Sedation In ICU Research Articles

Effect of Implementing Nursing Guideline on Critically Patients Outcomes' Regarding Sedation

Sedation can help alleviate pain of intrusion allows patients to tolerate painful/distressing procedures optimize mechanical ventilation used to decrease O2 consumption, decrease ICP in neurosurgical patient,and facilitate cooling Control agitation. Reduce anxiety to alleviate pain, for amnesia during neuromuscular blocked. Aim of the present study was to evaluate the effect of implementing nursing guideline on critically patients' outcomes regarding sedation in ICU at Assiut University Hospitals. Design: Quesi experimental design was used to conduct the aim of this study. Subjects: A purposive sample of 60 adult's critically ill patients from both Sexes admitted in the general intensive care unit at Assiut University hospital Tools: Tool I: Patient assessment sheet, Tool II: Sedative assessment scales Method: the researcher used the study toolsand implement nursing guideline for study group. Results: finding of the present study revealed that there was a signifficant statistical diffrences between both study and control groups in relation to sedative complication tracheostomy, long ICU stay, and mortality (p < 0.05) Conclusion: implementation of nursing guidline about sedation was significantly effective in improve outcomes of critically se

A comparison of propofol-to-BIS post-operative intensive care sedation by means of target controlled infusion, Bayesian-based and predictive control methods: an observational, open-label pilot study

PurposeWe evaluated the feasibility and robustness of three methods for propofol-to-bispectral index (BIS) post-operative intensive care sedation, a manually-adapted target controlled infusion protocol (HUMAN), a computer-controlled predictive control strategy (EPSAC) and a computer-controlled Bayesian rule-based optimized control strategy (BAYES).MethodsThirty-six patients undergoing short lasting sedation following cardiac surgery were included to receive propofol to maintain a BIS between 40 and 60. Robustness of control for all groups was analysed using prediction error and spectrographic analysis.ResultsAlthough similar time courses of measured BIS were obtained in all groups, a higher median propofol effect-site concentration (CePROP) was required in the HUMAN group compared to the BAYES and EPSAC groups. The time course analysis of the remifentanil effect-site concentration (CeREMI) revealed a significant increase in CeREMI in the EPSAC group compared to BAYES and HUMAN during the case. Although similar bias and divergence in control was found in all groups, larger control inaccuracy was observed in HUMAN versus EPSAC and BAYES. Spectrographic analysis of the system behavior shows that BAYES covers the largest spectrum of frequencies, followed by EPSAC and HUMAN.ConclusionsBoth computer-based control systems are feasible to be used during ICU sedation with overall tighter control than HUMAN and even with lower required CePROP. EPSAC control required higher CeREMI than BAYES or HUMAN to maintain stable control.Clinical trial number: NCT00735631.

Comparison of dexmedetomidine and midazolam infusion for sedation in patients admitted in intensive care unit

Introduction: Dexmedetomidine and midazolam are frequently used to maintain sedation in mechanically ventilated patient in intensive care unit. The study compared dexmedetomidine and midazolam infusion in mechanically ventilated patient in terms providing effective sedation.&#x0D; Methods: This was one year prospec­tive comparative study conducted in 130 mechanically ventilated patients who were randomly divided in two groups receiving either dexmedetomidine or midazolam infusion for sedation. Sedation level was assessed by Riker Sedation-Agitation Scale with the aim of maintaining target sedation score of 3 to 4. The two drugs were compared in terms of sedation level in first 24 hours, time required to achieve target sedation level, hemody­namic changes and adverse effects including ICU delirium. The outcome was measured in terms of duration of mechanical ventilation, length of ICU stays and ICU mortality.&#x0D; Results: Both dexmedetomidine and midazolam achieved target sedation level in a comparable time duration. The median sedation level for both the drugs was 4 and 3 in initial 4 and 24 hours respectively. Dexmedetomidne produced significant decrease in blood pressure and heart rate (P=0.044 and P=0.007 respectively). Patients treated with dexmedetomidine had less incidence of ICU delirium (odds ratio=2.669, P=0.029).Dexmedetomidine infusion had significantly shorter duration mechanical ventilation (4.10 ± 2.05 vs. 5.15 ± 2.44, P=0.011), early discharge from ICU (6.05 ± 2.02 vs. 7.48 ± 2.42, p=0.001). ICU mortality was comparable between the groups.&#x0D; Conclusion: Dexmedetomidine and midazolam both were equally effective in maintaining sedation in Critically ill patient. Compared to midazolam, dexmedetomidine could be a preferred sedative in ICU in terms of early removal from mechanical ventilation, early discharge from ICU and less incidence of delirium.

