Sedation in the Intensive Care Unit.
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ABSTRACT: Purpose of review
This narrative review illustrates literature over the last 5 years relating to sedation delivery to mechanically ventilated adult patients in intensive care units.Recent findings
There has been an increase in dexmedetomidine-related publications but although systematic reviews suggest dexmedetomidine reduces delirium, agitation, and length of stay, clinical trials have not supported these findings. It is likely to be useful for the managing patients with persisting agitation. Guidelines continue to recommend lightly sedating patients but considerable variation remains in clinical practice and in research trials. Protocols with no sedative infusions and morphine boluses as needed are feasible and safe, while educational interventions can decrease sedation-related adverse events.Summary
Research trials have mainly focused on individual drugs rather than practice. Given evidence is slow to translate into practice; work is needed to understand and respond to the concerns of clinicians regarding deep sedation and agitation.
SUBMITTER: Page V
PROVIDER: S-EPMC8065316 | biostudies-literature |
REPOSITORIES: biostudies-literature
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| S-EPMC9334735 | biostudies-literature
Project description:IntroductionThe purpose of this study was to evaluate sedation practice in UK intensive care units (ICUs), particularly the implementation of daily sedation holding, written sedation guidelines, sedation scoring tools and choice of agents.MethodsA national postal survey was conducted in all UK ICUs.ResultsA total of 192 responses out of 302 addressed units were received (63.5%). Of the responding ICUs, 88% used a sedation scoring tool, most frequently the Ramsey Sedation Scale score (66.4%). The majority of units have a written sedation guideline (80%), and 78% state that daily sedation holding is practiced. A wide variety of sedating agents is used, with the choice of agent largely determined by the duration of action rather than cost. The most frequently used agents were propofol and alfentanil for short-term sedation; propofol, midazolam and morphine for longer sedation; and propofol for weaning purposes.ConclusionsMost UK ICUs use a sedation guideline and sedation scoring tool. The concept of sedation holding has been implemented in the majority of units, and most ICUs have a written sedation guideline.
| S-EPMC2646317 | biostudies-literature
Project description:Comfort of the critically unwell pediatric patient is paramount to ensuring good outcomes. Analgesia-based, multimodal sedative approaches are the foundation for comfort, whereby pain is addressed first and then sedation titrated to a predefined target based on the goals of care. Given the heterogeneity of patients within the pediatric critical care population, the approach must be individualized based on the age and developmental stage of the child, physiologic status, and degree of invasive treatment required. In both the adult and pediatric intensive care unit (PICU), sedation titration is practiced as standard of care to meet therapeutic goals with a focus on facilitating early rehabilitation and extubation while avoiding under- and over-sedation. Sedation protocols have been developed as methods to reduce variability and optimize goal-directed therapy. Components of a sedation protocol include routine analgesia and sedation scoring with validated tools at specified intervals and a predefined algorithm that allows the titration of analgesia and sedation based on those assessments. Sedation protocols are designed to improve communication and documentation of sedation goals while also empowering the bedside team to respond rapidly to changes in a patient's clinical status. Previously it was thought that sedation protocols would consistently reduce duration of mechanical ventilation (MV) and length of stay (LOS) for patients in the PICU, however, this has not been the case. Nonetheless, introduction of sedation protocols has provided several benefits, including: (I) reduction in benzodiazepine usage; (II) improvements in interprofessional communication surrounding sedation goals and management of sedation goals; and (III) reductions in iatrogenic withdrawal symptoms. Successful implementation of sedation protocols requires passionate clinical champions and a robust implementation, education, and sustainability plan. Emerging evidence suggests that sedation protocols as part of a bundle of quality improvement initiatives will form the basis of future studies to improve short- and long-term outcomes after PICU discharge. In this review, we aim to define sedation protocols in the context of pediatric critical care and highlight important considerations for clinical practice and research.
