Spontaneous Awakening Trials Research Articles

Utilization of Spontaneous Awakening Trials in Mechanically Ventilated Patients

SESSION TITLE: Mechanical Ventilation and Respiratory Failure Posters SESSION TYPE: Original Investigation Poster PRESENTED ON: Wednesday, October 28, 2015 at 01:30 PM - 02:30 PM PURPOSE: The purpose of this study is to establish current duration of time from intubation to first spontaneous awakening trial (SAT) and variables that may be associated with decreased likelihood of implementation of this intervention. These results will inform a clinical trial designed to increase adherence to daily spontaneous awakening and spontaneous breathing trials in patients with acute respiratory failure. METHODS: Patients from Northwestern Memorial Hospital (NMH), a tertiary academic medical center in Chicago, Illinois, and Northwestern Lake Forest Hospital, a community hospital affiliated with NMH located in an affluent suburb of Chicago, were included. Patients were excluded if they were less than 18 years of age at intubation, on the ventilator less than 12 hours, had a tracheostomy at time of hospital admission, suffered cardiac arrest immediately prior to or during their admission, were transitioned to comfort-focused care, or were managed on continuous intravenous sedation for alcohol withdrawal or delirium tremens. Based on power calculations, we collected data from the first 377 patients who were intubated in the intensive care units and met our inclusion criteria from June 23, 2013, to October 11, 2013. RESULTS: In our sample, mean age at intubation was 60.6 years, 153 (40.6%) were women, and 214 (56.8%) self-identified as white or Caucasian, 100 (26.5%) as black or African-American. Out of the 377 patients included in the analysis, 39 (10.3%) were never started on sedative infusions and of those who were started on infusions of sedatives (narcotics, benzodiazepines, and/or propofol), median time to first SAT (defined as at least 4 hours off all sedative infusions) was 40.6 hours. Of the patients started on sedative infusions, 270 (79.9%) did not receive an SAT within the first 24 hours of intubation. CONCLUSIONS: Median time to first SAT was substantially longer than recommended by most professional organizations and only a small number of patients had an SAT within the first 24 hours of intubation. CLINICAL IMPLICATIONS: Daily SATs are associated with reduced duration of mechanical ventilation and intensive care unit stay, and this data gives us evidence that adherence to this best practice is low and helps inform the design of a novel intervention to improve these rates. DISCLOSURE: The following authors have nothing to disclose: Margaret Ragland, Shayna Weiner, Curtis Weiss No Product/Research Disclosure Information

ABCDE, but in that order? A cross-sectional survey of Michigan intensive care unit sedation, delirium, and early mobility practices.

A bundled approach to intensive care unit (ICU) care known as "Awakening and Breathing Coordination, Delirium monitoring/management, and Early exercise/mobility" (ABCDE) has been proposed, with evidence supporting individual interventions as well as the bundle as a whole. Few data exist on the bundle's implementation and efficacy in community practice. To evaluate self-reported rates of implementation of ABCDE components and their association with outcomes in a state-wide quality improvement collaborative. A written survey was administered to representatives attending the 2012 annual meeting of the Michigan Health and Hospital Association's Keystone ICU collaborative. Respondents reported on their practices regarding spontaneous awakening trials, delirium assessments, and early mobility. There were 212 respondents, a 76% response rate. Wide variation in focus was noted across the assessed components of ABCDE. Only 12% reported having implemented routine spontaneous awakening trials and delirium assessments as well as early mobility, 36% reported not having early mobility as an active goal in their units (nonmovers), and 52% reported attempts at early mobility without both routine sedation interruption and delirium screening implementation. In adjusted models, those who implemented exercise with sedation interruption and delirium screening were 3.5 (95% confidence interval, 1.4-8.6) times more likely to achieve higher levels of exercise in ventilated patients than those who implemented exercise without both sedation interruption and delirium screening. There is incomplete penetrance of aspects of ABCDE across ICUs in this highly motivated statewide quality improvement collaborative. Yet, implementation of exercise in the context of both sedation interruption and delirium screening was associated with improved self-reported mobility outcomes. Effective knowledge translation and implementation strategies may offer substantial benefits to ICU patients.

