Clinical effectiveness of a sedation protocol minimizing benzodiazepine infusions and favoring early dexmedetomidine: a before-after study

Abstract

IntroductionRandomized controlled trials suggest clinical outcomes may be improved with dexmedetomidine as compared with benzodiazepines; however, further study and validation are needed. The objective of this study was to determine the clinical effectiveness of a sedation protocol minimizing benzodiazepine use in favor of early dexmedetomidine.MethodsWe conducted a before-after study including adult surgical and medical intensive care unit (ICU) patients requiring mechanical ventilation and continuous sedation for at least 24 hours. The before phase included consecutive patients admitted between 1 April 2011 and 31 August 31 2011. Subsequently, the protocol was modified to minimize use of benzodiazepines in favor of early dexmedetomidine through a multidisciplinary approach, and staff education was provided. The after phase included consecutive eligible patients between 1 May 2012 and 31 October 2012.ResultsA total of 199 patients were included, with 97 patients in the before phase and 102 in the after phase. Baseline characteristics were well balanced between groups. Use of midazolam as initial sedation (58% versus 27%, P <0.0001) or at any point during the ICU stay (76% versus 48%, P <0.0001) was significantly reduced in the after phase. Dexmedetomidine use as initial sedation (2% versus 39%, P <0.0001) or at any point during the ICU stay (39% versus 82%, P <0.0001) significantly increased. Both the prevalence (81% versus 93%, P =0.013) and median percentage of days with delirium (55% (interquartile range (IQR), 18 to 83) versus 71% (IQR, 45 to 100), P =0.001) were increased in the after phase. The median duration of mechanical ventilation was significantly reduced in the after phase (110 (IQR, 59 to 192) hours versus 74.5 (IQR, 42 to 148) hours, P =0.029), and significantly fewer patients required tracheostomy (20% versus 9%, P =0.040). The median ICU length of stay was 8 (IQR, 4 to 12) days in the before phase and 6 (IQR, 3 to 11) days in the after phase (P =0.252).ConclusionsImplementing a sedation protocol that targeted light sedation and reduced benzodiazepine use led to significant improvements in the duration of mechanical ventilation and the requirement for tracheostomy, despite increases in the prevalence and duration of ICU delirium.

Frequent Versus Infrequent Monitoring of Endotracheal Tube Cuff Pressures

“…This may be due in part to the staffing practices in the medical ICUs and the history of efforts directly aimed at optimizing the care of ventilated subjects in those units. 6,[8][9][10] However, we cannot be certain that our findings would be the same in ICUs having different staffing models and protocols for the prevention of events such as VAEs and VAP. Our study data were also derived from a single center, which limits the generalizability of our findings.…”

“…6,7 Moreover, the medical ICUs have a long history of routinely using protocols for the weaning of mechanical ventilation, sedation management, and prevention of VAP and VAEs developed in conjunction with the infection prevention department and the Barnes-Jewish Hospital Departments of Respiratory Care and Nursing. 6,[8][9][10] We also recorded the exact number of endotracheal tube cuff pressure assessments performed in both groups.…”

“…Historically in these ICUs, mechanical ventilation, weaning of mechanical ventilation, as well as the use of sedation, are standardized according to the protocols established for Barnes-Jewish Hospital. 6,[8][9][10]…”

Avaliação metabólica e hemodinâmica de dois protocolos de sedação prolongada em cães

“…Cada animal recebeu aproximadamente 500mL de propofol em 24 horas, e possivelmente o curto tempo para extubação e o moderado tempo para recuperação ocorreram devido ao baixo efeito cumulativo do propofol (Luiz et al, 2013). Em UTI humana, a associação de propofol e midazolam é normalmente utilizada, entretanto altas doses de benzodiazepínicos têm sido associadas com aumento do tempo de recuperação e desmame da VM (Skrupky et al, 2015). Vieira et al (2013) também não observaram diferenças no tempo para extubação, deambulação e recuperação total em cães submetidos à infusão de propofol e propofol/cetamina em taxas variadas durante 60 minutos, porém esses tempos aumentam consideravelmente em infusões para procedimentos de OSH, devido à necessidade de maiores doses para a manutenção dos planos.…”

ICU Delirium: Diagnosis, Risk Factors, and Management

“…decreased sedation, decreased duration of mechanical ventilation, etc.) but have had either no effect on delirium incidence [31,32] or strangely in one study of a protocol minimizing benzodiazepines in favor of dexmedetomidine-an increase in delirium prevalence (81 vs. 93 %, p = 0.013) [33]. A systematic review on ICU delirium bundles concluded that creating an integrated management protocol with a higher number of individual elements (at least six different prevention strategies), such as the PAD or ABCDE bundles, may improve clinical outcomes such as mortality and hospital length of stay, but did not appear to be associated with decreased incidence of delirium [34].…”