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Variation in diurnal sedation in mechanically ventilated patients who are managed with a sedation protocol alone or a sedation protocol and daily interruption.

ABSTRACT: Mechanically ventilated patients may receive more sedation during the night than during the day, potentially delaying extubation. We compared nighttime and daytime benzodiazepine and opioid administration in adult patients enrolled in a multicenter sedation trial comparing protocolized sedation alone or protocolized sedation combined with daily sedation interruption; and we evaluated whether nighttime and daytime doses were associated with liberation from mechanical ventilation.This is a secondary analysis of a randomized trial which was conducted in 16 North American medical-surgical ICUs. In all 423 patients, nurses applied a validated sedation scale hourly to titrate benzodiazepine and opioid infusions to achieve a light level of sedation. Using fentanyl equivalents and midazolam equivalents, we compared dosages administered during night (19:00 to 07:00) and day (07:00 to 19:00) shifts. Using multivariable logistic regression we evaluated the association between nighttime and daytime opioid and sedative doses, and spontaneous breathing trial (SBT) conduct, SBT success, and extubation.Nighttime benzodiazepine and opioid doses were significantly higher than daytime doses (mean difference midazolam equivalents 23.3 mg, 95 % CI 12.9, 33.8, p?

SUBMITTER: Mehta S

PROVIDER: S-EPMC4968433 | biostudies-literature | 2016 Aug

REPOSITORIES: biostudies-literature

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Variation in diurnal sedation in mechanically ventilated patients who are managed with a sedation protocol alone or a sedation protocol and daily interruption.

Mehta Sangeeta S Meade Maureen M Burry Lisa L Mallick Ranjeeta R Katsios Christina C Fergusson Dean D Dodek Peter P Burns Karen K Herridge Margaret M Devlin John W JW Tanios Maged M Fowler Robert R Jacka Michael M Skrobik Yoanna Y Olafson Kendiss K Cook Deborah D

Critical care (London, England) 20160801 1

<h4>Background</h4>Mechanically ventilated patients may receive more sedation during the night than during the day, potentially delaying extubation. We compared nighttime and daytime benzodiazepine and opioid administration in adult patients enrolled in a multicenter sedation trial comparing protocolized sedation alone or protocolized sedation combined with daily sedation interruption; and we evaluated whether nighttime and daytime doses were associated with liberation from mechanical ventilatio ...[more]

PMID: 27480314

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Project description:BACKGROUND:Daily sedative interruption and intermittent sedation are effective in abbreviating the time on mechanical ventilation. Whether one is superior to the other has not yet been determined. Our aim was to compare daily interruption and intermittent sedation during the mechanical ventilation period in a low nurse staffing ICU. METHODS:Adult patients expected to need mechanical ventilation for more than 24 hours were randomly assigned, in a single center, either to daily interruption of continuous sedative and opioid infusion or to intermittent sedation. In both cases, our goal was to maintain a Sedation Agitation Scale (SAS) level of 3 or 4; that is patients should be calm, easily arousable or awakened with verbal stimuli or gentle shaking. Primary outcome was ventilator-free days in 28 days. Secondary outcomes were ICU and hospital mortality, incidence of delirium, nurse workload, self-extubation and psychological distress six months after ICU discharge. RESULTS:A total of 60 patients were included. There were no differences in the ventilator-free days in 28 days between daily interruption and intermittent sedation (median: 24 versus 25 days, P?=?0.160). There were also no differences in ICU mortality (40 versus 23.3%, P?=?0.165), hospital mortality (43.3 versus 30%, P?=?0.284), incidence of delirium (30 versus 40%, P?=?0.472), self-extubation (3.3 versus 6.7%, P?=?0.514), and psychological stress six months after ICU discharge. Also, the nurse workload was not different between groups, but it was reduced on day 5 compared to day 1 in both groups (Nurse Activity Score (NAS) in the intermittent sedation group was 54 on day 1 versus 39 on day 5, P?<?0.001; NAS in daily interruption group was 53 on day 1 versus 38 on day 5, P?<?0.001). Fentanyl and midazolam total dosages per patient were higher in the daily interruption group. The tidal volume was higher in the intermittent sedation group during the first five days of ICU stay. CONCLUSIONS:There was no difference in the number of ventilator-free days in 28 days between both groups. Intermittent sedation was associated with lower sedative and opioid doses. TRIAL REGISTRATION:ClinicalTrials.gov Identifier: NCT00824239.

Project description:ObjectivesFirst, to implement successfully a light-sedation protocol, favoring initial as-needed (prioritizing as-needed) boluses over continuous infusion sedation, and second, to evaluate if this protocol was associated with differences in patient-level sedative requirements, clinical outcomes, and unit-level longitudinal changes in pharmacy charges for sedative medications.DesignRetrospective review comparing patients who received the prioritizing as-needed sedation protocol to similar patients eligible for the prioritizing as-needed protocol but treated initially with continuous infusion sedation.SettingThirty-two bed medical ICUs in a large academic medical center.PatientsA total of 254 mechanical ventilated patients with a target Riker Sedation-Agitation Scale goal of 3 or 4 were evaluated over a 2-year period. Of the evaluable patients, 114 received the prioritizing as-needed sedation protocol and 140 received a primary continuous infusion approach.InterventionsA multidisciplinary leadership team created and implemented a light-sedation protocol, focusing on avoiding initiation of continuous sedative infusions and prioritizing prioritizing as-needed sedation.Measurements and main resultsOverall, 42% of patients in the prioritizing as-needed group never received continuous infusion sedation. Compared with the continuous infusion sedation group, patients treated with the prioritizing as-needed protocol received significantly less opioid, propofol, and benzodiazepine. Patients in the prioritizing as-needed group experienced less delirium, shorter duration of mechanical ventilation, and shorter ICU length of stay. Adverse events were similar between the two groups. At the unit level, protocol implementation was associated with reductions in the use of continuous infusion sedative medications.ConclusionsImplementation and use of a prioritizing as-needed protocol targeting light sedation appear to be safe and effective. These single-ICU retrospective findings require wider, prospective validation.