Sedative drugs used for mechanically ventilated patients in intensive care units: a systematic review and network meta-analysis

Background: The effects of different sedative drugs on all-cause mortality rate, duration of ICU stay, and risk of delirium in mechanically ventilated ICU patients are unclear. This meta-analysis aimed to compare the effectiveness and safety of individual sedative drugs and drug combinations in mechanically ventilated ICU patients.Materials and methods: Medline, Embase, Cochrane, EBSCOhost, and ISI Web of Science databases were searched for studies that assessed sedation in ICU mechanically ventilated patients. A Bayesian random-effects model was used to combine the direct comparisons and indirect evidence.Results: Thirty-one randomized, controlled trials were included, which consisted of 4491 patients who received one of seven sedative drugs or a combination of drugs. There were no significant differences regarding the all-cause mortality rate. Compared to propofol, inhalation anesthetics (hazard ratio [HR] 0.121; 95% credible interval [CrI] -7.58 to 7.62), alpha agonists (HR 2.2; 95% CrI 0.776 to 5.22), propofol with benzodiazepines (HR 0.306; 95% CrI -6.97 to 7.65), ketamine with benzodiazepines (HR 6.57; 95% CrI -6.05 to 19.1) and placebo (HR 2.4; 95% CrI -5.37 to 10.3), benzodiazepines (HR 3.62; 95% CrI 0.834 to 6.2) may increase the duration of ICU stay. Compared to alpha agonists, propofol (HR 2.4; 95% CrI 0.304 to 21.1) and placebo (HR 6.12; 95% CrI 0.745 to 54.6), benzodiazepines (HR 2.59; 95% CrI 1.08 to 7.4) were associated with incremental risks of delirium.Conclusion: Compared to propofol, benzodiazepines may increase the duration of ICU stay. Compared to alpha agonists, benzodiazepines were associated with an increased risk of delirium.

A Study On comparison of dexmedetomidine, Propofol and Midazolam for Sedation in Surgical Icu

A Study On comparison of dexmedetomidine, Propofol and Midazolam for Sedation in Surgical Icu

Inhalative sedation with small tidal volumes under venovenous ECMO.

Inhalative sedation is an emerging method for long-term sedation in intensive care therapy. There is evidence that it is easy to control and may be beneficial compared to intravenous sedation. Yet little is known about the use in patients with compromised lung function. In this retrospective analysis, we searched files of patients receiving inhalative sedation under venovenous extracorporeal membrane oxygenator (vv-ECMO) support due to lung failure. After ethical approval, we performed a retrospective analysis of patients receiving vv-ECMO support and inhalative sedation in the surgical ICU in 2015. Isoflurane was administered via the AnaConDa®-system. Sedation was tested using Richmond Agitation and Sedation scale (RASS). 7 patients were identified. Median age was 50years (26/70years). All were male. Median ECMO runtime was 129h (37/1008h) and the survival rate was 57.9%. Dose of isoflurane was 1.7ml/h (0.8 / 4.0ml/h) resulting in expiratory concentrations of 0.8 Vol% (0.3/1.8 Vol%), inspiratory of 0.6 Vol% (0.1/1.4 Vol%). Higher concentrations of isoflurane were associated with increased depth of sedation (expiratory p = 0.016; inspiratory p = 0.027; averaged p = 0.015). With tidal volume below 350ml, association was still present for expiratory and averaged concentrations of isoflurane (expiratory p = 0.031; inspiratory p = 0.082; average p = 0.039). This is the first study that shows that inhalative concentrations of isoflurane are associated with depth of sedation in patients with lung failure. We were able to show that even with major impacts in lung mechanics and function targeted sedation with volatile anaesthetics is feasible and dose-response relationship appears to exist.

