Current practices of mobilization, analgesia, relaxants and sedation in Indian ICUs: A survey conducted by the Indian Society of Critical Care Medicine

Abstract

Background and Aim:Use of sedation, analgesia and neuromuscular blocking agents is widely practiced in Intensive Care Units (ICUs). Our aim is to study the current practice patterns related to mobilization, analgesia, relaxants and sedation (MARS) to help in standardizing best practices in these areas in the ICU.Materials and Methods:A web-based nationwide survey involving physicians of the Indian Society of Critical Care Medicine (ISCCM) and the Indian Society of Anesthesiologists (ISA) was carried out. A questionnaire included questions on demographics, assessment scales for delirium, sedation and pain, as also the pharmacological agents and the practice methods.Results:Most ICUs function in a semi-closed model. Midazolam (94.99%) and Fentanyl (47.04%) were the most common sedative and analgesic agents used, respectively. Vecuronium was the preferred neuromuscular agent. Monitoring of sedation, analgesia and delirium in the ICU. Ramsay's Sedation Scale (56.1%) and Visual Analogue Scale (48.07%) were the preferred sedation and pain scales, respectively. CAM (Confusion Assessment Method)-ICU was the most preferred method of delirium assessment. Haloperidol was the most commonly used agent for delirium. Majority of the respondents were aware of the benefit of early mobilization, but lack of support staff and safety concerns were the main obstacles to its implementation.Conclusion:The results of the survey suggest that compliance with existing guidelines is low. Benzodiazepines still remain the predominant ICU sedative. The recommended practice of giving analgesia before sedation is almost non-existent. Delirium remains an underrecognized entity. Monitoring of sedation levels, analgesia and delirium is low and validated and recommended scales for the same are rarely used. Although awareness of the benefits of early mobilization are high, the implementation is low.

Worldwide Survey of the “Assessing Pain, Both Spontaneous Awakening and Breathing Trials, Choice of Drugs, Delirium Monitoring/Management, Early Exercise/Mobility, and Family Empowerment” (ABCDEF) Bundle

“…(29)Our findings regarding use of SATs and SBTs in Europe (47% and 50%) are also consistent with previously reported data. (27)…”

“…Nearly all (95%) respondents reported using midazolam for sedation, followed by propofol (68%), and dexmedetomidine (60%); fentanyl was the most common analgesic agent used (47 %). (29)In our study, 35% of respondents reported they do not use sedation protocols, especially those in Africa, Europe and Oceania.…”

“…(27–29)In an Australian point prevalence study, routine sedation scale use was recorded in 63% of invasively ventilated patients. (28) In a European Survey, routine sedation monitoring was reported in 88% of the ICUs, with most reporting use of RASS (54%), Ramsay (27%), or SAS (6%).…”

“…(29) Similarly, a multicenter European Survey round that only 56% of respondents reported screening patients for symptoms of delirium. (27) In an Australian point prevalence study, routine assessment of delirium occurred in only 3% of patients.…”

Inspiratory muscle training to enhance recovery from invasive mechanical ventilation

“…Given the wide variety in practices of early mobilisation around Australia and the world (Chawla et al, 2014, Malone et al, 2015, Nydahl et al, 2014, it is probably prudent to limit extrapolations of these findings to units with similar practices regarding mobilisation and rehabilitation.…”