Sedation Policy Research Articles

Opioid, sedative, preadmission medication and iatrogenic withdrawal risk in UK adult critically ill patients: a point prevalence study

BackgroundIatrogenic withdrawal syndrome, after exposure medication known to cause withdrawal is recognised, yet under described in adult intensive care.AimTo investigate, opioid, sedation, and preadmission medication practice in critically ill adults with focus on aspects associated with iatrogenic withdrawal syndrome.MethodOne-day point prevalence study in UK intensive care units (ICUs). We collected ICU admission medication and/or substances with withdrawal potential, sedation policy, opioid and sedative use, dose, and duration.ResultsThirty-seven from 39 participating ICUs contributed data from 386 patients. The prevalence rate for parenteral opioid and sedative medication was 56.1% (212 patients). Twenty-three ICUs (59%) had no sedation/analgesia policy, and no ICUs screened for iatrogenic withdrawal. Patient admission medications with withdrawal-potential included antidepressants or antipsychotics (43, 20.3%) and nicotine (41, 19.3%). Of 212 patients, 202 (95.3%) received opioids, 163 (76.9%) sedatives and 153 (72.2%) both. Two hundred and two (95.3%) patients received opioids: 167 (82.7%) by continuous infusions and 90 (44.6%) patients for longer than 96-h. One hundred and sixty-three (76.9%) patients received sedatives: 157 (77.7%) by continuous infusions and 74 (45.4%) patients for longer than 96-h.ConclusionOpioid sedative and admission medication with iatrogenic withdrawal syndrome potential prevalence rates were high, and a high proportion of ICUs had no sedative/analgesic policies. Nearly half of patients received continuous opioids and sedatives for longer than 96-h placing them at high risk of iatrogenic withdrawal. No participating unit reported using a validated tool for iatrogenic withdrawal assessment.

Utilization of neonatal sedation and anesthesia: an SPR survey

There is little data regarding the use of sedation and anesthesia for neonatal imaging, with practice patterns varying widely across institutions. To understand the current utilization of sedation and anesthesia for neonatal imaging, and review the current literature and recommendations. One thousand, two hundred twenty-six questionnaire invitations were emailed to North American physician members of the Society for Pediatric Radiology using the Survey Monkey platform. Descriptive statistical analysis of the responses was performed. The final results represented 59 institutions from 26U.S. states, the District of Columbia and three Canadian provinces. Discrepant responses from institutions with multiple respondents (13 out of 59 institutions) were prevalent in multiple categories. Of the 80 total respondents, slightly more than half (56%) were associated with children's hospitals and 44% with the pediatric division of an adult radiology department. Most radiologists (70%) were cognizant of the neonatal sedation policies in their departments. A majority (89%) acknowledged awareness of neurotoxicity concerns in the literature and agreed with the validity of these concerns. In neonates undergoing magnetic resonance imaging (MRI), 46% of respondents reported attempting feed and bundle in all patients and an additional 46% attempt on a case-by-case basis, with most (35%) using a single swaddling attempt before sedation. Sedation was most often used for neonatal interventional procedures (93%) followed by MR (85%), nuclear medicine (48%) and computed tomography (31%). More than half of respondents (63%) reported an average success rate of greater than 50% when using neonatal sedation for MR. Current practice patterns, policies and understanding of the use of sedation and anesthesia for neonatal imaging vary widely across institutions in North America, and even among radiologists from the same institution. Our survey highlights the need for improved awareness, education, and standardization at both the institutional level and the societal level. Awareness of the potential for anesthetic neurotoxicity and success of non-pharmacologic approaches to neonatal imaging is crucial, along with education of health care personnel, systematic approaches to quality control and improvement, and integration of evidence-based protocols into clinical practice.

Adherence to a Pediatric Continuous Infusion Propofol Policy for Sedation in Mechanically Ventilated Patients: Opportunities for Change and Improvement.

