Sedation Interruption Research Articles

Optimising drug dosing in patients receiving extracorporeal membrane oxygenation.

Optimal pharmacological management during extracorporeal membrane oxygenation (ECMO) involves more than administering drugs to reverse underlying disease. ECMO is a complex therapy that should be administered in a goal-directed manner to achieve therapeutic endpoints that allow reversal of disease and ECMO wean, minimisation of complications (treatment of complications when they do occur), early interruption of sedation and rehabilitation, maximising patient comfort and minimising risks of delirium. ECMO can alter both the pharmacokinetics (PK) and pharmacodynamics (PD) of administered drugs and our understanding of these alterations is still evolving. Based on available data it appears that modern ECMO circuitry probably has a less significant impact on PK when compared with critical illness itself. However, these findings need further confirmation in clinical population PK studies and such studies are underway. The altered PD associated with ECMO is less understood and more research is indicated. Until robust dosing guidelines become available, clinicians will have to rely on the principles of drug dosing in critically ill and known PK alterations induced by ECMO itself. This article summarises the PK alterations and makes preliminary recommendations on possible dosing approaches.

Does daily sedation interruption avert the experience of memory impairment in ICU survivors

Introduction: Sedation is an integral part of management of mechanically ventilated critically ill patients in intensive care units (ICU). Daily sedation interruption (DSI) has been associated with better outcomes such as short ventilator, ICU and hospital length of stay (LOS), decreased incidence of ventilator acquired pneumonia. However, long-term outcomes such as memory impairment have not been explored in relation to DSI. This paper disseminates findings from a larger study that explored the experience of critically ill patients in the context of DSI.

The Relationship between Daily Sedative Interruption and Selected Patients' Outcomes among Mechanically Ventilated Patients

The Relationship between Daily Sedative Interruption and Selected Patients' Outcomes among Mechanically Ventilated Patients

The Effect of Daily Sedation-Weaning Application on Morbidity and Mortality in Intensive Care Unit Patients.

Background/aimsSedation is one of the most important components of intensive care unit (ICU) in patients who are mechanically ventilated at intensive care conditions. As a result of sedation and analgesia in the intensive care unit, the patient is to be awakened a comfortable and easy process. The aim of the study is to demonstrate the effects of day-time sedation interruptions in intensive care patients.Material and methodsWe made a retrospective review of 100 patients who were monitored, mechanically ventilated and treated at our intensive care unit between January 2008 and January 2013. Patients were divided into two groups, including Group P (continuous infusion of sedative agent) and Group D (daily sedation interruptions - daily recovery).Demographics, mechanical ventilation time, stay at intensive care unit, hospitalization period, time of first weaning, success of weaning, ventilator-related pneumonia (VRP), total doses of drugs, re-intubation frequency, Acute Physiology and Chronic Health Evaluation II (APACHE II), Sequential Organ Failure Assessment (SOFA) scores and mortality rates of patients were compared. Ramsay Sedation Score (RSS) was used to evaluate the level of sedation. Considering that ideal sedation level is "3" with RSS, RSS < 3 is considered as mild sedation, while RSS > 3 is considered as deep sedation.ResultsThere was no difference between demographics of patients. Mechanical ventilation period was significantly longer in Group P than Group D (p < 0.001). When stay at ICU unit was considered, ICU stay was significantly longer in Group P than Group D (p < 0.001). No statistically significant difference was found between two groups with respect to hospitalization period. In inter-group comparison, time to start first weaning was significantly late in Group P than Group D (p < 0.05). There was no difference between groups in terms of frequency of success of weaning and mortality rate (p > 0.05). In inter-group comparison the frequency of reintubation viewed in Group D was significantly less than in Group P (p < 0.05). Considering development of VRP, it was significantly more common in Group P in comparison with Group D (p < 0.05). No statistically significant difference was found between groups in terms of doses of sedative agents (p > 0.05). Considering doses of opioid analgesics, the total dose of fentanyl was significantly higher in Group P than Group D (p = 0.04), while no difference was found for doses of morphine (p > 0.05). Again, no statistical difference was found in doses of muscle relaxant agents (p > 0.05).ConclusionIt was observed that the sedation technique with daily interruption is superior to continuous infusion of sedatives. Accordingly, we believe that daily weaning will make positive contributions to patients who are mechanically ventilated at intensive care unit.