Pharmacist leadership in ICU quality improvement: coordinating spontaneous awakening and breathing trials.

Coordinating efforts across disciplines in the intensive care unit is a key component of quality improvement (QI) efforts. Spontaneous awakening trials (SATs) and spontaneous breathing trials (SBTs) are considered key components of guidelines, yet unfortunately are often not done or coordinated properly. To determine if a pharmacist-driven awakening and breathing coordination (ABC) QI program would improve compliance (ie, process measures) as compared with the previous protocol, which did not involve pharmacists. The QI program included pharmacist-led education, daily discussion on rounds, and weekly performance reports to staff. Using a pre-QI versus during-QI versus post-QI intervention design, we compared data from 500 control ventilator-days (pre-QI period) versus 580 prospective ventilator-days (during-QI period). We then evaluated the sustainability of the QI program in 216 ventilator-days in the post-QI period. SAT safety screens were performed on only 20% pre-QI patient-days versus 97% of during-QI patient-days (P < 0.001) and 100% of post-QI patient-days (P = 0.25). The rates of passing the SAT safety screen in pre-QI and during-QI periods were 63% versus 78% (P = 0.03) and 81% in the post-QI period (P = 0.86). The rates of SATs among eligible patients on continuous infusions were only 53% in the pre-QI versus 85% in the during-QI (P = 0.0001) and 87% in the post-QI (P = 1) periods. In this QI initiative, a pharmacist-driven, interdisciplinary ABC protocol significantly improved process measures compliance, comparing the pre-QI versus during-QI rates of screening, performing, and coordinating SAT and SBTs, and these results were sustained in the 8-month follow-up period post-QI program.

Recent advances in mechanical ventilation in patients without acute respiratory distress syndrome.

While being an essential part of general anesthesia for surgery and at times even a life-saving intervention in critically ill patients, mechanical ventilation has a strong potential to cause harm. Certain ventilation strategies could prevent, at least to some extent, the injury caused by this intervention. One essential element of so-called ‘lung-protective’ ventilation is the use of lower tidal volumes. It is uncertain whether higher levels of positive end-expiratory pressures have lung-protective properties as well. There are indications that too high oxygen fractions of inspired air, or too high blood oxygen targets, are harmful. Circumstantial evidence further suggests that spontaneous modes of ventilation are to be preferred over controlled ventilation to prevent harm to respiratory muscle. Finally, the use of restrictive sedation strategies in critically ill patients indirectly prevents ventilation-induced injury, as daily spontaneous awakening and breathing trials and bolus instead of continuous sedation are associated with shorter duration of ventilation and shorten the exposure to the injurious effects of ventilation.

Achieving Quality Health Outcomes Through the Implementation of a Spontaneous Awakening and Spontaneous Breathing Trial Protocol

Continuous sedation infusions can lead to prolonged treatment with mechanical ventilation (MV), resulting in serious complications. Spontaneous awakening trials (SATs) and spontaneous breathing trials (SBTs) are strategies that limit the amount of sedative agents a patient receives and promote extubation. The objective of this performance improvement project was to evaluate the outcomes of an evidence-based practice protocol that included SATs and SBTs on the duration of treatment with MV, ventilator utilization ratio (VUR), intensive care unit (ICU) length of stay (LOS), and incidence of self-extubations and reintubations. A convenience sample of 112 discharged patients' medical records was used for this descriptive, comparative secondary data analysis. An evidence-based SAT/SBT practice protocol was designed by a multidisciplinary team and implemented. Three months after the implementation, a retrospective medical record review was conducted to evaluate patient outcomes. The median duration of treatment with MV was significantly lower in the postprotocol group (3.8 days vs 2.7 days, U = 1222, Z = -2.013, P = .04, r = 0.19). A significant decrease was found in the VUR (0.68 vs 0.52, U = 2.5, Z = -2.293, P = .02, r = 0.69). No difference was found in the ICU LOS and frequency of self-extubation or reintubation after a self-extubation between the preprotocol and postprotocol groups. Ten of 45 SAT opportunities (22%) and 67 of 130 SBT opportunities (52%) were missed by the nurse or the respiratory therapist. The duration of treatment with MV and the VUR were reduced in patients who received the SAT/SBT protocol. The incidence of self-extubation was not different when an SAT was implemented. The ICU LOS was not reduced in patients who received SATs and SBTs.