To evaluate adherence to an institutional continuous infusion propofol policy for sedation in mechanically ventilated patients, investigate the rate of propofol-related infusion syndrome (PRIS), and explore areas of improvement to enhance policy compliance and safety. This was a single center, retrospective chart review of patients admitted to a pediatric or cardiac intensive care unit within a large free-standing quaternary care pediatric hospital who received continuous propofol for non-procedural continuous sedation for at least 6 hours between 2014 and 2019. Propofol exposure (dose and duration), laboratory data, and hemodynamic outcomes of patients were evaluated. A total of 104 patients (108 admissions and 133 treatment courses) met inclusion criteria. Policy adherence to propofol dosing and duration limitations were 70% (93/133 courses) and 68% (91/133 courses), respectively. Adherence to all elements of laboratory and hemodynamic monitoring was 23%. Hypotension and bradycardia were common among patients during propofol treatment courses. Except for hypertriglyceridemia, no significant difference in specific laboratory values were detected between patients exposed to greater than 66 mcg/kg/min (4 mg/kg/hr), compared with those exposed to less than 66 mcg/kg/min of propofol. Patients receiving therapy for longer than 48 hours had the highest rates of laboratory values associated with PRIS. No patient in the study cohort met full criteria for PRIS. Adherence to elements of an institutional propofol policy was variable. Improvements in policy adherence may be enhanced by updating policy features, leveraging the electronic medical record order-set, and gaining consensus among key stakeholders.

Safety Profile of Endoscopist-directed Balanced Propofol Sedation for Procedural Sedation: An Experience at a Hospital-based Endoscopy Unit.

Nurse-administered propofol sedation was restricted to anesthesiologists in 2009, a practice that has contributed to spiraling health care costs in the United States. The aim of this study was to evaluate the safety of endoscopist-directed balanced propofol sedation (EDBPS). We identified patients undergoing endoscopy with EDBPS from January 1, 2017, to June 20, 2017, and abstracted their medical records. Adverse events (AEs) included: hypoxia (oxygen saturation < 90%); hypotension [(a) systolic blood pressure < 90 mm Hg, (b) systolic blood pressure decline of >50 mm Hg, (c) decline in mean arterial pressure of >30%]; bradycardia (heart rate of < 40 beats/min). Logistic regression identified factors independently associated with AEs. A total of 1897 patients received EDBPS during the study period [mean age: 55 y (SD=11.4 y); 56.4% women]. Patients received median doses of 50 µg fentanyl, 2 mg of midazolam, and a mean propofol dose of 160±99 mg. There were no major complications (upper 95% confidence interval, 0.19%). Overall, 334 patients (17.6%) experienced a clinically insignificant AE: 65 (3.4%) experienced transient hypoxia, 277 patients (14.6%) experienced hypotension, 2 had transient bradycardia. In bivariate analysis, older age was associated with risk for hypotension, propofol dose was associated with transient hypoxemia, and procedure duration was associated with both hypotension and transient hypoxia. In multivariate analysis, only procedure length was associated with AEs (odds ratio scale 10; odds ratio=1.07; 95% confidence interval, 1.05-1.09, P<0.001). EDBPS is safe for endoscopic sedation. Given the higher cost of anesthesia-administered propofol, endoscopists should reinstate EDBPS by revising institutional sedation policies.

Sedation Rate Reduction in Paediatric Renal Nuclear Medicine Examinations: Consequences of a Targeted Audit.

Background: Nuclear medicine investigations are essential diagnostic tools in paediatric urology. Child-orientated examination techniques and the avoidance of sedation or anaesthesia vary in different institutions. We aimed at evaluating child friendly measures in our department to identify the potential for improvement. Based on these data, we changed the standards regarding the sedation policy and consequently re-evaluated sedation rates. Methods: Four-hundred thirty-five consecutive investigations were evaluated regarding the need for sedation, outcome and patient satisfaction at our department. After the revision of our department standards, we re-evaluated 159 examinations. Statistical analysis was performed with JUMBO (Java-supported Münsterian biometrical platform). Results: Eighty-six percent (60/70) would agree to perform an investigation under identical conditions again. Seventy-seven percent (17/22) of eligible patients >5 years of age felt good during the investigation. By changing our sedation policy, we could reduce the sedation rate from 27.1% to 7.5% (p < 0.0001; OR 0.219 95% CI 0.111–0.423). Conclusion: The evaluation of child friendly examination protocols demonstrated high reliability and patient satisfaction using situational sedation with a relatively high proportion of patients being sedated. Through protocol adaption with clear age limits, individual indication and education of staff, as well as the use of optimized sedatives, the need for sedation could be further reduced whilst maintaining a high patient satisfaction.