Role of Ramsay Sedation Scale in Sedative Dosage Modulation for Critically-Ill Intubated Patients

SESSION TITLE: ICU Management SESSION TYPE: Original Investigation Poster PRESENTED ON: Wednesday, November 1, 2017 at 01:30 PM - 02:30 PM PURPOSE: Titratable palliative sedation (TPS) is frequently applied in sedative therapeutics to ameliorate unendurable and refractory distress via reduction in patient consciousness. TPS may be adjusted based on objective and subjective data: vitals, labs, Ramsay Sedation Scale (RSS) and Richmond Agitation Sedation Scale (RASS). Inappropriate dosing, including oversedation from variability in clinician assessment of sedation scales, can contribute to significant negative clinicaloutcomes. We evaluated interrater reliability (IRR) and its relationship to variations in dosing to determine whether additional training in sedation scale assessment is necessary at our community institution. METHODS: This was a prospective study assessing sedation in ICU mechanically ventilated patients without neurogenic abnormalities. Non-nursing healthcare personnel conducted independent sedation assessments using the RSS and compared their evaluations to those documented by nursing staff. Data obtained from the patients' chart included: demographics, Ramsay Score, past medical history, diagnosis, and BMI. Post-analysis, non-nursing healthcare personnel scores were classified into three categories: equal to, higher than, or lower than those charted by nursing staff. RESULTS: There were 83 random RSS assessments conducted in 44 patients with a mean age of 63.6 +/- 10.09 years (range 38-82) and a mean BMI of 31.2 +/- 12.4 (range 15-77). 19/42 (45%) patients had a diagnosis of respiratory failure or pneumonia. Other diagnoses included CHF (3), seizures (5), AVR (1), SBO (1), drug overdose (2), cardiac arrest (2), and UTI (1), STEMI (2), PE (2), CABG (1), SEPSIS (1), hemoptysis (1), AMS (1). Non-nursing healthcare professionals' assessments were compared to nurses' and observed to be equal in 29%, higher in 59%, and lower in 12% of the cases. Of the 83 assessments, the average RSS score non-nursing healthcare professionals assigned was 4.8 +/- 1.6 while the nurses' charted average was3.39 +/- 0.97; a mean difference of 1.45, 95% CI (1.04 - 1.85)p< 0.0001. CONCLUSIONS: Our data demonstrated equal RSS ratings in only 29% of cases for non-nursing healthcare personnel and nurses’ evaluations. Without proper education the RSS may not be a reliable tool for sedation assessments, and may result in oversedation of critically ill patients. CLINICAL IMPLICATIONS: Recurrent nursing education is warranted to ensure proper use and optimization of the RSS. DISCLOSURE: The following authors have nothing to disclose: harmeet deol, Francis Dimtri, Arash Minaie, Salim Surani, George Udeani No Product/Research Disclosure Information

Optimizing sedation in the ICU: the eCASH concept

Optimizing sedation in the ICU: the eCASH concept

Analgesia-based sedation

Analgesia-based sedation

Abstract PR116

Background & Objectives: The ideal sedative agent should have both sedative and analgesic, minimal cardiovascular side effect, controllable respiratory side effect, rapid onset and offset of action, no accumulation in renal or hepatic dysfunction, has inactive metabolite and minimal interaction with other drugs. The aim of this study was to assess the efficacy between remifentanil and dexmedetomidine in term of haemodynamic, sedation and pain control during weaning in mechanically ventilated ICU patients. Materials & Methods: A prospective, randomized controlled trial was carried out in the SICU, after ethical approval. All patients were started on regular sedation with infusion midazolam and morphine until the decision for weaning was made by the specialist in-charge based on clinical assessment and investigations. During the weaning period, these drugs were discontinued and was replaced by either one of the study drugs. A total of 44 patients in the weaning process, were randomized equally into two groups for sedation in ICU for 6–72 hours. Patients in remifentanil group (R) received remifentanil with dosage range of 6-12microgram/kg/hour. Meanwhile, patient in dexmedetomidine group (D) received dexmedetomidine infusion with a range of 0.2–0.7 microgram/kg/hour. The patients were kept at Richmond Agitation Sedation Scale (RASS) of +1 to -1. Propofol (0.5–4.0 mg/kg/hour) was supplemented only in case of insufficient sedation at maximal remifentanil or dexmedetomidine dose. For remifentanil infusion, the infusion rate was titrated in stages to 0.1mcg/kg/min (6mcg/kg/hour) over a period of one hour prior to extubation. Patient’s haemodynamic RASS and Behavioral Pain Scale were documented. Patients will be excluded if they had not been extubated after 72 hours of starting the study drug infusion. Results: A total of 44 patients were enrolled in this study; 22 patients were given remifentanil infusion and another 22 patients were given dexmedetomidine infusion as sedation in ICU in the weaning process. There was no significant difference for SBP, MAP, HR, sedation score and behavioral pain score between (R) and (D) group during treatment period. However, there was a significant difference in DBP between (R) and (D) group with a mean (95% CI) of 67.29 (56.58, 112.64) and 84.61 (62.87,71.72) during the treatment period. There was a significant difference for sedation score when intragroup comparison for baseline and treatment period in remifentanil group (p =0.01). Similar result also was seen in the dexmedetomidine group, (p = 0.008). Conclusion: In conclusion, both remifentanil and dexmedetomidine regime can be used as sedation in patients with anticipated short-term duration of mechanical ventilation. Both regimes are equally well tolerated. Disclosure of Interest: None declared