Achieving Quality Health Outcomes Through the Implementation of a Spontaneous Awakening and Spontaneous Breathing Trial Protocol

Background: Continuous sedation infusions can lead to prolonged treatment with mechanical ventilation (MV), resulting in serious complications. Spontaneous awakening trials (SATs) and spontaneous breathing trials (SBTs) are strategies that limit the amount of sedative agents a patient receives and promote extubation. Objective: The objective of this performance improvement project was to evaluate the outcomes of an evidence-based practice protocol that included SATs and SBTs on the duration of treatment with MV, ventilator utilization ratio (VUR), intensive care unit (ICU) length of stay (LOS), and incidence of self-extubations and reintubations. Methods: A convenience sample of 112 discharged patients’ medical records was used for this descriptive, comparative secondary data analysis. An evidence-based SAT/SBT practice protocol was designed by a multidisciplinary team and implemented. Three months after the implementation, a retrospective medical record review was conducted to evaluate patient outcomes. Results: The median duration of treatment with MV was significantly lower in the postprotocol group (3.8 days vs 2.7 days, U = 1222, Z = −2.013, P = .04, r = 0.19). A significant decrease was found in the VUR (0.68 vs 0.52, U = 2.5, Z = −2.293, P = .02, r = 0.69). No difference was found in the ICU LOS and frequency of self-extubation or reintubation after a self-extubation between the preprotocol and postprotocol groups. Ten of 45 SAT opportunities (22%) and 67 of 130 SBT opportunities (52%) were missed by the nurse or the respiratory therapist. Conclusion: The duration of treatment with MV and the VUR were reduced in patients who received the SAT/SBT protocol. The incidence of self-extubation was not different when an SAT was implemented. The ICU LOS was not reduced in patients who received SATs and SBTs.

Let's change our behaviors: From bed rest and heavy sedation to awake, spontaneously breathing and early mobilized Intensive Care Unit patients.

Let's change our behaviors: From bed rest and heavy sedation to awake, spontaneously breathing and early mobilized Intensive Care Unit patients.

Interventions to Improve the Physical Function of ICU Survivors: A Systematic Review

ICU admissions are ever increasing across the United States. Following critical illness, physical functioning (PF) may be impaired for up to 5 years. We performed a systematic review of randomized controlled trials evaluating the efficacy of interventions targeting PF among ICU survivors. The objective of this study was to identify effective interventions that improve long-term PF in ICU survivors. MEDLINE, Excerpta Medica Database (EMBASE), Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Physiotherapy Evidence-Based Database (PEDro) were searched between 1990 and 2012. Two reviewers independently evaluated studies for eligibility, critically appraised the included studies, and extracted data into standardized evidence tables. Fourteen studies met the inclusion criteria. Interventions included exercise/physical therapy (PT), parenteral nutrition, nurse-led follow-up, spontaneous awakening trials, absence of sedation during mechanical ventilation, and early tracheotomy. Nine studies failed to demonstrate efficacy on PF of the ICU survivors. However, early physical exercise and PT-based interventions had a positive effect on long-term PF. The only effective intervention to improve long-term PF in critically ill patients is exercise/PT; its benefit may be greater if started earlier. Further research in this area comparing different interventions and timing is needed.