Regulatory Challenges to Emergency Medicine Procedural Sedation

As currently written, national regulatory guidance on procedural sedation has elements that are contradictory, confusing, and out of date. As a result, hospital procedural sedation policies are often widely inconsistent between institutions despite similar settings and resources, putting emergency department (ED) patients at risk by denying them uniform access to safe, effective, and appropriate procedural sedation care. Many hospitals have chosen to take overly conservative stances with respect to regulatory compliance to minimize their perceived risk. Herein, we review and critique standards and policies from the Centers for Medicare & Medicaid Services, The Joint Commission, state nursing boards, the Food and Drug Administration, and others with respect to their effect on ED procedural sedation. Where appropriate, we recommend modifications of and enhancements to their guidance that would improve the access of ED patients to modern, safe, and effective procedural sedation care.

Improving safety and reducing error in endoscopy (ISREE): a survey of UK services

BackgroundThe Joint Advisory Group on Gastrointestinal Endoscopy (JAG) ‘Improving Safety and Reducing Error in Endoscopy’ (ISREE) strategy was developed in 2018. In line with the strategy, a survey was conducted...

Creation and Implementation of a Palliative Sedation Policy: Foundational Aspects and Lessons Learned (QI610)

Creation and Implementation of a Palliative Sedation Policy: Foundational Aspects and Lessons Learned (QI610)

Impact of Anesthetic Management on Safety and Outcomes Following Mechanical Thrombectomy for Ischemic Stroke in SWIFT PRIME Cohort.

Background and purpose: The optimal anesthetic management of acute ischemic stroke patients during mechanical thrombectomy (MT) remains controversial. In this post-hoc analysis, we investigated the impact of anesthesia type on clinical outcomes in patients included in SWIFT PRIME trial.Methods: Ninety-seven patients treated with MT were included. Patients treated in centers with general anesthesia (GA) policy (n = 32) were compared with those treated in centers with conscious sedation (CS) policy (n = 65). Primary outcomes studied included times to treatment initiation (TTI), rates of successful recanalization (TICI 2b/3), and functional independence (mRS 0–2 at 90 days). Secondary outcomes were adverse events, lowest systolic and diastolic blood pressures (LSBP and LDBP) during MT. Univariate analysis and multivariate regression logistic modeling were conducted.Results: The GA-policy and CS-policy groups presented comparable TTI (94 ± 36 min vs. 102 ± 48 min; p = 0.44), rates of TICI 2b/3 recanalization (22/32 [68.8%] vs. 51/65 [78.5%]; p = 0.32). CS-policy was associated to higher rate of functional independence than GA-policy, but the difference was not significant (43/65 [66.2%] vs. 16/32 [50.0%]; p = 0.18). GA-policy patients had a higher rate of postoperative pneumonia (11/32 [34.4%] vs. 8/65 [12.3%]; p = 0.02) and lower LSBP (110 [30,160] mmHg vs. 119 [77,170] mmHg; p = 0.03) and LDBP (55 (15,75) mmHg vs. 67 [40,121]; p < 0.001). When corrected for differences in baseline characteristics, GA-policy was associated with lower rate of functional independence (OR 0.32; p = 0.05). A 10-point increase in perprocedural LDBP was associated with an increased likelihood of favorable outcome (OR 1.51; p = 0.01).Conclusions: GA-policy for MT presented comparable TTI and rates of successful revascularization to CS-policy. However, GA-policy was associated with lower rates of functional independence and with higher incidence of perprocedural hypotension and postoperative pneumonia.Clinical Trial Registration: URL—http://www.clinicaltrials.gov. Unique identifier: NCT01657461