Nurses' Sedation Practices During Weaning of Adults From Mechanical Ventilation in an Intensive Care Unit.

Sedation and analgesia have an important impact on the outcome of patients treated with mechanical ventilation. International guidelines recommend use of sedation protocols to ensure best patient care. To determine the sedation practice of intensive care nurses weaning adults from mechanical ventilation. A cross-sectional survey with a self-administered questionnaire was used to determine sedation practices of Flemish critical care nurses during weaning. Consensus on content validity was achieved through a Delphi procedure among experts. Data were collected during the 32nd Annual Congress of the Flemish Society of Critical Care Nurses in Ghent, Belgium, December 2014. A total of 342 nurses were included in the study. Of these, 43.7% had a sedation protocol in their unit that was used by 61.8% of the respondents. Sedation protocols were more often available (P < .001) in academic hospitals (72%) than in general hospitals (41.5%). Sedatives were administered via continuous infusion with bolus doses if needed (81%). Level of sedation was assessed every 2 hours (56%), mostly via the Richmond Agitation-Sedation Scale (59.1%). Daily interruption of sedation was used by 16.5% of respondents. The biggest barriers to daily interruption were patient comfort (49.4%) and fear of respiratory worsening (46.6%). A considerable discrepancy exists between international recommendations and actual sedation practices. Standardization of sedation practices across different institutions on a regional and national level may improve the quality of care.

Sedacija u jedinicama intenzivnog lečenja

Critically ill patients during the treatment in the intensive care units (ICU) are exposed to various interventions and stressors from the environment that represent a significant source of discomfort. Sedative and analgesic medications are commonly administered to provide comfort and improve tolerance of ICU management. It has been recognized that pain and delirium, coupled with oversedation, are associated with increased morbidity and mortality if not properly addressed. Routine monitoring with reliable tools enables early detection of agitation and pain, thus avoiding excessive sedation and harsh consequences of delirium. Individual approach implies selection of medications that meet patient's needs while taking into account the presence of organ dysfunctions that may influence drug metabolism and predispose a patient to severe side effects of sedation. The current evidence reveals that a deep sedation should always be avoided as long as there is no mandatory clinical indication. The newest guidelines also suggest the use of non-benzodiazepine (either propofol or dexmedetomidine) sedation whenever feasible to improve clinical outcomes in mechanically ventilated patients. Aside from specific situations (increased intracranial pressure, the administration of muscle relaxants, seizures) the required goal should be an alert, cooperative patient who can tolerate necessary interventions in the ICU. It has been demonstrated that daily interruption of sedation and sleep promotion are beneficial in decreasing the duration of mechanical ventilation and decreasing the incidence of cognitive impairments. Further studies are needed to elucidate the association of non-pharmacological interventions with long-term psychological outcomes.

Immediate interruption of sedation for post-operative patients in the ICU reduces time on mechanical ventilation

Traditionally intensive care patients undergoing invasive mechanical ventilation have been sedated. In the last two decades increasing focus has been on reducing sedation for critically ill patients. Brook and colleagues reported a reduction in length of stay by implementing a nurse drive sedation protocol (1). This trial was very simple just giving the nurses the possibility to adjust the sedation to the patients need without having to contact a doctor. Also the trial made bolus doses possible instead of continuous infusion. Kress and colleagues reported reduced time on mechanical ventilation by performing a daily interruption of sedation (2). The intervention group was kept sedated to RAMSAY 3–4 and received a daily wake up trial. The sedation was afterwards stated on half the previous dose ensuring that patients were not over sedated. These finding was confirmed and further findings reported by Girard and colleagues in the ABC trial (3).