The Methodological Approach Used to Develop the 2013 Pain, Agitation, and Delirium Clinical Practice Guidelines for Adult ICU Patients

In 2006, the American College of Critical Care Medicine assembled a 20-member task force to revise the 2002 guidelines for sedation and analgesia in critically ill adults. This article describes the methodological approach used to develop the American College of Critical Care Medicine's 2013 ICU Pain, Agitation, and Delirium Clinical Practice Guidelines. Review article. Multispecialty critical care units. Adult ICU patients. The task force was divided into four subcommittees, focusing on pain, sedation, delirium, and related outcomes. Unique aspects of this approach included the use of: 1) the Grading of Recommendations Assessment, Development and Evaluation method to evaluate the literature; 2) a librarian to conduct literature searches and to create and maintain the pain, agitation, and delirium database; 3) creation of a single web-based database; 4) rigorous psychometric analyses of pain, sedation, and delirium assessment tools; 5) the use of anonymous electronic polling; and 6) creation of an ICU pain, agitation, and delirium care bundle. The pain, agitation, and delirium database includes over 19,000 references. With the help of psychometric experts, members developed a scoring system and analyzed the psychometric properties of 6 behavioral pain scales, 10 sedation/agitation scales, and 5 delirium monitoring tools. A meta-analysis was performed to assess the overall impact of benzodiazepine versus nonbenzodiazepine sedation on ICU outcomes. The pain, agitation, and delirium guidelines include 54 evidence-based statements and recommendations. The quality of evidence and strength for each statement and recommendation was ranked. In the absence of sufficient evidence or group consensus, no recommendations were made. An ICU pain, agitation, and delirium care bundle was created to facilitate adoption of the pain, agitation, and delirium guidelines. It focuses on taking an integrated approach to assessing, treating, and preventing pain, agitation/sedation, and delirium in critically ill patients, and it links pain, agitation, and delirium management to spontaneous awakening trials, spontaneous breathing trials, and ICU early mobility and sleep hygiene programs in order to achieve synergistic benefits to ICU patient outcomes. The 2013 ICU pain, agitation, and delirium guidelines provide critical care providers with an evidence-based, integrated, and interdisciplinary approach to managing pain, agitation/sedation, and delirium. The methodological approach used to develop the guidelines ensures that they are rigorous, evidence-based, and transparent. Implementation of the ICU pain, agitation, and delirium care bundle is expected to have a significant beneficial impact on ICU outcomes and costs.

Contextual Issues Influencing Implementation and Outcomes Associated With an Integrated Approach to Managing Pain, Agitation, and Delirium in Adult ICUs

This pilot study was designed to identify which contextual factors facilitate/hinder the implementation of the awakening, breathing, coordination, delirium, and early mobility (ABCDE) bundle for guidance in future studies. The sources of data for this study included document review, planned site visits (including interviews and observations), a brief online contextual factors survey, and self-reported process and outcome data. All patients in the four participating SF Bay Area ICUs were eligible to be included in this pilot study. This study took place in the four San Francisco Bay Area ICUs participating in the ICU Clinical Impact Interest Group, funded by the Gordon and Betty Moore Foundation from January 2012 through June 2013. This was a pilot evaluation study to identify factors that facilitated/hindered the implementation of the ABCDE bundle, interventions designed to decrease the prevalence of ICU-acquired delirium and muscle weakness. The ABCDE bundle consists of spontaneous awakening trials, spontaneous breathing trials, coordination of awakening and breathing trials, choice of sedation, delirium screening and treatment, and early progressive mobility. Process data related to bundle element compliance were collected at baseline and monthly during the intervention period. Outcome data (average ICU length of stay and average days on mechanical ventilation) were collected at baseline and quarterly during the intervention period. Hospital-specific results of the online contextual factors survey and information gathered through interviews and observations during site visits also contributed to the analysis. Factors related to structural characteristics of the ICU, an organizational-wide patient safety culture, an ICU culture of quality improvement, implementation planning, training/support, and prompts/documentation are believed to have facilitated the rate and success of ABCDE bundle implementation. Excessive turnover (both in project and ICU leadership), staff morale issues, lack of respect among disciplines, knowledge deficits, and excessive use of registry staff are believed to have hindered implementation. Successful implementation of the elements of the ABCDE bundle can result in significant improvements in ICU patient care. The results of this study highlight specific structural and cultural elements of ICUs and hospitals that can positively and negatively influence the implementation of complex care bundles like the ABCDE bundle. Further research is needed to assess the influence of these contextual factors across a broader variety of ICUs and hospitals.