Sedation practices in gastrointestinal endoscopy—A survey from southern India

Gastrointestinal endoscopies can cause an unpleasant experience for the patient. In India, most endoscopists follow a common institutional policy for sedation. The aim of this study was to analyze the sedation practices in various endoscopy centers across southern India. Data were collected with the help of a structured questionnaire given to a senior endoscopist of the center. Data from the completed questionnaire were later analyzed. Data were obtained from 19 centers across southern India. All endoscopy suites had central oxygen supply and emergency cart. A defibrillator was available in 12 centers (63.2%). Common criteria followed for administering sedation included therapeutic procedures (84.2%), patients who requested sedation (63.2%), children (63.2%), high-risk procedures (57.9%), and uncooperative patients (57.9%). Monitoring methods included pulse oximetry alone in six centers (31.6%), pulse oximetry with blood pressure monitoring in five centers (26.3%), and pulse oximetry, blood pressure, and electrocardiography (ECG) monitoring in eight centers (42.1%). For advanced procedures like endoscopic ultrasonography (EUS) and endoscopic retrograde cholangiopancreatography (ERCP), sedation was universally used. An anesthesiologist was available in the endoscopy suite in eight centers (42.1%). Five endoscopists administered propofol sedation without anesthesiologist's presence (26.3%). Thirteen centers had a written protocol for pre-procedure risk assessment (68.4%). A dedicated post-procedure observation area was available in seventeen centers (89.5%). Seven centers followed a written post-sedation discharge protocol (36.8%). Significant variations exist in the practice of sedation among endoscopists in southern India. There is an urgent need to formulate guidelines by endoscopy societies for ensuring better patient outcomes in endoscopy.

Feasibility of single- vs two-physician procedural sedation in a small community emergency department

ObjectiveSedation is commonly required for painful procedures in the emergency department (ED). Some facilities mandate two physicians be present for deep sedation cases. Evidence is lacking, however, that a two-physician approach improves safety outcomes. We report our experience on the feasibility of replacing a two-physician ED procedural sedation policy with a single-physician policy in a small, single-coverage community ED. MethodsThis is a retrospective, before/after, single-center observational study of prospectively collected data from January 2013 through December 2016. In September 2014, our medical center implemented a single-physician policy requiring only one emergency physician, accompanied by a sedation-trained ED registered nurse. The primary outcome was a sedation-related escalation of care that resulted in one of the following adverse events or interventions: dysrhythmia (symptomatic bradycardia or ventricular arrhythmias), cardiac arrest, endotracheal intubation, or unanticipated hospitalization. Secondary outcomes included hypoxemia (peripheral oxygen saturation less than 90% for greater than 1min), the use of bag-valve mask ventilation (BVM), use of a reversal agent, laryngospasm or pulmonary aspiration. ResultsWe performed 381 sedations during the study period: 135 patients in the two-physician group (before) and 246 patients in the single-physician group (after). The two groups were comparable in age and gender. There was no occurrence of the primary outcome. Secondary outcomes were uncommon, and were similar in the two groups. ConclusionsIn this small, single-coverage community ED, replacement of a two-physician policy with a single-physician policy for deep sedation in the ED was feasible and was not associated with an increase in adverse events.