ICU sedation with dexmedetomidine after severe traumatic brain injury

Objective: To comprehensively describe the use of dexmedetomidine in a single institutional series of adult ICU patients with severe TBI. This study describes the dexmedetomidine dosage and infusion times, as well as the physiological parameters, neurological status and daily narcotic requirements before, during and after dexmedetomidine infusion.Methods: This study identified 85 adult patients with severe TBI who received dexmedetomidine infusions in the Trauma ICU at Vanderbilt University Medical Center between 2006–2010. Demographic, haemodynamic, narcotic use and sedative use data were systematically obtained from the medical record and analysed for changes associated with dexmedetomidine infusion.Results: During infusion with dexmedetomidine, narcotic and sedative use decreased significantly (p < 0.001 and p < 0.05). Median MAP, SBP, DBP and HR also decreased significantly during infusion when compared to pre-infusion values (p < 0.001). Despite the use of dexmedetomidine, RASS and GCS scores improved from pre-infusion to infusion time periods.Conclusions: The findings demonstrate that initiation of dexmedetomidine infusion is not associated with a decline in neurological functioning in adults with severe TBI. Although there was an observed decrease in haemodynamic parameters during infusion with dexmedetomidine, the change was not clinically significant and the requirements for narcotics and additional sedatives were minimized.

Analgosedation: Improving Patient Outcomes in ICU Sedation and Pain Management

Sedation practices in the critical care unit have been trending toward lighter sedation since the start of the new millennium, but patients continue to experience inadequate pain management and excessive sedation. This paper includes a brief examination of the problem of pain management in the ICU; trends in sedation practices, including light sedation and the daily interruption of sedation; and a literature review of analgosedation. While the analgosedation literature is relatively sparse, it offers a promising, patient-centered method for managing the triad of pain, agitation, and delirium, while reducing common complications associated with long-term ventilation. This paper concludes with a recommended method for analgosedation, the nursing implications, and a discussion of limitations and recommendations.

Propofol Use in Israeli PICUs.

In Israel, the recommendation for the use of propofol is age limited. Furthermore, procedural sedations involving propofol must be performed only by anesthesiologists. Propofol is frequently used in the PICUs in Israel. Questionnaire survey. PICUs in Israel. None. None. Physicians from 13 PICUs (86.6%) responded to the questionnaire. Propofol was used for induction, procedural sedation, and ongoing ICU sedation in 100%, 70%, and 12% of cases, respectively. Eighty-eight percent of the participants limited the duration of propofol infusion to 24 hours at a dose of less than or equal to 4 mg/kg/1 hr, but 40% administered propofol as needed without specifying an upper dose limit. Twenty-five percent encountered adverse effects such as apnea, desaturation, and bradycardia, but only two of the participants suspected propofol infusion syndrome, each in one patient. All the participants agreed to expand the indications for propofol use in the pediatric age group. Ketamine was the drug mostly used instead of propofol (50%), followed by fentanyl (30%), midazolam (30%), and remifentanil (5%). Apart from anesthesiologists, PICU physicians support the use of propofol by physicians who have the technical skills for rapid-sequence intubation and advanced airway management. Off-label use of propofol is an accepted practice in Israeli PICUs. Propofol has a unique profile that makes it an attractive sedative agent in many clinical settings. PICU physicians may want to prescribe it, at least for short periods and at low doses.