Diverse Attitudes to and Understandings of Spontaneous Awakening Trials

Spontaneous awakening trials (SATs) improve outcomes in mechanically ventilated patients, but implementation remains erratic. We examined variation in reported practice, prevalence of attitudes and fears regarding spontaneous awakening trials, and organizational practices associated with routine implementation of spontaneous awakening trials in an ICU quality improvement collaborative. Written survey. Michigan Health and Hospital Association's Keystone ICU, a quality improvement collaborative of 73 hospitals. Attendees of the yearly Keystone ICU meeting, January 2011, including nurses, physicians, hospital administrators, and other healthcare professionals. Respondents were asked about institutional characteristics, spontaneous awakening trial practice, attitudes and barriers regarding spontaneous awakening trials, and organizational cultural characteristics that might influence SAT practice. The association of organizational cultural characteristics and attitudes with reported spontaneous awakening trial use was evaluated using logistic regression. Three hundred nineteen participants attended the meeting. The survey response rate was 83.4%. Respondents reported wide variation in approach to spontaneous awakening trial performance and patient selection. 48.6% of respondents reported regular spontaneous awakening trial use, defined as greater than 75% of mechanically ventilated patients undergoing spontaneous awakening trials each day. In bivariable analysis, addressing sedation goals routinely in rounds and having spontaneous awakening trials as part of unit culture were positively associated with regular spontaneous awakening trial use, whereas the perception that spontaneous awakening trials increased short-term adverse effects, staff fears of spontaneous awakening trials, and the perception that spontaneous awakening trials are hard work were negatively associated with regular spontaneous awakening trial use. In multivariable analysis, only addressing sedation in rounds (odds ratio, 2.85 [95% CI, 1.55-5.23]), incorporation of spontaneous awakening trials into unit culture (odds ratio, 3.36 [95% CI, 1.75-6.43]), and the perception that spontaneous awakening trials are hard work (odds ratio, 0.53 [95% CI, 0.30-0.96]) remained statistically significantly associated with regular spontaneous awakening trial use. Respondents in managerial positions were less likely to perceive spontaneous awakening trials as hard work (odds ratio, 0.44 [95% CI, 0.22-0.85]). Even in a motivated statewide quality improvement collaborative, spontaneous awakening trial practice varies widely and concerns persist regarding spontaneous awakening trials. Cultural practices may counteract the effect of concerns regarding spontaneous awakening trials and are associated with increased performance of this beneficial intervention. Patient selection should be a focus for continuing medical education. Differences in perception of work between management and staff may also be a focus for improved communication.

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Introduction: In patients requiring mechanical ventilation, daily respiratory therapy (RT) guided spontaneous breathing trials (SBT) effectively liberate patients from the ventilator earlier and reduces mortality. When SBTs are performed simultaneously with daily spontaneous awakening trials (SAT) guided by nursing staff, the success rate is higher in the Intensive Care Unit (ICU). The local expertise of providers is in concordance with the Pareto principle of quality science for health care delivery. Hypothesis: Application of the Pareto Principle in the ICU can identify the few barriers limiting of nursing and respiratory therapy driven SBT protocols. Methods: Surveys were administered to both medical ICU nursing and respiratory therapy staff. The frequency of SBTs were measured and the most common barriers to achieving compliance between services were recorded. Results: A survey was administered to 109 nurses and respiratory therapists. Eighty-seven providers completely answered the survey. Both nursing and respiratory therapy staff reported similar challenges. Communication problems (27%) were the most cited barriers to achieve compliance. Medical team daily work schedule (24%), unit staffing 21% and physician availability (21%), encompassed 93% of the total reported barriers. Conclusions: Use of the Pareto instrument identified communication between nursing and respiratory services to be the most significant barrier to achieving compliance with daily SBT and SAT trials. Interventions directed towards improved communication between nursing and respiratory services may improve the quality of patient care in the ICU.