206 Safety of Single- vs Two-physician Procedural Sedation in a Small Community Emergency Department

Sedation is commonly required for painful procedures in the emergency department (ED). Many hospital have policies that mandate two physicians participate in deep sedation cases. Evidence is lacking, however, that a two-physician approach improves safety outcomes. We compared the safety of ED procedural sedation between a two-physician and a single-physician policy in a small, single-coverage community ED. This is a before/after single-center observational study of prospectively collected data from January 2013 through December 2016. The study population included a consecutive series of ED patients of any age who received procedural sedation for any indication during the study period. Data collection occurred within the context of a facility-wide quality assurance and process improvement program that included standardization of sedation data reporting and monthly structured safety audits of all procedural sedation cases in the medical center. In 2012 a policy was implemented which required two physicians to participate in deep sedations in the ED. Given the practice environment in this small single-coverage community ED, it was frequently impractical to have two physicians reliably available for time-sensitive urgent, and often emergent, procedures in the ED. This led to impaired delivery of modern, high-quality ED sedation services, most notably delays in patient care. In September 2014, our medical center switched from a two-physician policy to a single-physician policy requiring only one emergency physician, accompanied by a sedation-trained ED registered nurse, and often a respiratory therapist. The primary outcome was a sedation-related escalation of care that resulted in one of the following adverse events: dysrhythmia (symptomatic bradycardia or ventricular arrhythmias), cardiac arrest, endotracheal intubation, or unanticipated hospitalization. Secondary outcomes included hypoxemia (peripheral oxygen saturation less than 90% for greater than one minute), the need for bag-valve mask ventilation (BVM), use of a reversal agent, laryngospasm or pulmonary aspiration. We performed 381 sedations during the study period: 135 patients in the two-physician group (before) and 246 patients in the single-physician group (after). The two groups were comparable in age and sex. Procedures for which sedation was indicated were similar between the groups, with joint or fracture reductions being the most common. Deep and dissociative sedation was more commonly employed in both groups, but was significantly more common in the single-physician group than the two-physician group (93% vs 68%, p<0.001). Propofol and ketamine were the most commonly used sedative agents for deep sedation in both groups. There was no occurrence of the primary outcome, and no clinically relevant adverse events in either group. Secondary outcomes were uncommon, and were similar in the two groups. The use of BVM was 1.5% in the two-physician group and 3.2% in the single-physician group (p=0.5). Rates of hypoxemia and other expected sedation events were uncommon (0-1.5%) and were similar in both groups. In this small, single-coverage community ED, replacement of a two-physician policy with a single-physician policy for deep sedation in the ED was not associated with an increase in adverse events.

Efficacy of the Sequential Administration of Melatonin, Hydroxyzine, and Chloral Hydrate for Recording Sleep EEGs in Children

Sedation of children for electroencephalography (EEG) recordings is often required. Chloral hydrate (CH) requires medical clearance and continuous monitoring. To try to reduce personnel and time resources associated with CH administration, a new sedation policy was formulated. This study included all children who underwent an EEG during a consecutive 3-month period following the implementation of the new sedation policy, which consists of the sequential administration of melatonin, hydroxyzine (if needed), and CH (if needed). The comparator group included all children with a recorded EEG during a consecutive 3-month period when the sedation policy consisted of the sole administration of CH. A total of 803 children with a mean age of 7.9 years (SD = 5.1, range = 0.5-17.7 years) were included. Sleep EEG recordings were obtained in 364 of 385 children (94.6%) using the old sedation policy and in 409 of 418 children (97.9%) using the new one. With the new sedation policy, the percentage of children requiring CH dropped from 37.1% to 6.7% (P < .001). Time to sleep onset and duration of sleep were not significantly different between the 2 policies. The new sedation policy was very well tolerated. The new sedation policy is very safe, is highly efficacious in obtaining sleep EEG recordings, and will result in substantial saving of time and personnel resources.

From Root Cause to Action Plan: How an Adverse Event Uncovered Deficiencies in Resident Knowledge of Sedation Policies and Practices.

Mild or moderate sedation for procedures frequently is administered outside the operating room by resident physicians with varying degrees of training. An adverse event at our institution involving procedural sedation prompted us to conduct a survey among resident physicians. This survey investigated resident knowledge and attitudes about sedatives and analgesics, in addition to knowledge of risk factors for sedation-related adverse events. The survey identified a range of knowledge deficiencies among resident physicians and a lack of awareness of institutional sedation policies. Identification of knowledge gaps facilitated an educational initiative that promoted training in the pharmacology of sedatives and analgesics, safe sedation practices, and institutional sedation policies. Additional interventions included updating our sedation policy and creation of an electronic order set to facilitate the safe prescription of sedatives.

Neonatal preintubation sedation: a national survey in Malaysia.

