Decreased duration of mechanical ventilation when comparing analgesia-based sedation using remifentanil with standard hypnotic-based sedation for up to 10 days in intensive care unit patients: a randomised trial [ISRCTN47583497]

2012

CPAA

Critically ill patients are routinely provided analgesia and sedation to prevent pain and anxiety, permit invasive procedures, reduce stress and oxygen consumption, and improve synchrony with mechanical ventilation. Regional preferences, patient history, institutional bias, and individual patient and practitioner variability, however, create a wide discrepancy in the approach to sedation of critically ill patients. Untreated pain and agitation increase the sympathetic stress response, potentially leading to negative acute and long-term consequences. Oversedation, however, occurs commonly and is associated with worse clinical outcomes, including longer time on mechanical ventilation, prolonged stay in the intensive care unit, and increased brain dysfunction (delirium and coma). Modifying sedation delivery by incorporating analgesia and sedation protocols, targeted arousal goals, daily interruption of sedation, linked spontaneous awakening and breathing trials, and early mobilization of patients have all been associated with improvements in patient outcomes and should be incorporated into the clinical management of critically ill patients. To improve outcomes, including time on mechanical ventilation and development of acute brain dysfunction, conventional sedation paradigms should be altered by providing necessary analgesia, incorporating propofol or dexmedetomidine to reach arousal targets, and reducing benzodiazepine exposure.

Section: Sedationsupporting

confidence: 80%

Sedation in the intensive care setting

Hughes

McGrane²,

2012

CPAA

“…We expect greater variation in sedative dosing within ICUs that do not use sedation scales to guide dosing; our results may therefore be conservatively biased. Our results may also be less applicable in ICUs that employ strategies including dexmedetomidine (32, 49), analgosedation (31, 50), or avoidance of sedating medications (50). Second, delirium may have gone undetected in some instances, resulting in misclassification bias.…”

Section: Discussionmentioning

confidence: 96%

Diurnal sedative changes during intensive care

Seymour

Koestner

et al. 2012

Critical Care Medicine

Objective To determine whether benzodiazepine and propofol doses are increased at night and whether daytime and nighttime sedative doses are associated with delirium, coma, and delayed liberation from mechanical ventilation. Design Single-center, prospective cohort study nested within the Awakening and Breathing Controlled randomized trial Setting Saint Thomas Hospital in Nashville, TN from 2004–2006 Patients Adult patients receiving mechanical ventilation for greater than 12 hours with continuous recording of hourly sedation dosing Interventions We measured hourly doses of benzodiazepine and propofol exposure during the daytime (7am–11pm) and nighttime (11pm–7am) for five days. We quantified nighttime dose increases by subtracting the average hourly daytime dose on the preceding day from subsequent average hourly nighttime dose. We used multivariable logistic regression to determine if daytime and nighttime dose increases were independently associated with delirium, coma, and delayed liberation from mechanical ventilation. Measurements and main results Among 140 patients, the median APACHE II score was 27 [IQR: 22, 33]. Among those receiving the sedatives, benzodiazepine and propofol doses were increased at night on 40% and 41% of patient-days, respectively. Of 485 patient-days, delirium was present on 160 (33%) and coma on 206 (42%). In adjusted models, greater daytime benzodiazepine dose was independently associated with failed SBT and extubation, and subsequent delirium (p<0.02 for all). Nighttime increase in benzodiazepine dose was associated with failed SBT (p<0.01) and delirium (p=0.05). Daytime propofol dose was marginally associated with subsequent delirium (p=0.06). Conclusions Nearly half of mechanically ventilated ICU patients received greater doses of sedation at night, a practice associated with failed SBTs, coma, and delirium. Over the first five days in our study, patients spent 75% of their time in coma or delirium, outcomes that may be reduced by efforts to decrease sedative exposure during both daytime and nighttime hours in the ICU.

“…al. (62) compared a sedation regimen using remifentanil to midazolam and found that the remifentanil-based sedation regimen decreased duration of mechanical ventilation and the time from the start of weaning to extubation. Two studies comparing sedation protocols using dexmedetomidine (α 2 agonist) to benzodiazepine infusions showed similar results.…”

Section: Choosing the Right Sedative Regimen In Critically Ill Patientsmentioning

confidence: 99%

The complex interplay between delirium, sedation, and early mobility during critical illness: applications in the trauma unit

Banerjee

Girard

Current Opinion in Anaesthesiology

2011

Purpose of the review Critically ill patients are prescribed sedatives and analgesics to decrease pain and anxiety, improve patient – ventilator dyssynchrony and ensure patient safety. These medications may themselves lead to delirium and ICU-acquired weakness, which are associated with worse clinical outcomes. This review will focus on the epidemiology of these two disease processes and discuss strategies aimed at reducing these devastating complications of critical illness. Recent Findings Delirium and ICU-acquired weakness are associated with longer hospital stay, increased cost and decreased quality of life after discharge from the ICU. Delirium has also shown to be associated with increased mortality. Strategies aimed at reducing sedative exposure through protocols and coordination of daily sedation and ventilator cessation trials, avoiding benzodiazepines in favor of alternative sedative regimens and early mobilization of patients have all shown to significantly improve patient outcomes. Summary Delirium and ICU-acquired weakness are complications of critical illness associated with worse clinical outcomes and functional decline in survivors. An evidence-based approach based on the following tenets; minimization of sedative medication, particularly benzodiazepines, delirium monitoring and management and early mobilization may mitigate these complications.