Effect of sedation on quantitative electroencephalography after cardiac arrest

BackgroundElectroencephalography (EEG) has clinical and prognostic importance after cardiac arrest (CA). Recently, interest in quantitative EEG (qEEG) analysis has grown. The qualitative effects of sedation on EEG are well known, but potentially confounding effects of sedatives on qEEG after anoxic injury are poorly characterized. We hypothesize that sedation increases suppression ratio (SR) and decreases alpha/delta ratio (ADR) and amplitude-integrated EEG (aEEG), and that the magnitude of sedation effects will be associated with outcome. MethodsWe routinely monitor comatose post-arrest patients with EEG for 48–72h. We included comatose EEG-monitored patients after CA who had protocolized daily sedation interruptions. We used Persyst v12 to quantify qEEG parameters and calculated medians for 10min immediately prior to sedation interruption and for the last 5min of interruption. We used paired t-tests to determine whether qEEG parameters changed with sedation cessation, and logistic regression to determine whether these changes predicted functional recovery or survival at discharge. Results78 subjects were included (median age 56, 65% male). Interruptions occurred a median duration of 34h post-arrest and lasted a median duration of 60min. Prior to interruption, higher aEEG predicted survival, while lower SR predicted both survival and favorable outcome. During interruption, SR decreased (p<0.001), aEEG increased (p=0.002), and ADR did not change. Larger decreases in SR predicted decreased survival (OR=1.04 per percent change; 95% CI 1.00–1.09). ConclusionHigher aEEG and lower SR predict survival after CA. Sedation alters aEEG and SR, but importantly does not appear to affect the relationship between these parameter values and outcome.

Factors Associated With Pediatric Ventilator-Associated Conditions in Six U.S. Hospitals: A Nested Case-Control Study.

A newly proposed surveillance definition for ventilator-associated conditions among neonatal and pediatric patients has been associated with increased morbidity and mortality among ventilated patients in cardiac ICU, neonatal ICU, and PICU. This study aimed to identify potential risk factors associated with pediatric ventilator-associated conditions. Retrospective cohort. Six U.S. hospitals PATIENTS:: Children less than or equal to 18 years old ventilated for greater than or equal to 1 day. None. We identified children with pediatric ventilator-associated conditions and matched them to children without ventilator-associated conditions. Medical records were reviewed for comorbidities and acute care factors. We used bivariate and multivariate conditional logistic regression models to identify factors associated with ventilator-associated conditions. We studied 192 pairs of ventilator-associated conditions cases and matched controls (113 in the PICU and cardiac ICU combined; 79 in the neonatal ICU). In the PICU/cardiac ICU, potential risk factors for ventilator-associated conditions included neuromuscular blockade (odds ratio, 2.29; 95% CI, 1.08-4.87), positive fluid balance (highest quartile compared with the lowest, odds ratio, 7.76; 95% CI, 2.10-28.6), and blood product use (odds ratio, 1.52; 95% CI, 0.70-3.28). Weaning from sedation (i.e., decreasing sedation) or interruption of sedation may be protective (odds ratio, 0.44; 95% CI, 0.18-1.11). In the neonatal ICU, potential risk factors included blood product use (odds ratio, 2.99; 95% CI, 1.02-8.78), neuromuscular blockade use (odds ratio, 3.96; 95% CI, 0.93-16.9), and recent surgical procedures (odds ratio, 2.19; 95% CI, 0.77-6.28). Weaning or interrupting sedation was protective (odds ratio, 0.07; 95% CI, 0.01-0.79). In mechanically ventilated neonates and children, we identified several possible risk factors associated with ventilator-associated conditions. Next steps include studying propensity-matched cohorts and prospectively testing whether changes in sedation management, transfusion thresholds, and fluid management can decrease pediatric ventilator-associated conditions rates and improve patient outcomes.

Sedation and Mobilization During Venovenous Extracorporeal Membrane Oxygenation for Acute Respiratory Failure: An International Survey.