Clinical study of midazolam sequential with dexmedetomidine for agitated patients undergoing weaning to implement light sedation in intensive care unit

PurposeTo evaluate midazolam sequential with dexmedetomidine for agitated patients undergoing weaning to implement light sedation in ICU.MethodsThis randomized, prospective study was conducted in Tianjin Third Central Hospital, China. Using a sealed-envelope method, the patients were randomly divided into 2 groups (40 patients per group). Each patient of group A received an initial loading dose of midazolam at 0.3–3 mg/kg·h 24 h before extubation, followed by an infusion of dexmedetomidine at a rate of 0.2–1 μg/kg·h until extubation. Each patient of group B received midazolam at a dose of 0.3–3 mg/kg·h until extubation. The dose of sedation was regulated according to RASS sedative scores maintaining in the range of -2-1. All patients were continuously monitored for 60 min after extubation. During the course, heart rate (HR), mean artery pressure (MAP), extubation time, adverse reactions, ICU stay, and hospital stay were observed and recorded continuously at the following time points: 24 h before extubation (T1), 12 h before extubation (T2), extubation (T3), 30 min after extubation (T4), 60 min after extubation (T5).ResultsBoth groups reached the goal of sedation needed for ICU patients. Dexmedetomidine was associated with a significant increase in extubation quality compared with midazolam, reflected in the prevalence of delirium after extubation (20% (8/40) vs 45% (18/40)), respectively (p = 0.017). There were no clinically significant decreases in HR and MAP after infusing dexmedetomidine or midazolam. In the group A, HR was not significantly increased after extubation; however, in the group B, HR was significantly increased compared with the preextubation values (p < 0.05). HR was significantly higher in the group B compared with the group A at 30 and 60 min after extubation (both, p < 0.05). Compared with preextubation values, MAP was significantly increased at extubation in the group B (p < 0.05) and MAP was significantly higher at T3, T4, T5 in the group B than group A (p < 0.05). There was a significant difference in extubation time ((3.0 ± 1.5) d vs (4.3 ± 2.2) d, p < 0.05), ICU stay ((5.4 ± 2.1) d vs (8.0 ± 1.4) d, p < 0.05), hospital stay ((10.1 ± 3.0) d vs (15.3 ± 2.6) d, p < 0.05) between group A and B.ConclusionMidazolam sequential with dexmedetomidine can reach the goal of sedation for ICU agitated patients, meanwhile it can maintain the respiratory and circulation parameters and reduce adverse reactions.

Dexmedetomidine combined with remifentanil used for sedation and analgesia in ICU patients with hypertensive cerebral hemorrhage

Objective To explore the administration of Dexmedetomidine combined with remifentanil for sedation and analgesia of ICU patients with hypertensive cerebral hemorrhage after operation. Methods A total of 60 patients with hypertensive cerebral hemorrhage treated with hematoma removal under craniotomy were selected from May 2013 to June 2015. The patients were randomly (random number) divided into the Dexmedetomidine combined with remifentanil group (D +R, n=30) , and Midazolam combined with remifentanil group (M +R, n=30). The blood pressure, respiration rate, oxygen saturation, heart rate, ICP (intracranial pressure) , Ramsay sedation scores, and IL-1, and TNF-α levels were recorded after sedation and analgesia in ICU, and 6 h, 24 h, 48 h after operation (T0-T3). Results Compared with M +R group, the MAP, RR, HR, ICP, IL-1β, TNF-α, rate of reoperation for check bleeding, and mortality were significantly decreased in D +R group (P <0.05) , and Ramsay sedation score was significantly increased at the same time (P <0.05) without excessive sedation and analgesia noticed. Conclusions Dexmedetomidine combined with remifentanil exhibits significant benefit in many respects including control of great fluctuations of blood pressure and intracranial pressure after craniotomy, reduce the production and release of inflammatory mediators, reduce the occurrence of rebleeding after operation. It shows good controllability and safety, it is an optimal method producing sedation and analgesia in ICU patients with hypertensive cerebral hemorrhage after operation. Key words: ICU; Dexmedetomidine; Remifentanil; Hypertensive cerebral hemorrhage after operation; Rebleeding; Cerebral protection; Sedation; Analgesia

Evaluation of Richmond Agitation Sedation Scale According To Alveolar Concentration of Sevoflurane During a Sedation With Sevoflurane in Icu Patients

In ICU sedation, use of inhalated gaz has interesting qualities, but remains limited due to lack of available and appropriate material. a new medical device (MirusTM (Pall)) allows feedback of the delivered flow rate from the targeted minimal alveolar concentration (MAC). Sedation is usually monitored by the RASS (Richmond Assessment Sedation Score).