Project description:BackgroundGuidelines currently recommend targeting light sedation with dexmedetomidine or propofol for adults receiving mechanical ventilation. Differences exist between these sedatives in arousability, immunity, and inflammation. Whether they affect outcomes differentially in mechanically ventilated adults with sepsis undergoing light sedation is unknown.MethodsIn a multicenter, double-blind trial, we randomly assigned mechanically ventilated adults with sepsis to receive dexmedetomidine (0.2 to 1.5 μg per kilogram of body weight per hour) or propofol (5 to 50 μg per kilogram per minute), with doses adjusted by bedside nurses to achieve target sedation goals set by clinicians according to the Richmond Agitation-Sedation Scale (RASS, on which scores range from -5 [unresponsive] to +4 [combative]). The primary end point was days alive without delirium or coma during the 14-day intervention period. Secondary end points were ventilator-free days at 28 days, death at 90 days, and age-adjusted total score on the Telephone Interview for Cognitive Status questionnaire (TICS-T; scores range from 0 to 100, with a mean of 50±10 and lower scores indicating worse cognition) at 6 months.ResultsOf 432 patients who underwent randomization, 422 were assigned to receive a trial drug and were included in the analyses - 214 patients received dexmedetomidine at a median dose of 0.27 μg per kilogram per hour, and 208 received propofol at a median dose of 10.21 μg per kilogram per minute. The median duration of receipt of the trial drugs was 3.0 days (interquartile range, 2.0 to 6.0), and the median RASS score was -2.0 (interquartile range, -3.0 to -1.0). We found no difference between dexmedetomidine and propofol in the number of days alive without delirium or coma (adjusted median, 10.7 vs. 10.8 days; odds ratio, 0.96; 95% confidence interval [CI], 0.74 to 1.26), ventilator-free days (adjusted median, 23.7 vs. 24.0 days; odds ratio, 0.98; 95% CI, 0.63 to 1.51), death at 90 days (38% vs. 39%; hazard ratio, 1.06; 95% CI, 0.74 to 1.52), or TICS-T score at 6 months (adjusted median score, 40.9 vs. 41.4; odds ratio, 0.94; 95% CI, 0.66 to 1.33). Safety end points were similar in the two groups.ConclusionsAmong mechanically ventilated adults with sepsis who were being treated with recommended light-sedation approaches, outcomes in patients who received dexmedetomidine did not differ from outcomes in those who received propofol. (Funded by the National Institutes of Health; ClinicalTrials.gov number, NCT01739933.).

Project description:Purpose: To investigate physicians' perception of patients' tolerance levels regarding sedation, which could affect sedation practice for mechanically ventilated (MV) patients. Methods: This is a questionnaire survey combined with a 24 h cross-sectional study. The physician's propensity score for light sedation (PS-LS) was estimated by his/her response to the given answers for each item of the questionnaire, which tested the levels of interviewee's desire to manage MV patient with light sedation. Thereby, the mean physicians' PS-LS of each participating ICU (ICU-meanPS-LS) was calculated. The practical measurements of all variables listed on the questionnaire were used to semi-quantitatively assess stimulus intensity of what the recruited patients suffered (i.e., semi-quantitative stimulus intensity, SSI). Sedation depth was assessed by Richmond Agitation Sedation Scale (RASS). Results: 555 of 558 (99.5%) physicians from 102 ICUs were concerned with patients' tolerance levels regarding sedation while titrating sedation depth. The physician's PS-LS was non-normally distributed with median (IQR) of 3 (0-5). ICU-meanPS-LS was calculated in 92 out of 102 ICUs participating in the cross-sectional study, which was ranged from -5 to 7 with a median (IQR) of 2.37 (0.16-4.33). A significant increasing trend in prevalence of light sedation was observed over increasing ICU-meanPS-LS quartiles (from Q1 to Q4, ?2-test for trend, p = 0.002). Moreover, odds ratio for probability of light sedation remained significant in MV patients from Q4 ICUs vs. Q1 ICUs, adjusted by APACHE II score (OR, 2.332; 95% CI: 1.463-3.717; p < 0.001) or SSI score (OR, 2.445; 95% CI: 1.468-4.074; p = 0.001). Notably, adjusted OR for mortality was significant in deeply sedated MV patients (OR, 2.034; 95% CI: 1.435-2.884; p < 0.001). Conclusions: ICU physician's individualized perception for patients' tolerance levels regarding sedation, in light sedation affected sedation practice for MV patients.

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Variation in diurnal sedation in mechanically ventilated patients who are managed with a sedation protocol alone or a sedation protocol and daily interruption.

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Variation in diurnal sedation in mechanically ventilated patients who are managed with a sedation protocol alone or a sedation protocol and daily interruption.

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