To characterize sedation, analgesia, delirium, and mobilization practices in patients supported with venovenous extracorporeal membrane oxygenation for severe acute respiratory failure. Cross-sectional electronic survey administered January 2016 to March 2016. Three-hundred ninety-four extracorporeal membrane oxygenation centers registered with the Extracorporeal Life Support Organization. Extracorporeal membrane oxygenation medical directors and program coordinators. None. We analyzed responses from 209 respondents (53%), mostly from academic centers (63%); 41% respondents provide venovenous extracorporeal membrane oxygenation to adults exclusively. Following venovenous extracorporeal membrane oxygenation initiation, 97% respondents administer sedative/analgesic infusions, and the sedation target was "sedated" or "very sedated" for 59%, "calm and cooperative" for 25%, and "unarousable" for 16%. Use of daily sedation interruption and a sedation/analgesia protocol was reported by 51% and 39%, respectively. Midazolam (48%) and propofol (19%) were reported as the most frequently used sedatives; fentanyl (44%) and morphine (20%) the most frequent opioids. Use of a delirium scale was reported by 55% respondents. Physical therapy was reported by 84% respondents, with 41% initiating it within 72 hours after cannulation. Mobilization goals varied from range of motion exercises (81%) to ambulation (22%). The most frequently perceived barriers to mobilization were hemodynamic instability, hypoxemia, and dependency on venovenous extracorporeal membrane oxygenation support. The majority of respondents reported targeting moderate to deep sedation following cannulation, with the use of sedative and opioid infusions. There is considerable variability surrounding early physical therapy and mobilization goals for patients with acute respiratory failure supported by venovenous extracorporeal membrane oxygenation.

The Neurological Wake-up Test—A Role in Neurocritical Care Monitoring of Traumatic Brain Injury Patients?

The most fundamental clinical monitoring tool in traumatic brain injury (TBI) patients is the repeated clinical examination. In the severe TBI patient treated by continuous sedation in a neurocritical care (NCC) unit, sedation interruption is required to enable a clinical evaluation (named the neurological wake-up test; NWT) assessing the level of consciousness, pupillary diameter and reactivity to light, and presence of focal neurological deficits. There is a basic conflict regarding the NWT in the NCC setting; can the clinical information obtained by the NWT justify the risk of inducing a stress response in a severe TBI patient? Furthermore, in the presence of advanced multimodal monitoring and neuroimaging, is the NWT necessary to identify important clinical alterations? In studies of severe TBI patients, the NWT was consistently shown to induce a stress reaction including brief increases in intracranial pressure (ICP) and changes in cerebral perfusion pressure (CPP). However, it has not been established whether these short-lived ICP and CPP changes are detrimental to the injured brain. Daily interruption of sedation is associated with a reduced ventilator time, shorter hospital stay and reduced mortality in many studies of general intensive care unit patients, although such clinical benefits have not been firmly established in TBI. To date, there is no consensus on the use of the NWT among NCC units and systematic studies are scarce. Thus, additional studies evaluating the role of the NWT in clinical decision-making are needed. Multimodal NCC monitoring may be an adjunct in assessing in which TBI patients the NWT can be safely performed. At present, the NWT remains the golden standard for clinical monitoring and detection of neurological changes in NCC and could be considered in TBI patients with stable baseline ICP and CPP readings. The focus of the present review is an overview of the existing literature on the role of the NWT as a clinical monitoring tool for severe TBI patients.

