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Practice Patterns and Outcomes Associated With Early Sedation Depth in Mechanically Ventilated Patients: A Systematic Review and Meta-Analysis.

ABSTRACT: OBJECTIVES:Emerging data suggest that early deep sedation may negatively impact clinical outcomes. This systematic review and meta-analysis defines and quantifies the impact of deep sedation within 48 hours of initiation of mechanical ventilation, as described in the world's literature. The primary outcome was mortality. Secondary outcomes included hospital and ICU lengths of stay, mechanical ventilation duration, and delirium and tracheostomy frequency. DATA SOURCES:The following data sources were searched: MEDLINE, EMBASE, Scopus, Cochrane Central Register of Controlled Trials, Database of Abstracts of Reviews and Effects, Cochrane Database of Systematic Reviews databases, ClinicalTrials.gov, conference proceedings, and reference lists. STUDY SELECTION:Randomized controlled trials and nonrandomized studies were included. DATA EXTRACTION:Two reviewers independently screened abstracts of identified studies for eligibility. DATA SYNTHESIS:Nine studies (n = 4,521 patients) published between 2012 and 2017 were included. A random effects meta-analytic model revealed that early light sedation was associated with lower mortality (9.2%) versus deep sedation (27.6%) (odds ratio, 0.34 [0.21-0.54]). Light sedation was associated with fewer mechanical ventilation (mean difference, -2.1; 95% CI, -3.6 to -0.5) and ICU days (mean difference, -3.0 (95% CI, -5.4 to -0.6). Delirium frequency was 28.7% in the light sedation group and 48.5% in the deep sedation group, odds ratio, 0.50 (0.22-1.16). CONCLUSIONS:Deep sedation in mechanically ventilated patients, as evaluated in a small number of qualifying heterogeneous randomized controlled trials and observational studies, was associated with increased mortality and lengths of stay. Interventions targeting early sedation depth assessment, starting in the emergency department and subsequent ICU admission, deserve further investigation and could improve outcome.

SUBMITTER: Stephens RJ

PROVIDER: S-EPMC5825247 | biostudies-literature | 2018 Mar

REPOSITORIES: biostudies-literature

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Practice Patterns and Outcomes Associated With Early Sedation Depth in Mechanically Ventilated Patients: A Systematic Review and Meta-Analysis.

Stephens Robert J RJ Dettmer Matthew R MR Roberts Brian W BW Ablordeppey Enyo E Fowler Susan A SA Kollef Marin H MH Fuller Brian M BM

Critical care medicine 20180301 3

<h4>Objectives</h4>Emerging data suggest that early deep sedation may negatively impact clinical outcomes. This systematic review and meta-analysis defines and quantifies the impact of deep sedation within 48 hours of initiation of mechanical ventilation, as described in the world's literature. The primary outcome was mortality. Secondary outcomes included hospital and ICU lengths of stay, mechanical ventilation duration, and delirium and tracheostomy frequency.<h4>Data sources</h4>The following ...[more]

PMID: 29227367

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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.

Project description:ObjectivesWe sought to study the association between sedation status, medications (benzodiazepines, opioids, and antipsychotics), and clinical outcomes in a resource-limited setting.DesignA longitudinal study of critically ill participants on mechanical ventilation.SettingFive intensive care units (ICUs) in four public hospitals in Lima, Peru.PatientsOne thousand six hundred fifty-seven critically ill participants were assessed daily for sedation status during 28 days and vital status by day 90.ResultsAfter excluding data of participants without a Richmond Agitation Sedation Scale score and without sedation, we followed 1338 (81%) participants longitudinally for 18,645 ICU days. Deep sedation was present in 98% of participants at some point of the study and in 12,942 ICU days. Deep sedation was associated with higher mortality (interquartile odds ratio (OR) = 5.42, 4.23-6.95; p < 0.001) and a significant decrease in ventilator (- 7.27; p < 0.001), ICU (- 4.38; p < 0.001), and hospital (- 7.00; p < 0.001) free days. Agitation was also associated with higher mortality (OR = 39.9, 6.53-243, p < 0.001). The most commonly used sedatives were opioids and benzodiazepines (9259 and 8453 patient days respectively), and the latter were associated with a 41% higher mortality in participants with a higher cumulative dose (75th vs 25th percentile, interquartile OR = 1.41, 1.12-1.77; p < 0.01). The overall cumulative dose of benzodiazepines and opioids was high, 774.5 mg and 16.8 g, respectively, by day 7 and by day 28; these doses approximately doubled. Haloperidol was only used in 3% of ICU days; however, the use of it was associated with a 70% lower mortality (interquartile OR = 0.3, 0.22-0.44, p < 0.001).ConclusionsDeep sedation, agitation, and cumulative dose of benzodiazepines were all independently associated with higher 90-day mortality. Additionally, deep sedation was associated with less ventilator-, ICU-, and hospital-free days. In contrast, haloperidol was associated with lower mortality in our study.

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Practice Patterns and Outcomes Associated With Early Sedation Depth in Mechanically Ventilated Patients: A Systematic Review and Meta-Analysis.

Publications

Practice Patterns and Outcomes Associated With Early Sedation Depth in Mechanically Ventilated Patients: A Systematic Review and Meta-Analysis.

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