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There is strong, recent, convincing evidence that delirium, immobility, sedation, and ventilator management are closely interrelated. The purpose of this study was to evaluate the efficacy and safety of the ABCDE bundle in critically-ill patients receiving mechanical ventilation. We hypothesized that implementation of the ABCDE bundle would result in improved patient outcomes. This prospective, cohort, before-after study was conducted at a large, tertiary medical center located in the Midwestern United States. Subjects were recruited from 5 adult intensive care units (ICUs), 1 progressive care unit, and another unit that cared for critically-ill immunocompromised patients. A total of 186 (93 pre- and 94 post-ABCDE bundle implementation) mechanically ventilated patients were included in this analysis. The primary endpoint, defined a priori, was ventilator free days. Baseline characteristics including age, APACHE II score, Charlson Comorbidity Score, and sedative drug use prior to enrollment were similar between the two groups. After ABCDE bundle implementation, patients were more likely to receive a spontaneous awakening trial [Pre N=35 (53%) vs. Post N=42 (71.2%); p=0.0372], a spontaneous breathing trial [Pre N=65 (70.7%) vs. Post N=79 (84%); p=0.0290], and get out of bed at least once during their ICU stay [N=44 (47.3%) vs. Post N=57 (60.6%); p-0.0675]. Patients in the post ABCDE bundle group spent more days breathing without ventilator assistance than those in the pre group [24 days vs. 21 days; p=0.0371]. Patients treated with the ABCDE bundle were less likely to experience delirium [Pre N=70 (75.3%) vs. Post N=62 (66.0%); p=0.1623] and spent significantly fewer days delirious [Pre N=2 (1, 5) vs. Post N=1 (0, 3); p=0.00437]. No significant differences in the time to ICU or hospital discharge, incidence or duration of coma, or change in residence were noted between groups. ICU mortality was higher in the pre (N=24, 25.8%) vs. post (N= 14 14.9%) group (p=0.0913). Six subjects (6.5%) in the pre- and 5 (5.3%) in the post ABCDE bundle period self-extubated (p=0.7421). The number of subjects who self-extubated who later required reintubation did not differ between groups [Pre N=1 (1.1%) vs. Post N=1 (1.1%); p=0.9999]. Our results suggest patients treated with the ABCDE bundle experience more days breathing without assistance and a shorter duration of ICU delirium. Adoption of this interprofessional, multicomponent bundle into everyday clinical care is warranted.

Sedation in the intensive care setting

Critically ill patients are routinely provided analgesia and sedation to prevent pain and anxiety, permit invasive procedures, reduce stress and oxygen consumption, and improve synchrony with mechanical ventilation. Regional preferences, patient history, institutional bias, and individual patient and practitioner variability, however, create a wide discrepancy in the approach to sedation of critically ill patients. Untreated pain and agitation increase the sympathetic stress response, potentially leading to negative acute and long-term consequences. Oversedation, however, occurs commonly and is associated with worse clinical outcomes, including longer time on mechanical ventilation, prolonged stay in the intensive care unit, and increased brain dysfunction (delirium and coma). Modifying sedation delivery by incorporating analgesia and sedation protocols, targeted arousal goals, daily interruption of sedation, linked spontaneous awakening and breathing trials, and early mobilization of patients have all been associated with improvements in patient outcomes and should be incorporated into the clinical management of critically ill patients. To improve outcomes, including time on mechanical ventilation and development of acute brain dysfunction, conventional sedation paradigms should be altered by providing necessary analgesia, incorporating propofol or dexmedetomidine to reach arousal targets, and reducing benzodiazepine exposure.