Immediate interruption of sedation compared with usual sedation care in critically ill postoperative patients (SOS-Ventilation): a randomised, parallel-group clinical trial

Avoidance of excessive sedation and subsequent prolonged mechanical ventilation in intensive care units (ICUs) is recommended, but no data are available for critically ill postoperative patients. We hypothesised that in such patients stopping sedation immediately after admission to the ICU could reduce unnecessary sedation and improve patient outcomes. We did a randomised, parallel-group, clinical trial at three ICUs in France. Stratified randomisation with minimisation (1:1 via a restricted web platform) was used to assign eligible patients (aged ≥18 years, admitted to an ICU after abdominal surgery, and expected to require at least 12 h of mechanical ventilation because of a critical illness defined by a Sequential Organ Failure Assessment score >1 for any organ, but without severe acute respiratory distress syndrome or brain injury) to usual sedation care provided according to recommended practices (control group) or to immediate interruption of sedation (intervention group). The primary outcome was the time to successful extubation (defined as the time from randomisation to the time of extubation [or tracheotomy mask] for at least 48 h). All patients who underwent randomisation (except for those who were excluded after randomisation) were included in the intention-to-treat analysis. This study is registered with ClinicalTrials.gov, number NCT01486121. Between Dec 2, 2011, and Feb 27, 2014, 137 patients were randomly assigned to the control (n=68) or intervention groups (n=69). In the intention-to-treat analysis, time to successful extubation was significantly lower in the intervention group than in the control group (median 8 h [IQR 4-36] vs 50 h [29-93], group difference -33·6 h [95% CI -44·9 to -22·4]; p<0·0001). The adjusted hazard ratio was 5·2 (95% CI 3·1-8·8, p<0·0001). Immediate interruption of sedation in critically ill postoperative patients with organ dysfunction who were admitted to the ICU after abdominal surgery improved outcomes compared with usual sedation care. These findings support interruption of sedation in these patients following transfer from the operating room. Délégation à la Recherche Clinique et à l'Innovation du Groupement de Coopération Sanitaire de la Mission d'Enseignement, de Recherche, de Référence et d'Innovation (DRCI-GCS-MERRI) de Montpellier-Nîmes.

Postoperative interruption of sedation on arrival in the surgical ICU: a new standard of care

Postoperative interruption of sedation on arrival in the surgical ICU: a new standard of care

Multicenter assessment of sedation and delirium practices in the intensive care units in Poland - is this common practice in Eastern Europe?

BackgroundThe majority of critically ill patients experience distress during their stay in the Intensive Care Unit (ICU), resulting from systemic illness, multiple interventions and environmental factors. Providing humane care should address concomitant treatment of pain, agitation and delirium. The use of sedation and approaches to ICU delirium should be monitored according to structured guidelines. However, it is unknown to what extent these concepts are followed in Eastern European countries like Poland. The aim of this study was to evaluate sedation and delirium practices in ICUs in Poland, as a representative of the Eastern European block, particularly the implementation of sedation and ICU delirium screening tools, availability of written sedation guidelines, choice of sedation and delirium treatment agents.MethodsA national postal survey was conducted in all Polish ICUs in early 2016.ResultsA total of 165 responses out of 436 addressed units were received (37.8%). Out of responding ICUs delirium is monitored in only 11.9% of the units in Poland. Sedation monitoring tool is used in only 46.1% of units. Only 19.4% of ICUs have written protocols for sedation and 32.1% do not practice daily sedation interruption. The most frequently used agents for short-term sedation (<24 h) were propofol and fentanyl infusions and benzodiazepines (midazolam) and morphine for longer sedation (>24 h). The preferred agents for delirium treatment were haloperidol (77.6%), dexmedetomidine (43.6%) and quetiapine (19.4%). Close to one-third (32.7%) of respondents chose a benzodiazepine (diazepam) for ICU delirium treatment. Non-pharmacological treatment for ICU delirium was reported by only 45% of the respondents.ConclusionsA majority of Polish ICUs do not adhere to international guidelines regarding sedation and delirium practices. There continues to be inadequate use of sedation and delirium monitoring tools. High usage of benzodiazepines for sedation and ICU delirium treatment reveals persistence of non-evidence-based practice. This study should prompt further assessment of other Eastern Europe countries and help generate a collective response to update these aspects of patient safety and comfort.

Protocol-Directed Sedation Versus Non-Protocol-Directed Sedation to Reduce the Duration of Mechanical Ventilation in Intensive Care Patients.

