Sedation In ICU Patients Research Articles

Measuring pain or discomfort during routine nursing care in lightly sedated mechanically ventilated intensive care patients: A prospective preliminary cohort study

BackgroundPain is routinely measured on mechanically ventilated ICU patients. However, the tools used are not designed to discriminate between pain and non-pain discomfort, a distinction with therapeutic implications. ObjectivesTo evaluate whether clinical measurement tools can discern both pain and non-pain discomfort. MethodsA prospective observational cohort study was conducted in a General ICU at a tertiary Medical Center in Israel. The Behavior Pain Scale (BPS) and Visual Analog Scale (VAS) of Discomfort were simultaneously assessed by a researcher and bedside nurse on thirteen lightly sedated patients during 71 routine nursing interventions in lightly sedated, mechanically ventilated, adult patients. Patients were asked whether they were in pain due to these interventions. ResultsStatistically significant increases from baseline during interventions were observed [median change: 1.00 (-1–5), 1.5(-4–8.5), p < 0.001] as measured by BPS and VAS Discomfort Scale, respectively. BPS scores ranged between 4 and 6 when the majority (53 %) of the patients replied that they had no pain but were interpreted by the clinicians as discomfort. Endotracheal suctioning caused the greatest increase in BPS and VAS, with no statistically significant differences in BPS and VAS Discomfort Scale scores whether patients reported or did not report pain. A BPS>6 had a higher sensitivity and specificity to reported pain (accuracy of 76 %) compared to a BPS of 4–6. ConclusionsStandard assessments are sensitive to pain caused by routine nursing care interventions. However, this study presents evidence that among lightly sedated ICU patients, moderate BPS scores could also measure non-pain discomfort. ICU nurses should be aware that signs of unpleasantness measured by a pain scale could reflect non-pain discomfort.

Clinical Application and Research Progress of Remimazolam for Pediatric Patients.

Remimazolam is a novel ultrashort-acting benzodiazepine that allosterically modulates γ-aminobutyric acid type A (GABAA) receptors to exert sedative effects. Remimazolam has the properties of controllable sedation, rapid onset, and a short duration of action, along with minor depression of circulation and respiration. Remimazolam has been approved for clinical use since 2020 in Japan, and it has been applied for procedural sedation, general anesthesia induction and maintenance, and sedation in ICU patients, and has been proven to be safe and effective. Currently, no consensus has been reached on the clinical application of remimazolam in pediatric patients. This review introduces the clinical research progress and limitations of remimazolam in recent years, aiming to supply scientific guidance and a theoretical reference for the application of remimazolam in pediatric anaesthesia.

Efficacy and Safety of Ciprofol Sedation in ICU Patients Undergoing Mechanical Ventilation: A Multicenter, Single-Blind, Randomized, Noninferiority Trial.

To determine the effectiveness and safety of ciprofol for sedating patients in ICUs who required mechanical ventilation (MV). A multicenter, single-blind, randomized, noninferiority trial. Twenty-one centers across China from December 2020 to June 2021. A total of 135 ICU patients 18 to 80 years old with endotracheal intubation and undergoing MV, who were expected to require sedation for 6-24 hours. One hundred thirty-five ICU patients were randomly allocated into ciprofol (n = 90) and propofol (n = 45) groups in a 2:1 ratio. Ciprofol or propofol were IV infused at loading doses of 0.1 mg/kg or 0.5 mg/kg, respectively, over 4 minutes ± 30 seconds depending on the physical condition of each patient. Ciprofol or propofol were then immediately administered at an initial maintenance dose of 0.3 mg/kg/hr or 1.5 mg/kg/hr, to achieve the target sedation range of Richmond Agitation-Sedation Scale (+1 to -2). Besides, continuous IV remifentanil analgesia was administered (loading dose: 0.5-1 μg/kg, maintenance dose: 0.02-0.15 μg/kg/min). Of the 135 patients enrolled, 129 completed the study. The primary endpoint-sedation success rates of ciprofol and propofol groups were 97.7% versus 97.8% in the full analysis set (FAS) and were both 100% in per-protocol set (PPS). The noninferiority margin was set as 8% and confirmed with a lower limit of two-sided 95% CI for the inter-group difference of -5.98% and -4.32% in the FAS and PPS groups. Patients who received ciprofol had a longer recovery time (p = 0.003), but there were no differences in the remaining secondary endpoints (all p > 0.05). The occurrence rates of treatment-emergent adverse events (TEAEs) or drug-related TEAEs were not significantly different between the groups (all p > 0.05). Ciprofol was well tolerated, with a noninferior sedation profile to propofol in Chinese ICU patients undergoing MV for a period of 6-24 hours.