BackgroundThere is a shift of practice towards administering sedation in neonates around the world. At the present moment, there is no available data or literature on the practice of sedation before intubation of neonates in Malaysia thus, evaluation of these practice was not possible. This study was conducted to evaluate neonatal preintubation sedation practice and the availability of neonatal preintubation sedation policy in government, university and private Malaysian Neonatal Intensive Care Units (NICUs) in 2007.MethodsAll 43 NICUs in Malaysia were identified and approached to participate in the study. Phone interviews with doctors’ in-charge of NICUs were conducted in 29 governments, 3 universities and in 7 private NICUs.ResultsOnly 7 NICUs had written policy on neonatal preintubation sedation use. Seventy-seven percent and 97.4 % of NICUs used sedation during emergency intubation and during planned intubation respectively. Sixty seven percent used either morphine or midazolam with no preference of either drug.ConclusionThis study showed a significant proportion of NICUs used sedation during emergency or planned intubation. However, the majority does not write policy on neonatal preintubation sedation use (82.1 %). The types and drug administration methods are not standardized in all of the NICUs. This will require a standard national written policy to be developed.

Plan to Have No Unplanned: A Collaborative, Hospital-Based Quality-Improvement Project to Reduce the Rate of Unplanned Extubations in the Pediatric ICU.

Although under-reported and understudied, unplanned extubations carry a significant risk of patient harm and even death. They are an important yardstick of quality control of care of intubated patients in the ICU. A unit-based risk assessment and multidisciplinary approach is required to decrease the incidence of unplanned extubations. As part of a quality-improvement initiative of Children's Hospital at Montefiore, all planned and unplanned extubations in a multidisciplinary 20-bed pediatric ICU were evaluated over a 12-month period (January to December 2010). At the end of 6 months, an interim analysis was performed, and high-risk patient groups and patient care factors were identified. These factors were targeted in the second phase of the project. Over this period, there were a total of 267 extubations, of which 231 (87%) were planned extubations and 36 (13%) were unplanned. A patient care policy targeting the risk factors was instituted, along with extensive nursing and other personnel education in the second phase. As a result of this intervention, the unplanned extubation rate in the pediatric ICU decreased from 3.55 to 2.59/100 intubation days. All subjects who had an unplanned extubation during nursing procedures or transport required re-intubation, whereas none of the unplanned extubations during ventilator weaning required re-intubation. A targeted approach based on unit-specific risk factors is most effective in quality-improvement projects. A specific policy for sedation and weaning can be very helpful in managing intubated patients and preventing unintended harm.

A web-based survey of United Kingdom sedation practice in the intensive care unit

PurposeThe purpose of this work was to obtain a detailed perspective of sedation practice. Sedation included sedative and opioid choice, presence of local guidelines, and use of scoring systems. MethodsA Web-based survey was designed. The aim was to gain sufficient detail of UK sedation while also being succinct enough to complete in 15 minutes. It was composed of relevant demographics, policy, sedative choice, and analgesia. The survey was piloted before launch. The investigators selected the intensive care unit (ICU) pharmacist as the respondent. ResultsOne hundred fifty-seven ICUs responded. Eighty-nine (59%) reported use of sedation guidelines, 78% undertook sedation holds, and 87% use sedation scores. Only 42% used a daily sedation target. Seventy (43%) assess for delirium; 27 of those use a validated tool.Propofol (89%) use was common, followed by midazolam (49%). Morphine (49%), fentanyl (34%), and alfentanil (34%) were the most frequently used opioids. ConclusionThis survey confirmed expected variation in UK sedation practice. Recognized strategies such as target sedation score and sedation policy are underused. A 43% uptake in delirium screening suggests that larger engagement is required to meet national standards.

Physician-Directed Bolus Sedation for Colonoscopy Improves Endoscopy Unit Efficiency