Protocol-Directed Sedation Versus Non-Protocol-Directed Sedation to Reduce the Duration of Mechanical Ventilation in Intensive Care Patients.

Mechanical ventilation weaning protocol improves medical adherence and results

IntroductionImplementation of a weaning protocol is related to better patient prognosis. However, new approaches may take several years to become the standard of care in daily practice. We conducted a prospective cohort study to investigate the effectiveness of a multifaceted strategy to implement a protocol to wean patients from mechanical ventilation (MV) and to evaluate the weaning success rate as well as practitioner adherence to the protocol. MethodsWe investigated all consecutive MV-dependent subjects admitted to a medical-surgical intensive care unit (ICU) for >24h over 7years. The multifaceted strategy consisted of continuing education of attending physicians and ICU staff and regular feedback regarding patient outcomes. The study was conducted in three phases: protocol development, protocol and multifaceted strategy implementation, and protocol monitoring. Data regarding weaning outcomes and physician adherence to the weaning protocol were collected during all phases. ResultsWe enrolled 2469 subjects over 7years, with 1,943 subjects (78.7%) experiencing weaning success. Physician adherence to the protocol increased during the years of protocol and multifaceted strategy implementation (from 38% to 86%, p<0.01) and decreased in the protocol monitoring phase (from 73.9% to 50.0%, p<0.01). However, during the study years, the weaning success of all subjects increased (from 73.1% to 85.4%, p<0.001). When the weaning protocol was evaluated step-by-step, we found high adherence for noninvasive ventilation use (95%) and weaning predictor measurement (91%) and lower adherence for control of fluid balance (57%) and daily interruption of sedation (24%). Weaning success was higher in patients who had undergone the weaning protocol compared to those who had undergone weaning based in clinical practice (85.6% vs. 67.7%, p<0.001). ConclusionsA multifaceted strategy consisting of continuing education and regular feedback can increase physician adherence to a weaning protocol for mechanical ventilation.

Clinical application and evaluation of an early non-sedation protocol for critically ill respiratory patients

Objective: To study the value of an early (mechanical ventilation after 24 h) non-sedation protocol for intubated, mechanically ventilated patients in the respiratory intensive care unit (RICU). Methods: Seventy intubated, mechanically ventilated patients were prospectively enrolled and randomly assigned to management with early non-sedation (intervention group; n=35) or with daily interruption of sedation (DIS) (control group; n=35). The duration of mechanical ventilation, length of the RICU and hospital stay, RICU and hospital mortality, drug consumption, RICU and hospitalization expenses, incidence of complications and adverse events and serum levels of vital organ damage and inflammatory markers after mechanical ventilation for 48 h were recorded and compared. Results: Patients in the intervention group had a shorter duration of mechanical ventilation than those in the control group [(7±5) vs (11±9) d, P<0.05] and were discharged from the RICU [(9±7) vs (18±9) d, P<0.05] and hospital earlier [(17±14) vs (29±22) d, P<0.05] than those in the control group. The doses of midazolam were significantly lower in the intervention group than in the control group [(99±104) vs (482±337) mg, P<0.05]. The RICU and hospitalization expenses were both significantly lower in the intervention group than in the control group [53(84) vs 88(173), 72(195) vs 154(234) thousand CHY, P<0.05]. In the intervention group, the occurrence rates of ventilator associated pneumonia (23% vs 46%), tracheotomy (14% vs 37%) and gastrointestinal adverse reactions (17% vs 40%) were significantly lower than those in the control group (P<0.05). No differences were recorded in RICU and hospital mortality (P>0.05). The occurrence rates of unplanned extubation and reintubation and the need for CT brain scans were similar in the 2 groups (P>0.05). The levels of cardiac, liver and renal damage markers, lactic acid and C-reactive protein were the same in both groups (P>0.05). Conclusions: The early non-sedation protocol decreased the duration of mechanical ventilation and the length of stay in the RICU and hospital, and it did not increase the incidence of complications and adverse events.