A multinational, drug utilisation study to investigate the use of dexmedetomidine (DEXDOR®) in clinical practice in the EU

Dexmedetomidine (Dex) is a sedative drug approved as dexdor® (Orion Pharma, Finland) for ICU sedation in adults in the European Union in 2011. This observational, retrospective drug utilisation study was requested by the Committee for Human Medicinal Products for Human Use of the European Medicines Agency to investigate Dex use in clinical practice.

Comparison Between Dexmedetomidine and Propofol with Validation of Bispectral Index For Sedation in Mechanically Ventilated Intensive Care Patients.

Sedation plays a pivotal role in the care of the critically ill patient. It is equally important to assess depth of sedation. The present study had been designed to compare dexmedetomidine and propofol for sedation in mechanically ventilated intensive care patients. It also intended to verify the clinical validity, reliability and applicability of objective assessment tool bispectral index (BIS) for monitoring sedation and observe for correlation with the commonly used subjective scale, Ramsay sedation score (RSS). This prospective randomized study was carried out in 60 haemodynamically stable patients, aged between 18 to 80 years, requiring sedation and mechanical ventilation. These were divided equally into two groups. Group A received dexmedetomidine loading dose (1μg/kg) over 10 min followed by maintenance infusion of 0.5μg/kg/hr (0.2-0.7 μg/kg/hr). Group B received propofol loading dose (1mg/kg) over 5 min followed by infusion of 2mg/kg/hr (1-3mg/kg/hr). All patients received fentanyl 1 μg/kg prior to the study drugs. Vital parameters and sedation levels (using RSS and BIS) were monitored for the study period of 12 hours with level 4 or 5 of RSS as target for sedation. Ramsay score was compared with the average of BIS values. Statistical analysis was done using SPSS VERSION 17 software. The study revealed statistically significant lower heart rates during sedation in dexmedetomidine group whereas fall in mean arterial pressure (MAP) following loading dose in propofol group. Patients sedated with dexmedetomidine were easily arousable. Need for rescue drug for achieving the desired RSS as well as incidence of bradycardia was more in dexmedetomidine group than other. Good correlation exists between Ramsay score and BIS values. Dexmedetomidine reduces heart rate while propofol transiently affects MAP. However, adequate sedation is achieved with both the drugs. The data obtained from the study validate BIS monitoring for ICU sedation.

English

English

Nurse decision making regarding the use of analgesics and sedatives in the pediatric cardiac ICU.

To describe nurse decision making and patient responses associated with the administration of analgesics and sedatives in the pediatric cardiac ICU. Prospective nonexperimental mixed methods study of pediatric cardiac ICU nursing practice. Three tertiary academic pediatric heart centers in the United States. Pediatric cardiac ICU nurses caring for 217 patients completed 1,330 surveys. Four-item open-ended nurse survey completed each time an as needed dose of an analgesic or sedative was administered, an analgesic or sedative infusion/dose was titrated, and/or a new analgesic or sedative was administered. Responses to survey questions were entered verbatim and then collapsed using a consensus process. Collapsing of the data continued until there was a working set of "symptoms," "changes," and "clinical situation managed" categories. Nurses identified 28 symptoms managed with analgesia and sedation. The most frequent symptoms included hypertension, tachycardia, crying, pain, and agitation. Nurses identified 20 patient changes that resulted from their interventions. The most prevalent changes included improved hemodynamics, calm state, sleep, comfort, and relaxed state. Nurses identified 22 clinical situations that they were attempting to manage. The most frequent clinical situations included pain, hemodynamics, procedures, hypertension, and agitation. Nurses responded that 22% of their interventions were influenced by others. Pediatric cardiac ICU nurses use many nonspecific indicators to describe patient level of comfort collectively. Decisions for managing patient comfort were influenced by their patients' overall hemodynamic stability.