; PDS + DSI = 96%] and time spent in the first 48 h after randomization without pain (CPOT ≤2)[AFS = 82%; PDS = 78%; PDS + DSI = 77%] and at goal RASS[AFS = 88%; PDS = 83%; PDS + DSI = 95%] were high and similar. Nurse-perceived [median (IQR)] study workload (10-point VAS) was higher with AFS [4(2–6)] than PDS [1(1–3)] or PDS + DSI [2(1–5)]; p = .002). Unplanned extubation was rare (AFS = 1; PDS = 0; PDS + DSI = 1). Days [median (IQR)] free of MV in the 28d after intubation [AFS 24(23,26); PDS 24(20,26); PDS + DSI 24(21,26)] was not different (p = .62). ConclusionA multicenter RCT evaluating AFS is feasible to conduct in North America.

Effect of Daily Interruption of Sedation on Level of Consciousness Among Mechanically Ventilated Patients

Effect of Daily Interruption of Sedation on Level of Consciousness Among Mechanically Ventilated Patients