Adaptive Sedation Monitoring From EEG in ICU Patients With Online Learning.

Sedative medications are routinely administered to provide comfort and facilitate clinical care in critically ill ICU patients. Prior work shows that brain monitoring using electroencephalography (EEG) to track sedation levels may help medical personnel to optimize drug dosing and avoid the adverse effects of oversedation and undersedation. However, the performance of sedation monitoring methods proposed to date deal poorly with individual variability across patients, leading to inconsistent performance. To address this challenge we develop an online learning approach based on Adaptive Regularization of Weight Vectors (AROW). Our approach adaptively updates a sedation level prediction algorithm under a continuously evolving data distribution. The prediction model is gradually calibrated for individual patients in response to EEG observations and routine clinical assessments over time. The evaluations are performed on a population of 172 sedated ICU patients whose sedation levels were assessed using the Richmond Agitation-Sedation Scale (scores between -5 = comatose and 0 = awake). The proposed adaptive model achieves better performance than the same model without adaptation (average accuracies with tolerance of one level difference: 68.76% vs. 61.10%). Moreover, our approach is shown to be robust to sudden changes caused by label noise. Medication administrations have different effects on model performance. We find that the model performs best in patients receiving only propofol, compared to patients receiving no sedation or multiple simultaneous sedative medications.

Comparative Study of Propofol and Midazolam Infusion for Sedation in ICU Patients

Comparative Study of Propofol and Midazolam Infusion for Sedation in ICU Patients

Heart rate variability: implications for perioperative anesthesia care.

Heart rate variability (HRV) is a measure of the balance between both the parasympathetic and sympathetic nervous system and may provide useful information for anesthesia care providers. HRV may offer predictive information about critically ill and operative patients. Further, HRV collection provides real-time information of patient autonomic nervous system status and may allow tailoring of the analgesia for patients in the ICU and operating room. Reduced and abnormal resting HRV predict sudden and nonsudden cardiac death. Recent evidence shows that decreased HRV correlates with worsened outcomes in both trauma patients and patients with sepsis, as well as the risk of developing hypotension after induction of general anesthesia and placement of intrathecal local anesthesia. In addition, HRV appears to provide an accurate assessment of the nociception-analgesia balance in deeply sedated ICU patients and those under general anesthesia. No study has assessed the prognostic value of preoperative HRV in patients presenting for surgery. Use of HRV for patient risk stratification and intraoperative analgesia management may allow tailored perioperative care and improved outcomes. If intraoperative HRV data leads to decreased perioperative opioid use, opioid-related adverse events, a serious perioperative issue, may be decreased. Not applicable.

Technology III: in-line vaporizer with reflector.

As the clinical advantages of vapor anesthesia (VA) for sedation of patients in ICU become more apparent, the ergonomics, economy and safety issues need to be better addressed. Here we describe the use of a new commercial digital in-line anesthetic vaporizer that can be attached to the inspiratory limb of a ventilator. If used with a simple, and easily assembled secondary circuit and anesthetic reflector, the circuit remains remote from the patient, the VA consumption approaches a physical minimum, VA level is controlled and monitored, and the tidal volume size is not limited.

Effect of Dexmedetomidine on Normal Coronary Vessel Diameter

Dexmedetomidine is a selective alpha2 agonist, which is widely used for conscious sedation in ICU patients. It is being increasingly used to provide conscious sedation in out-of-theatre procedures like CT scan, MRI, endoscopies and catheterization (cath) procedures. There is limited data till date regarding the effect of dexmedetomidine on coronary vessel diameter. The aim of this prospective observational study was to observe the effect of dexmedetomidine on normal coronary vessel diameter. Fifty patients who had come for elective coronary angiography in the cath lab were enrolled in the study. After taking the first shot of the coronary angiogram and confirming that the right coronary artery (RCA) is normal, dexmedetomidine was administered in a dose of 1 µg/kg intravenously over 15 min. Immediately after that, another shot was taken to check the diameter of RCA. Paired Student's t test was used to analyze the data. The mean diameter of RCA before giving dexmedetomidine was 2.7634 ± 0.3189 mm. The mean diameter decreased significantly to 2.6296 ± 0.3379 mm after administration of dexmedetomidine (p value <0.0001). Thus, dexmedetomidine decreases the coronary vessel diameter.

MIRUS™, a new system for sedation with halogenates in the ICU: a preliminary study of feasibility in postsurgical patients

Sedation is standard practice in the ICU [1]. The aim of this study was to investigate the efficiency and safety of the MIRUS™ system (Pall Medical), a new device for sedation in ICU patients [2]. The system delivers volatile anesthetics in mechanically ventilated patients. An open reservoir scavenger and a dedicated gas filter avoid residual volatile anesthetic halogenate escaping into the room air.

