Inadequate provision of postintubation anxiolysis and analgesia in the ED

Bonomo, Jordan; Butler, Andrew; Lindsell, Christopher J.; Venkat, Arvind

doi:10.1016/j.ajem.2007.05.024

Cited by 50 publications

(24 citation statements)

References 6 publications

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“…We were able to effect this change in medication ordering while maintaining the overall percentage of patients who received analgesia and/or sedation following mechanical ventilation at 82–83%, significantly above reported rates. 4 , 5 As follow up to this research, we are currently evaluating whether the increased use of an analgesia-first strategy in the ED reduces ventilator LOS in mechanically ventilated patients.…”

Section: Discussionmentioning

confidence: 99%

“…For example, Bonomo in 2007 found that 33% of mechanically ventilated patients in the ED received no anxiolytics, 53% received no analgesia, and 20% received neither analgesia nor anxiolytics. 4 Additionally, a large study using the National Ambulatory Medical Care Survey found that less than 50% of mechanically ventilated patients received a sedative or opioid medication. 5 …”

Section: Introductionmentioning

confidence: 99%

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Simple Changes to Emergency Department Workflow Improve Analgesia in Mechanically Ventilated Patients

Isenberg

Kissman

Salinski

et al. 2018

WestJEM

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IntroductionIn 2013 the Society for Critical Care Medicine (SCCM) published guidelines for the management of pain and agitation in the intensive care unit (ICU). These guidelines recommend using an analgesia-first strategy in mechanically ventilated patients as well as reducing the use of benzodiazepines. Benzodiazepines increase delirium in ICU patients thereby increasing ICU length of stay. We sought to determine whether a simple educational intervention for emergency department (ED) staff, as well as two simple changes in workflow, would improve adherence to the SCCM guidelines.MethodsThis was a cohort study that took place from 2014–2016. All patients who were intubated in the ED by an emergency physician (EP) during this time were eligible for inclusion in this study. In January 2015, we began an educational campaign with the ED staff consisting of a series of presentations and online trainings. The impetus for our educational campaign was to have best practices in place for our new emergency medicine residency program starting in July 2016. We made two minor changes in our ED workflow to support this educational objective. First, fentanyl infusions were stocked in the ED. Second, we instituted a medication order set for mechanically ventilated patients. This order set nudged EPs to choose medications consistent with the SCCM guidelines. We then evaluated the use of opioids and benzodiazepines in mechanically ventilated patients from 2014 through 2016 using Fisher’s exact test. All analyses were conducted in the overall sample (n=509) as well as in subgroups after excluding patients with seizures/status epilepticus as their primary admission diagnosis (n=461).ResultsIn 2014 prior to the interventions, 41% of mechanically ventilated patients received an opioid, either as an intravenous (IV) push or IV infusion. In 2015 immediately after the intervention, 71% of patients received an opioid and 64% received an opioid in 2016. The use of benzodiazepine infusions decreased from 22% in 2014 to 7% in 2015 to 1% in 2016.ConclusionA brief educational intervention along with two simple changes in ED workflow can improve compliance with the SCCM guidelines for the management of pain and agitation in mechanically ventilated patients.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Simple Changes to Emergency Department Workflow Improve Analgesia in Mechanically Ventilated Patients

Isenberg

Kissman

Salinski

et al. 2018

WestJEM

View full text Add to dashboard Cite

show abstract

“…In a recent retrospective study of intubated ED patients, Bonomo et al. demonstrated that 74% of patients received either inadequate or no anxiolysis, whereas 75% of patients received either inadequate or no analgesia (8).…”

Section: Sedation Analgesia and Neuromuscular Blockadementioning

confidence: 99%

Care of the Intubated Emergency Department Patient

Wood

Winters

2011

The Journal of Emergency Medicine

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“… 76 Adequate provision of analgesia for ventilated patients unable to communicate due to sedation, altered level of consciousness, and endotracheal intubation is challenging and often inadequate in both emergency department and intensive care unit settings. 77 , 78 Sedative agents may be administered more frequently than analgesia in the emergency department, 79 but professional society guidelines recommend sedation in ventilated patients should be commenced only after provision of adequate analgesia. 76 Various tools are now available to assess pain 80 , 81 in patients unable to communicate and sedation level, 82 , 83 and can be used in the emergency department setting.…”

Section: Invasive Ventilationmentioning

confidence: 99%

Management of critically ill patients receiving noninvasive and invasive mechanical ventilation in the emergency department

Rose

2012

OAEM

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Patients requiring noninvasive and invasive ventilation frequently present to emergency departments, and may remain for prolonged periods due to constrained critical care services. Emergency clinicians often do not receive the same education on management of mechanical ventilation or have similar exposure to these patients as do their critical care colleagues. The aim of this review was to synthesize the evidence on management of patients requiring noninvasive and invasive ventilation in the emergency department including indications, clinical applications, monitoring priorities, and potential complications. Noninvasive ventilation is recommended for patients with acute exacerbation of chronic obstructive pulmonary disease or cardiogenic pulmonary edema. Less evidence supports its use in asthma and other causes of acute respiratory failure. Use of noninvasive ventilation in the prehospital setting is relatively new, and some evidence suggests benefit. Monitoring priorities for noninvasive ventilation include response to treatment, respiratory and hemodynamic stability, noninvasive ventilation tolerance, detection of noninvasive ventilation failure, and identification of air leaks around the interface. Application of injurious ventilation increases patient morbidity and mortality. Lung-protective ventilation with low tidal volumes based on determination of predicted body weight and control of plateau pressure has been shown to reduce mortality in patients with acute respiratory distress syndrome, and some evidence exists to suggest this strategy should be used in patients without lung injury. Monitoring of the invasively ventilated patient should focus on assessing response to mechanical ventilation and other interventions, and avoiding complications, such as ventilator-associated pneumonia. Several key aspects of management of noninvasive and invasively ventilated patients are discussed, with a particular emphasis on initiation and ongoing monitoring priorities focused on maintaining patient safety and improving patient outcomes.

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Inadequate provision of postintubation anxiolysis and analgesia in the ED

Cited by 50 publications

References 6 publications

Simple Changes to Emergency Department Workflow Improve Analgesia in Mechanically Ventilated Patients

Simple Changes to Emergency Department Workflow Improve Analgesia in Mechanically Ventilated Patients

Care of the Intubated Emergency Department Patient

Management of critically ill patients receiving noninvasive and invasive mechanical ventilation in the emergency department

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