Effect of Protocolized Sedation on Clinical Outcomes in Mechanically Ventilated Intensive Care Unit Patients

Minhas, Mahad; Velasquez, Adrian; Kaul, Anubhav; Salinas, Pedro D; Celi, Leo Anthony

doi:10.1016/j.mayocp.2015.02.016

Cited by 56 publications

(44 citation statements)

References 31 publications

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“…This included lung-protective mechanical ventilation with low tidal volumes,22 23 higher positive end-expiratory pressure levels24 in patients with more severe forms of ARDS and prone positioning 25. Furthermore, a restrictive fluid protocol was used,26 and analgo-sedation was performed using validated sedation scales preferring bolus versus continuous sedation 27…”

Section: Methodsmentioning

confidence: 99%

Identification and validation of distinct biological phenotypes in patients with acute respiratory distress syndrome by cluster analysis

Bos

Schouten

Vught

et al. 2017

Thorax

240

212

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Rationale We hypothesized that acute respiratory distress syndrome (ARDS) patients can be clustered based on concentrations of plasma biomarkers and that the thereby identified biological phenotypes are associated with mortality. Methods Consecutive patients with ARDS were included in this prospective observational cohort study. Cluster analysis of 20 biomarkers of inflammation, coagulation and endothelial activation provided the phenotypes in a training cohort, not taking any outcome data into account. Logistic regression with backward selection was used to select the most predictive biomarkers, and these predicted phenotypes were validated in a separate cohort. Multivariable logistic regression was used to quantify the independent association with mortality. Results Two phenotypes were identified in 454 patients, which we named ‘uninflamed’ (N=218) and ‘reactive’ (N=236). A selection of four biomarkers (IL-6, interferon gamma, angiopoetin 1/2 and PAI-1) could be used to accurately predict the phenotype in the training cohort (area under the receiver operating characteristics curve: 0.98 [95%-confidence interval: 0.97–0.99]). Mortality rates were 15.6% and 36.4% (P<0.001) in the training cohort and 13.6% and 37.5% (P<0.001) in the validation cohort (N=207). The ‘reactive phenotype’ was independent from confounders associated with ICU mortality (training cohort: OR 1.13 [95%-CI: 1.04–1.23]; validation cohort: OR 1.18 [95%-CI: 1.06–1.31]). Conclusions ARDS patients can be clustered into two biological phenotypes, with different mortality rates. Four biomarkers can be used to predict the phenotype with high accuracy. The phenotypes were very similar to those found in cohorts derived from randomized controlled trials, and these results may improve patient selection for future clinical trials targeting host response in patients with ARDS.

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Section: Methodsmentioning

confidence: 99%

Identification and validation of distinct biological phenotypes in patients with acute respiratory distress syndrome by cluster analysis

Bos

Schouten

Vught

et al. 2017

Thorax

240

212

View full text Add to dashboard Cite

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“…(4,5) Sedation protocols (25) and daily sedation interruption (8) have been studied for over 15 years and have shown significant benefits in terms of outcomes (10,11) and safety with respect to adverse events, such as accidental extubation, extubation failure (9,25) and long-term psychological outcomes. (12) The results of our meta-analysis do not suggest significant differences between the two approaches in regard to important outcomes.…”

Section: Discussionmentioning

confidence: 99%

“…(10) The second systematic review included only randomized studies and pooled their results into a meta-analysis, which indicated that there were reduced ICU and hospital length of stay and reduced mortality with the use of both sedation reduction strategies. (11) Another meta-analysis also suggested that the two sedation minimization strategies were not associated with higher incidences of post-traumatic stress in the long term, (12) which was a fear that had been raised when the first study on daily sedation interruption was published. (13) …”

Section: Introductionmentioning

confidence: 99%

Sedation protocols versus daily sedation interruption: a systematic review and meta-analysis

Nassar¹,

Park²

2016

Revista Brasileira De Terapia Intensiva

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ObjectiveThe aim of this study was to systematically review studies that compared a mild target sedation protocol with daily sedation interruption and to perform a meta-analysis with the data presented in these studies.MethodsWe searched Medline, Scopus and Web of Science databases to identify randomized clinical trials comparing sedation protocols with daily sedation interruption in critically ill patients requiring mechanical ventilation. The primary outcome was mortality in the intensive care unit.ResultsSeven studies were included, with a total of 892 patients. Mortality in the intensive care unit did not differ between the sedation protocol and daily sedation interruption groups (odds ratio [OR] = 0.81; 95% confidence interval [CI] 0.60 - 1.10; I2 = 0%). Hospital mortality, duration of mechanical ventilation, intensive care unit and hospital length of stay did not differ between the groups either. Sedation protocols were associated with an increase in the number of days free of mechanical ventilation (mean difference = 6.70 days; 95%CI 1.09 - 12.31 days; I2 = 87.2%) and a shorter duration of hospital length of stay (mean difference = -5.05 days, 95%CI -9.98 - -0.11 days; I2 = 69%). There were no differences in regard to accidental extubation, extubation failure and the occurrence of delirium.ConclusionSedation protocols and daily sedation interruption do not appear to differ in regard to the majority of analyzed outcomes. The only differences found were small and had a high degree of heterogeneity.

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“…The need for sedation should be assessed regularly and sedative doses adjusted accordingly, with the aim of withdrawing sedatives completely as soon as possible. Sedative protocols may be of use (34), but most studies assessing protocolized sedation were conducted using benzodiazepines and there are few studies that have assessed this strategy in ICUs that use minimal sedation. Figure 1.…”

Section: Adequate Analgesiamentioning

confidence: 99%

Optimizing sedation in the ICU: the eCASH concept

Vincent¹

2017

Signa Vitae

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Deep sedation is known to be associated with poor long-term outcomes in critically ill patients, including cognitive and psychological complications and increased mortality. Yet many patients still receive high levels of sedation, particularly during the early days of their intensive care unit (ICU) stay. The eCASH (early Comfort using Analgesia, minimal Sedatives and maximal Humane care) concept is a threepronged approach to minimize sedation in ICU patients by ensuring adequate and timely analgesia is received; patient-centred care is encouraged, including communication aids, noise reduction to facilitate good sleep patterns, early mobilization, and family involvement; and, when needed, sedation is targeted to individual needs and regularly reassessed, with patients kept calm, comfortable and able to cooperate.

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Effect of Protocolized Sedation on Clinical Outcomes in Mechanically Ventilated Intensive Care Unit Patients

Abstract: In mechanically ventilated adults in closed, nonspecialty ICUs, protocolized sedation seems to decrease overall mortality (15%), ICU and hospital lengths of stay (1.73 and 3.55 days, respectively), and tracheostomy (31%) compared with usual care without protocolized sedation.

Cited by 56 publications

References 31 publications

Identification and validation of distinct biological phenotypes in patients with acute respiratory distress syndrome by cluster analysis

Identification and validation of distinct biological phenotypes in patients with acute respiratory distress syndrome by cluster analysis

Sedation protocols versus daily sedation interruption: a systematic review and meta-analysis

Optimizing sedation in the ICU: the eCASH concept

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