Daily Sedation Interruption Versus Targeted Light Sedation Strategies in ICU Patients

The updated clinical practice guidelines for the management of pain, agitation, and delirium recommend either daily sedation interruption or maintaining light levels of sedation as methods to improve outcomes for patients who are sedated in the ICU. We review the evidence supporting both methods and discuss whether one method is preferable or if they should be used concurrently. Original research articles identified using the electronic PubMed database. Randomized controlled trials and large prospective cohort studies of mechanically ventilated ICU patients requiring sedation were selected. The methods of daily sedation interruption and targeting light sedation levels (including avoidance of deep sedation) are safe in critically ill patients with no increase, and a potential decrease, in long-term psychiatric disturbances. Randomized trials comparing these methods with standard care, which has traditionally involved moderate to heavy sedation, found that both methods reduced duration of mechanical ventilation and ICU length of stay. Additionally, one trial noted that daily sedation interruption paired with spontaneous breathing trials improved 1-year survival, whereas a large observational study found that deep sedation was associated with decreased 180-day survival. Two common characteristics of these interventions in trials showing benefits were avoidance of deep levels of sedation and significant reductions in sedative doses, especially benzodiazepines. Thus, combining targeted light sedation with daily sedation interruption may be more beneficial than either method alone if sedative doses are reduced and arousal and mobility are facilitated during the ICU stay. Daily sedation interruption and targeting light sedation levels are safe and proven to improve outcomes for sedated ICU patients when these approaches result in reduced sedative exposure and facilitate arousal. It remains unclear as to whether one approach is superior, and further studies are needed to evaluate which patients benefit most from either or both techniques.

A New Era for Sedation in ICU Patients

A New Era for Sedation in ICU Patients

Sevrage de la sédation : modalités et conséquences

Only few studies have focused on the issues raised by discontinuing sedation in ICU patients. Several lines of evidence allow defining the risk factors for the occurrence of a weaning syndrome due to discontinuation of sedatives and analgesics in ICU patients. These primarily include a prolonged (more than seven days) period of continuous intravenous administration of high doses of hypnotics and opioids. Weaning from sedation is tightly linked to weaning from the ventilator and this area should be the target of research work in the near future.

Comparing Entropy and the Bispectral Index with the Ramsay Score in Sedated ICU Patients

ENTROPY is a new anesthetic depth monitor based on the analysis of the EEG signal. Our aim has been to evaluate sedation of intubated surgical critically ill patients by means of the Ramsay sedation score, the Bispectral index and ENTROPY, and to analyse the correlation between these variables. Sedation was evaluated every 15 min for a 1 h period in 50 non-paralysed postoperative critically ill, intubated patients, enrolled over a 6 month period. A 5 min steady-state period was allowed before each assessment. Both the Bispectral index and the Entropy parameters Response Entropy (RE) and State Entropy (SE), were collected before assessing the Ramsay scale. Mean values for SE, RE and BIS were 53 +/- 27, 60 +/- 30, and 62 +/- 24 respectively. The median value for the Ramsay was 6 (range 1-6). Significant correlation was found between the four variables (SE-BIS: r = 0.79, p < 0.001; RE-BIS: r = 0.80, p < 0.001; SE-Ramsay: rho = -0.71, p < 0.001, RE-Ramsay: rho = -0.72, p < 0.001; BIS-Ramsay: rho = -0.78, p < 0.001; RE-SE: r = 0.98, p < 0.001). An overlap of BIS and Entropy values for every Ramsay score value between 4-6 was found. ENTROPY, BIS and Ramsay score values correlate significantly in sedated postoperative ICU patients. ENTROPY does not appear superior to BIS for the assessment of sedation in this context.

Sedation practices in Denmark

The interest of sedation in ICU patients has been increasing the last 10 years. The benefits of protocol-driven care have become evident.

Novel measure for EEG/EMG responsiveness may indicate the level of sedation in ICU patients

The level of sedation in ICU patients is difficult to assess, and relies on clinical assessments such as the Ramsay score. These tests discriminate deep sedation poorly. We evaluated a novel measure, EEG/EMG responsiveness, and compared it with Ramsay scores. EEG/EMG responsiveness was calculated by applying an algorithm that detects abrupt changes in the measured EEG signal indicative of a patient's arousal or activation. The results were compared with those obtained using the EEG entropy.