Effect of ventilator bundle implementation on weaning indicator among mechanically ventilated patients at a selected private healthcare sector

Background Mechanical ventilator (MV) has serious complications; thus, the ultimate goal of MV is ventilator discontinuation. Ventilator bundle is a group of practices aimed to improve the patient outcomes. Aim The aim of this study was to examine the effect of ventilator bundle implementation on weaning indicator among mechanically ventilated patients. Research design A quasiexperimental design was utilized. Sample A purposive sample of 60 mechanically ventilated patients was enrolled. Patients were matched for age, sex, and medical characteristics and then randomly assigned to two groups. The study group included patients for whom all elements of the ventilator bundle were applied completely, whereas the control group included patients for whom the ventilator bundle elements were not applied completely. Setting This study was conducted in the ICUs of a selected private hospital in Cairo. Tools of data collection Three tools were utilized: sociodemographic and medical data sheet, ventilator bundle compliance checklist, and Burns’ Wean Assessment Program checklist. Results There was a significant statistical difference between the compliant (study group) and the noncompliant (control) group as regards weaning indicator scores (t=4.20; P=0.001). There was a significant difference between patients of the two groups as regards the compliance with individual ventilator bundle elements with respect to head-of-bed elevation (χ2=4.85, P=0.046), sedation interruption (χ2=6.4, P=0.03), and assessment of readiness to extubate (χ2=5.2, P=0.02). Conclusion Implementation of ventilator bundle plays a pivotal role in weaning from a MV. Recommendation Applying the ventilator bundle practices with focusing on the head-of-bed elevation, daily sedation interruption, and assessment of readiness to extubate is highly recommended. Moreover, the use of a structured tool to assess readiness for weaning can help in managing the mechanically ventilated patients. Furthermore, replication of the study on a larger probability sample from different geographical locations in Egypt ensures generalizability of the study.

Use of Daily Interruption of Sedation and Early Mobility in US Hospitals.

Although the Awakening and Breathing Coordination, Delirium assessment, and Early exercise/mobility (ABCDE) bundle may be effective, individual components of ABCDE may not be implemented as intended. We examined the use of daily interruption of sedation (DIS) and early mobility, looking for an association between these bundle elements. Despite the growing use of DIS and early mobility, the two do not seem to be adopted together, with serious implications for the effectiveness of the ABCDE bundle.

Analgesia and sedation in surgery Intensive Care Unit (ICU)

The goals of analgesia and sedation at the intensive care unit (ICU) are to facilitate mechanical ventilation, prevent patient and caregiver injury, and avoid the psychological and physiologic consequences of inadequate treatment of pain, anxiety, agitation, and delirium. Most ICU patients, especially the surgical and trauma ones, routinely experience pain at rest and with routine procedures. Treating pain in ICU patients depends on a clinician?s ability to perform a reproducible pain assessment and to monitor patients over time to determine the adequacy of therapeutic interventions to treat pain. Implementation of behavioral pain scales improves ICU pain management and clinical outcomes, including better use of analgesic and sedative agents and shorter durations of mechanical ventilation and ICU stay. Opioids are the primary medications for managing pain in critically ill patients. Multimodal approach to pain management in ICU patients has been recommended. Sedatives are commonly administered to ICU patients to treat agitation and its negative consequences. Sedation strategies using nonbenzodiazepine sedatives (propofol or dexmedetomidine) may be preferred over sedation with benzodiazepines (midazolam or lorazepam) to improve clinical outcomes in mechanically ventilated adult ICU patients. It is recommend daily sedation interruption or a light target level of sedation be routinely used in adult intensive care patients using mechanical ventilation. Delirium affecting up to 80% of mechanically ventilated adult ICU patients. ICU protocols that combine routine pain and sedation assessments, with pain management and sedation-minimizing strategies, along with delirium monitoring and prevention, may be the best strategy for avoiding the complications of oversedation. Protocolized pain, agitation and delirium assessment (PAD ICU), is significantly associated with a reduction in the use of analgesic medications, ICU length of stay, and duration of mechanical ventilation.