Introduction: To determine the impact of implementation of a physician-directed bolus sedation policy for colonoscopy on endoscopy unit efficiency and patient satisfaction. Methods: We performed a retrospective analysis of time data for colonoscopies performed between April 2010 and April 2011 at a hospital-based endoscopy unit affiliated with an academic health system. Colonoscopies performed prior to October 2010 were performed under a nurse-directed titration sedation policy, in which nurses administered incremental doses of fentanyl and midazolam until sedation was felt to be adequate to begin the procedure. Colonoscopies performed after October 2010 were performed under a physician-directed bolus sedation policy, in which physicians directed the administration of fentanyl and midazolam guided by a weight-based dosing nomogram. To evaluate the impact of sedation policy on endoscopy unit efficiency, we compared the total procedure time, which is the time interval from the administration of sedation to the completion of the colonoscopy between the two sedation groups. We also analyzed several sub intervals, including: sedation time (sedation start to colonoscopy start); colonoscopy time (colonoscopy start to colonoscopy completion); and recovery time (time from procedure completion to patient discharge). We also compared patient satisfaction surveys performed in a subset of patients from each sedation group. Patient satisfaction was rated on a five-point scale with 1 corresponding to the greatest level of satisfaction and 5 being the least. Results: The results of the analysis are provided in the Table. Bolus sedation had a shorter total procedure time (p<0.01) due to a reduction in sedation time (p<0.01). In contrast, colonoscopy time was minimally increased in the bolus sedation group. Bolus sedation did not significantly change the recovery time, and did not impact patient satisfaction. Conclusion: Physician-directed bolus sedation using a weight-based nomogram improves endoscopy unit efficiency by allowing a faster onset to colonoscopy start, reducing the total procedure time; this benefit does not come at the expense of patient satisfaction.Table 1

Palliative Sedation: An Analysis of International Guidelines and Position Statements.

To describe the suggested clinical practice of palliative sedation as it is presented in the literature and discuss available guidelines for its use. CINAHL, PubMed, and Web of Science were searched for publications since 1997 for recommended guidelines and position statements on palliative sedation as well as data on its provision. Keywords included palliative sedation, terminal sedation, guidelines, United States, and end of life. Inclusion criteria were palliative sedation policies, frameworks, guidelines, or discussion of its practice, general or oncology patient population, performance of the intervention in an inpatient unit, for humans, and in English. Exclusion criteria were palliative sedation in children, acute illness, procedural, or burns, and predominantly ethical discussions. Guidelines were published by American College of Physicians-American Society of Internal Medicine (2000), Hospice and Palliative Nurses Association (2003), American Academy of Hospice and Palliative Medicine (2006), American Medical Association (2008), Royal Dutch Medical Association (2009), European Association for Palliative Care (2009), National Hospice and Palliative Care Organization (2010), and National Comprehensive Cancer Network (2012). Variances throughout guidelines include definitions of the practice, indications for its use, continuation of life-prolonging therapies, medications used, and timing/prognosis. The development and implementation of institutional-based guidelines with clear stance on the discussed variances is necessary for consistency in practice. Data on provision of palliative sedation after implementation of guidelines needs to be collected and disseminated for a better understanding of the current practice in the United States.

A Census of Current Sedation Monitoring Practices in Adult General Intensive Care Units in England

Under- and over-sedation in intensive care units (ICUs) have potentially deleterious consequences. The Intensive Care Society (ICS) produced guidelines in 2007 to unify sedation management. The aim of the current census was to investigate how sedation practice was subsequently implemented in England. A telephone-based questionnaire to the ‘nurse-in-charge’ was iteratively developed at the host institution until respondent concordance was greater than 80%. Two hundred and four adult general ICUs across England were then contacted. One hundred and sixty units (79%) completed the survey; 82% of responding ICUs had a written sedation policy; all responding ICUs used a sedation scoring system, mainly the Richmond Scale (64%). All responding ICUs assessed and documented sedation levels, with 73% formally assessing this at least two-hourly; 91% of responding ICUs had a formal sedation holding policy; 73% of responding nurses felt there was adequate medical guidance provided on sedation depth; 27% of responding ICUs had bispectral index (BIS) monitors, with 74% of these units using them for monitoring sedated patients receiving neuromuscular blocking agents. Sedation management has improved nationally over the last five years. Written sedation policies, sedation scoring and sedation holding are standard practice. However, some nurses feel they need more guidance on choosing sedation depth, and some units assess sedation depth less frequently than two-hourly. In order to optimise clinical practice, we propose that sedation depth be a goal-directed therapy that is addressed at each patient review.