Sedation in PACU: The Role of Propofol

In critically ill patients, adequate sedation increases comfort, minimizes stress response and facilitates diagnostic and therapeutic procedures. Propofol (2-, 6-diisopropylphenol) is an intravenous sedative-hypnotic agent popular for sedation in the Intensive Care Unit. The favorable propofol pharmacokinetic, characterized by a three compartment linear model, allows rapid onset and short duration of action. The emergence time from sedation with propofol varies with the depth and the duration of sedation and the patient's bodyweight. Propofol causes hypotension, particularly in volume depleted patients, decreases cerebral oxygen consumption, reduces intracranial pressure and has potent anti-convulsant properties. It is a potent antioxidant, has anti-inflammatory properties and is a bronchodilator. As a consequence of these properties, propofol is being increasingly used in the management of traumatic head injury, status epilepticus, delirium tremens, status asthmaticus and in septic patients. Prolonged use (>48 h) of high doses of propofol (>66 mcg/Kg/min) has been associated with lactic acidosis, bradycardia, and lipidemia in pediatric patients. A rare complication firstly reported in pediatrics patients and also observed in adults is known as "propofol syndrome" characterized by myocardial failure, metabolic acidosis and rhabdomiolysis. Hyperkalemia and renal failure have also been associated with this syndrome. Hypertriglyceridemia and pancreatitis are uncommon complications. A large number of trials have compared the use of propofol with midazolam. Sedation with propofol is associated with adequate sedation in ICU patients, shorter weaning time and earlier tracheal extubation compared to midazolam, but not before ICU discharge.

Can BIS provide any information in sedated ICU patients suffering from acute neurological injury?

Can BIS provide any information in sedated ICU patients suffering from acute neurological injury?

Comparison of two bispectral index algorithms in monitoring sedation in postoperative intensive care patients*

Comparison of two versions of bispectral index (BIS) derived from the electroencephalogram in mechanically ventilated and continuously sedated patients after major abdominal surgery. Prospective, cohort, observational, unblinded study. Surgical intensive care unit of a university hospital. Forty-six patients undergoing major abdominal surgery scheduled for postoperative mechanical ventilation and continuous sedation. Patients were continuously sedated using propofol and sufentanil. Electrodes for determination of BIS were placed at the forehead of the patients according to the manufacturer's specifications immediately after arrival to the intensive care unit. The level of consciousness was assessed every 2 hrs by a clinical sedation scale (Ramsay sedation scale, levels 1-6). BIS, electromyographic activity, and signal quality index were recorded simultaneously at the same time as the Ramsay scale for 24 hrs or until patients were ready for extubation. BIS (version 2.10) and BIS XP (version 3.12) were determined at 2-hr intervals. BIS and BIS XP showed a high correlation of readings (rs = .79, p < .01). However, the methods did not yield identical results. Both variables were significantly influenced by electromyographic activity, especially at high values, whereas there was only a weak correlation with body temperature. Some of the deeply sedated patients (Ramsay 5 or 6) had BIS readings >80 (BIS, 16%; BIS XP, 13%; p = not significant). The newer algorithm BIS XP did not perform better than the previous version BIS in patients after major surgery who were mechanically ventilated and sedated on an intensive care unit. This precludes the use of BIS or BIS XP for distinguishing, among deeply sedated ICU patients, those with and without preserved cerebral electrical activity.

Implicit memory formation in sedated ICU patients after cardiac surgery

Recent research into memory formation under sedation has generated conflicting results. We investigated explicit and implicit memory in ICU patients during moderate to deep propofol sedation following cardiac surgery. Two different methods of memory testing were used; (1). free-association (F-A) word-pair testing (n=33) to test conceptual implicit memory and (2). process dissociation procedure (PDP) (n=26) to detect perceptual implicit and explicit memory. One hour after surgery, whilst sedated, the F-A group received one of two lists of 10 category-exemplar word-pairs through headphones, while the PDP group was presented with one of two lists of 16 five-letter words. When awake and co-operative, the F-A group was tested using F-A testing, and the PDP group was tested using the PDP. The F-A group had a mean (SD) correct response rate of 7 (9)% for the target list, and 9 (8)% for the distractor list. The PDP group had a mean (SD) correct response rate of 11 (14) and 10 (13)% for the inclusion and exclusion lists, respectively, with mean correct response rates of 13 (14)% for both the corresponding distractor lists. Neither group showed any significant differences between their responses and a list of distractor words (Wilcoxon tests). We found no evidence for memory formation in post-cardiac surgery patients under moderate to deep propofol sedation.

Can Patient State Index (PSI) as Determined by PSA 4000, an EEG Analyzer Be Useful in Assessing Sedation in ICU Patients?

Can Patient State Index (PSI) as Determined by PSA 4000, an EEG Analyzer Be Useful in Assessing Sedation in ICU Patients?