| S-EPMC8578750 | biostudies-literature
Project description:intensive care unit shotgun raw sequences Metagenome
| PRJNA562118 | ENA
Project description:Sedatives are commonly used for mechanically ventilated patients in intensive care units (ICU). However, a variety of sedatives are available and their efficacy and safety have been compared in numerous trials with inconsistent results. To resolve uncertainties regarding usefulness of these sedatives, we performed a systematic review and network meta-analysis. Randomized controlled trials comparing sedatives in mechanically ventilated ICU patients were included. Graph-theoretical methods were employed for network meta-analysis. A total of 51 citations comprising 52 RCTs were included in our analysis. Dexmedetomidine showed shorter MV duration than lorazepam (mean difference (MD): 68.7; 95% CI: 18.2-119.3 hours), midazolam (MD: 10.2; 95% CI: 7.7-12.7 hours) and propofol (MD: 3.4; 95% CI: 0.9-5.9 hours). Compared with dexmedetomidine, midazolam was associated with significantly increased risk of delirium (OR: 2.47; 95% CI: 1.17-5.19). Our study shows that dexmedetomidine has potential benefits in reducing duration of MV and lowering the risk of delirium.
| S-EPMC5359583 | biostudies-literature
Project description:BackgroundVolatile sedation in the intensive care unit (ICU) may reduce the number of adverse events and improve patient outcomes compared with intravenous (IV) sedation. We performed a systematic review and meta-analysis comparing the effects of volatile and IV sedation in adult ICU patients.MethodsWe searched the PubMed, Embase, Cochrane Central Register, and Web of Science databases for all randomized trials comparing volatile sedation using an anesthetic-conserving device (ACD) with IV sedation in terms of awakening and extubation times, lengths of ICU and hospital stay, and pharmacologic end-organ effects.ResultsThirteen trials with a total of 1027 patients were included. Volatile sedation (sevoflurane or isoflurane) administered through an ACD shortened the awakening time [mean difference (MD), -80.0 minutes; 95% confidence intervals (95% CIs), -134.5 to -25.6; P = .004] and extubation time (MD, -196.0 minutes; 95% CIs, -305.2 to -86.8; P < .001) compared with IV sedation (midazolam or propofol). No differences in the lengths of ICU and hospital stay were noted between the 2 groups. In the analysis of cardiac effects of sedation from 5 studies, patients who received volatile sedation showed lower serum troponin levels 6 hours after ICU admission than patients who received IV sedation (P < .05). The effect size of troponin was largest between 12 and 24 hours after ICU admission (MD, -0.27 μg/L; 95% CIs, -0.44 to -0.09; P = .003).ConclusionCompared with IV sedation, volatile sedation administered through an ACD in the ICU shortened the awakening and extubation times. Considering the difference in serum troponin levels between both arms, volatile anesthetics might have a myocardial protective effect after cardiac surgery even at a subanesthetic dose. Because the included studies used small sample sizes with high heterogeneity, further large, high-quality prospective clinical trials are needed to confirm our findings.
| S-EPMC5728884 | biostudies-literature
Project description:IntroductionDaily interruption of sedation (DIS) and sedation algorithms (SAs) have been shown to decrease mechanical ventilation (MV) duration. We conducted a randomized study comparing these strategies.MethodsMechanically ventilated adults 18 years old or older in the medical intensive care unit (ICU) were randomly assigned to DIS or SA. Exclusion criteria were severe neurocognitive dysfunction, administration of neuromuscular blockers, and tracheostomy. Study endpoints were total MV duration and 28-day ventilator-free survival.ResultsThe study was terminated prematurely after 74 patients were enrolled (DIS 36 and SA 38). The two groups had similar age, gender, racial distribution, Acute Physiology and Chronic Health Evaluation II score, and reason for MV. The Data Safety Monitoring Board convened after DIS patients were found to have higher hospital mortality; however, no causal connection between DIS and increased mortality was identified. Interim analysis demonstrated a significant difference in primary endpoint, and study termination was recommended. The DIS group had longer total duration of MV (median 6.7 versus 3.9 days; P = 0.0003), slower improvement of Sequential Organ Failure Assessment over time (0.70 versus 0.23 units per day; P = 0.025), longer ICU length of stay (15 versus 8 days; P < 0.0001), and longer hospital length of stay (23 versus 12 days; P = 0.01).ConclusionIn our cohort of patients, the use of SA was associated with reduced duration of MV and lengths of stay compared with DIS. Based on these results, DIS may not be appropriate in all mechanically ventilated patients.Trial registrationClinicalTrials.gov NCT00205517.