Weaning from mechanical ventilation and sedation

Guidelines for weaning from sedation and weaning from ventilator gained increasing interest in recent years. This includes patients with acute respiratory distress syndrome, as well as other mechanically ventilated patients. This review will give an overview of the current literature and practice guidelines in ventilator and sedation weaning. Sedation and ventilator weaning are closely linked. Weaning protocols for both sedation and ventilator weaning should be implemented in daily routine. The essential element of such algorithm should be a daily spontaneous awakening trial and spontaneous breathing trial. Furthermore, regularly monitoring for deepness of sedation and delirium should be implemented. Too deep sedation, as well as prolonged delirium is associated with higher mortality. The most important conclusion we come to from recent randomized controlled trials is that only using an integrative algorithm for sedation and ventilator weaning can improve survival of ICU patients.

Pharmacological and nonpharmacological management of delirium in critically ill patients.

Delirium is a common yet under-diagnosed syndrome of acute brain dysfunction, which is characterized by inattention, fluctuating mental status, altered level of consciousness, or disorganized thinking. Although our recognition of risk factors for delirium has progressed, our understanding of the underlying pathophysiologic mechanisms remains limited. Improvements in monitoring and assessment for delirium (particularly in the intensive care setting) have resulted in validated and reliable tools such as arousal scales and bedside delirium monitoring instruments. Once delirium is recognized and the modifiable risk factors are addressed, the next step in management (if delirium persists) is often pharmacological intervention. The sedatives, analgesics, and hypnotics most often used in the intensive care unit (ICU) to achieve patient comfort are all too frequently deliriogenic, resulting in a longer duration of ICU and hospital stay, and increased costs. Therefore, identification of safe and efficacious agents to reduce the incidence, duration, and severity of ICU delirium is a hot topic in critical care. Recognizing that there are no medications approved by the Food and Drug Administration (FDA) for the prevention or treatment of delirium, we chose anti-psychotics and alpha-2 agonists as the general pharmacological focus of this article because both were subjects of relatively recent data and ongoing clinical trials. Emerging pharmacological strategies for addressing delirium must be combined with nonpharmacological approaches (such as daily spontaneous awakening trials and spontaneous breathing trials) and early mobility (combined with the increasingly popular approach called: Awakening and Breathing Coordination, Delirium Monitoring, Early Mobility, and Exercise [ABCDE] of critical care) to develop evidence-based approaches that will ensure safer and faster recovery of the sickest patients in our healthcare system.

Bispectral Index to Monitor Propofol Sedation in Trauma Patients

This study tested the hypothesis that the bispectral index (BIS) is reliable relative to clinical judgment for estimating sedation level during daily propofol spontaneous awakening trials (SATs) in trauma patients. This was a prospective observational trial with waiver of consent conducted in the intensive care unit of Level I trauma center in 94 mechanically ventilated trauma patients sedated with propofol alone or in combination with midazolam. BIS, Richmond Agitation Sedation Scale (RASS), electromyography, and heart rate variability, as a test of autonomic function, were measured for 45 minutes during daily SATs. Data were evaluated with analysis of variance, linear regression, and nonparametric tests. The BIS wave form coincided almost exactly with propofol on/off. Steady-state BIS correlated with RASS (p < 0.0001) and with propofol dose (p < 0.0001), but the strengths of association were relatively low (all r(2) < 0.5). BIS wave form was not altered by age, heart rate, or heart rate variability and was similar with propofol alone or propofol plus midazolam, but the presence of brain injury or the use of paralytics shifted the curve downward (both p < 0.001). The overall test characteristics for BIS versus RASS without neuromuscular blockade were sensitivity: 90% versus 77% (p = 0.034); specificity: 90% versus 75% (p = 0.021); positive predictive value: 90% versus 76% (p = 0.021), and negative predictive value: 90% versus 76% (p = 0.021). In the first trial in trauma patients and largest trial in any surgical population, the (1) BIS was reliable and has advantages over RASS of being continuous and objective, at least during a propofol SAT; (2) BIS interpretation remains somewhat subjective in patients receiving paralytic agents or with traumatic brain injury.

Efficacy of implementation strategies of an evidenced-based awakening and breathing protocol: An observational quality improvement study

Breathing Protocol: an observational Quality Improvement study Osama Almuslim,MD; Mamdouh Rezk,MD; Naglaa Hassan,MD Critical Care, KFSH-Dammam ,Saudi Arabia Introduction: A protocol that paired spontaneous awakening trials (SAT) and spontaneous breathing trials (SBT) decreased the duration of mechanical ventilation, the ICU length of stay (LOS) and mortality. We studied the efficacy of multifaceted implementation strategies of an evidence-based protocol at a tertiary academic center. Methods: This was a retrospective observational cohort study with historical control (before and after, protocol implementation study design). The cohort consisted of consecutive adult patients who were extubated at least once during the ICU stay. The interventions were: multifaceted implementation strategies of an evidence-based protocol pairing SAT and SBT. These strategies included: preprinted daily order sheets, structured daily multidisciplinary rounds, daily monitoring of the ICU staff compliance with feedback, data collection and analysis followed by quality improvement (QI) action plans. The outcomes were: reintubation rate, duration of mechanical ventilation (MV), ICU LOS and hospital mortality. Statistical analysis: Fisher’s Exact test for categorical variables, Wilcoxon rank-sum test for continuous variables; Kaplan Meier method and covariate-adjusted Cox regression were used. Covariates were: age, APACHE II and maximum SOFA during ICU stay. Results: The total included patients were n=164 (2009 n=40;2010 n=124).The baseline characteristics were imbalance for age and APACHE II. The 2009 group was older and had higher APACHE II score. The 2010 group (after QI group) had less duration of mechanical ventilation, less ICU LOS and lower hospital mortality (table). The 2010 group had shorter time to successful extubation, adjusted hazard ratio = 2.0 (95 CI %: 1.4-2.9; p<0.01) and delayed time to death, adjusted hazard ra o = 0.37 ; (95 CI %: 0.20-0.68; ; p<0.01). Outcomes Group 2009, n=40 Group 2010, n=124 p-value Reintubation 32.5% (n=13) 14.5% (n=18) P = 0.02 MV duration in days 7 (IQR 3 15) 3 (IQR 1 7) P <0.01 ICU LOS in days 10 (IQR 6 16) 5 (IQR 3 10) P <0.01 Hospital mortality 60.0% (n=24) 16.9% (n=21) P <0.01

Efficacy of implementation strategies of an evidenced-based awakening and breathing protocol

A protocol that paired spontaneous awakening trials (SAT) and spontaneous breathing trials (SBT) decreased duration of mechanical ventilation (DMV), ICU length of stay (LOS) and mortality [1]. We studied the efficacy of multifaceted implementation strategies (MIS) of an evidenced-based protocol at a tertiary academic center.

Sedation, delirium and mechanical ventilation: the ‘ABCDE’ approach

Delirium and ICU-acquired weakness are frequent in critically ill mechanically ventilated patients. The number of mechanically ventilated patients is increasing, placing more patients at risk for these adverse outcomes. Sedation is given to ensure comfort and to minimize distress, but is linked to delirium and immobility. We review recent findings on the management of mechanically ventilated patients focusing on strategies that may improve neurologic and functional outcomes in critically ill patients. We present the evidence-based 'ABCDE' bundle, an integrated and interdisciplinary approach to the management of mechanically ventilated patients. Spontaneous awakening and breathing trials have been combined into 'awake and breathing coordination', shortening the duration of mechanical ventilation, ICU and hospital length of stay and improving survival. The choice of α-2 agonists reduces ICU delirium and duration of mechanical ventilation. Delirium monitoring improves recognition of this disorder, but data on pharmacologic treatment are mixed. Early mobility and exercise may reduce physical dysfunction and delirium rates. Outcomes of critically ill patients can be improved by applying evidence-based therapies for the 'liberation' from mechanical ventilation and sedation, and the 'animation' through early mobilization. Clinicians should be aware of organizational approaches such as the 'ABCDE' bundle to improve the management of mechanically ventilated patients.