| S-EPMC2481461 | biostudies-literature
Project description:Background:Analgosedation is a cornerstone therapy for mechanically ventilated patients in intensive care units (ICU). To avoid inadequate sedation and its complications, monitoring of analgosedation is of great importance. The aim of this study was to investigate whether monitoring of analgosedative drug concentrations (midazolam and sufentanil) might be beneficial to optimize analgosedation and whether drug serum concentrations correlate with the results of subjective (Richmond Agitation-Sedation Scale [RASS]/Ramsay Sedation Scale) and objective (bispectral (BIS) index) monitoring procedures. Methods:Forty-nine intubated, ventilated, and analgosedated critically ill patients treated in ICU were clinically evaluated concerning the depth of sedation using RASS Score, Ramsay Score, and BIS index twice a day. Serum concentrations of midazolam and sufentanil were determined in blood samples drawn at the same time. Clinical and laboratory data were statistically analyzed for correlations using the Spearman's rank correlation coefficient rho (?). Results:Average age of the population was 57.8?±?16.0 years, 61% of the patients were males. Most frequent causes for ICU treatments were sepsis (22%), pneumonia (22%), or a combination of both (25%). Serum concentrations of midazolam correlated weakly with RASS (??=?-?0.467) and Ramsay Scores (??=?0.476). Serum concentrations of sufentanil correlated weakly with RASS (??=?-?0.312) and Ramsay Scores (??=?0.295). Correlations between BIS index and serum concentrations of midazolam (??=?-?0.252) and sufentanil (??=?-?0.166) were low. Conclusion:Correlations between drug serum concentrations and clinical or neurophysiological monitoring procedures were weak. This might be due to intersubject variability, polypharmacy with drug-drug interactions, and complex metabolism, which can be altered in critically ill patients. Therapeutic drug monitoring is not beneficial to determine depth of sedation in ICU patients.
| S-EPMC6137863 | biostudies-other
Project description:We aim to develop evidence-based recommendations for intensivists caring for children admitted to intensive care units and requiring analgesia and sedation. A panel of national paediatric intensivists expert in the field of analgesia and sedation and other specialists (a paediatrician, a neuropsychiatrist, a psychologist, a neurologist, a pharmacologist, an anaesthesiologist, two critical care nurses, a methodologist) started in 2018, a 2-year process. Three meetings and one electronic-based discussion were dedicated to the development of the recommendations (presentation of the project, selection of research questions, overview of text related to the research questions, discussion of recommendations). A telematic anonymous consultation was adopted to reach the final agreement on recommendations. A formal conflict-of-interest declaration was obtained from all the authors. Eight areas of direct interest and one additional topic were considered to identify the best available evidence and to develop the recommendations using the Evidence-to-Decision framework according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. For each recommendation, the level of evidence, the strength of the recommendation, the benefits, the harms and the risks, the benefit/harm balance, the intentional vagueness, the values judgement, the exclusions, the difference of the opinions, the knowledge gaps, and the research opportunities were reported. The panel produced 17 recommendations. Nine were evaluated as strong, 3 as moderate, and 5 as weak. Conclusion: a panel of national experts achieved consensus regarding recommendations for the best care in terms of analgesia and sedation in critically ill children.
| S-EPMC8853329 | biostudies-literature