Targeting light versus deep sedation for patients receiving mechanical ventilation

Boncyk, Christina; Nahrwold, Daniel A.; Hughes, Christopher G.

doi:10.21037/jeccm.2018.10.03

Cited by 6 publications

(6 citation statements)

References 24 publications

(18 reference statements)

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“…According to reports, the use of lighter sedation (compared to deep sedation) does not increase the incidence of adverse effects [ 4 , 43 , 44 ]. The current recommendations of the Society of Critical Care Medicine prescribe the maintenance of light sedation in all patients undergoing mechanical ventilation while recognizing that it is a conditional recommendation due to the low quality of the available evidence [ 1 , 45 ]. Studies by Wang et al [ 46 ] indicate that over 87% of clinicians use analgosedation in ICU patients, and more than half never apply strategies for keeping the patient conscious.…”

Section: Discussionmentioning

confidence: 99%

“…Some studies define deep sedation as a RASS score from −3 to −5 [ 3 , 6 ] and others as a RASS score of −4 or −5 [ 14 ]. It should be emphasized that the cut-off point is an important clinical differentiation, as in the RASS scale a result of −3 means that the patient still responds to a voice, while the results of −4 or −5 show that the patient is unresponsive to a voice and is often in a coma [ 45 ]. This also has an impact on the pain assessment.…”

Section: Discussionmentioning

confidence: 99%

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Pain Assessment with the BPS and CCPOT Behavioral Pain Scales in Mechanically Ventilated Patients Requiring Analgesia and Sedation

Wojnar-Gruszka

Sega

Płaszewska‐Żywko

et al. 2022

IJERPH

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Background: Intensive Care Unit (ICU) patients often experience pain, especially during diagnostic, nursing, and therapeutic interventions. Pain assessment using the Behavioral Pain Scale (BPS) and Critical Care Pain Observation Tool (CCPOT) are recommended, but they are difficult to do in patients undergoing deep sedation. This study analyzed the usefulness of the BPS and CCPOT scales in assessing pain among patients with varying degrees of sedation. Methods: In 81 mechanically ventilated and sedated ICU patients, 1005 measurements were performed using the BPS and CCPOT scales. The study was conducted by 3 trained observers 3 times a day (each measurement at rest, during painful nursing interventions, and after the intervention). The Richmond Agitation-Sedation Scale (RASS), the Simplified Acute Physiology Score (SAPS II), and the Acute Physiology and Chronic Health Evaluation (APACHE II) were also analyzed from medical records as well as information on the length of hospitalization and treatment. Results: It was shown that signs of pain increased significantly (p < 0.001) during interventions in patients on both scales (BPS and CCPOT), and then returned to values close to the resting period. RASS results correlated significantly (p < 0.05) and positively with the results of the BPS and CCPOT. A strong correlation was found between the results of both scales at each stage of the study (R = 0.622–0.907). Conclusions: Nursing procedures are a source of pain in analgosedated patients. The BPS and CCPOT scales are useful tools for assessing the occurrence of pain in mechanically ventilated patients, including those in deep sedation.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Pain Assessment with the BPS and CCPOT Behavioral Pain Scales in Mechanically Ventilated Patients Requiring Analgesia and Sedation

Wojnar-Gruszka

Sega

Płaszewska‐Żywko

et al. 2022

IJERPH

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“…Yet, sedatives may predispose patients to develop of VAP by decreasing cough reflex, reducing endotracheal secretion clearance, or impairing gut motility [9]. However, evidence is limited and unclear due to inconsistency in how light sedation is defined [36]. The Society of Critical Care Medicine recommends light sedation for patients receiving MV [37].…”

Section: Discussionmentioning

confidence: 99%

Modifiable risk factors of ventilator-associated pneumonia in non-intensive care unit versus intensive care unit

Udompat

Rongmuang

Hershow

2021

J Infect Dev Ctries

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Introduction: Ventilator-associated pneumonia patients are treated in non-intensive care units because of a shortage of intensive care unit beds in Thailand. Our objective was to assess whether the type of unit and medications prescribed to the patient were associated with ventilator‑associated pneumonia and multidrug resistant ventilator‑associated pneumonia. Methodology: A matched case-control study nested in a prospective cohort of mechanical ventilation adult patients in a medical-surgical intensive care unit and five non-intensive care units from March 1 through October 31, 2013. The controls were randomly selected 1:1 with cases and matched based on duration and start date of mechanical ventilation. Results: 248 ventilator-associated pneumonia and control patients were analyzed. The most common bacteria were multidrug resistant Acinetobacter baumannii (82.4%). Compared with patients in the intensive care unit, those in the neurosurgical/surgical non-intensive care units were at higher risk (p = 0.278). Proton pump inhibitor was a risk factor (p = 0.011), but antibiotic was a protective factor (p = 0.054). Broad spectrum antibiotic was a risk factor (p < 0.001) for multidrug resistant ventilator-associated pneumonia. Conclusions: Post-surgical and neurosurgical patients treated in non-intensive care unit settings were at the highest risk of ventilator-associated pneumonia. Our findings suggest that alternative using proton pump inhibitors should be considered based on the risk-benefit of using this medication. In addition, careful stewardship of antibiotic use should be warranted to prevent multidrug resistant ventilator-associated pneumonia.

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“…This light sedation strategy in the control group could explain the primary outcome difference between the ROSE study and other Bias was rated high because of no blinding in four out of five studies (see Table 1) b Inconsistency across studies in these two outcomes based on I 2 was moderate c Imprecision was detected for this outcome because there was no value for this outcome available for 1 out of 5 studies trials. Light sedation was associated with less use of vasopressor, shorter time to extubation [33], and lower mortality in mechanically ventilated patients [17,18]. The meta-regression showed that the baseline PaO 2 / FIO 2 ratio and baseline PEEP variables had no effect on the 28-day mortality rate and NMBA.…”

Section: Discussionmentioning

confidence: 99%

“…NMBA, however, could be associated with muscular weakness and the need of more sedatives [6,14,15]. Of note, besides NMBA use, increasing evidence of other supportive treatments for ARDS patients such as sedation, positive end-expiratory pressure (PEEP) strategy, and prone positioning has been developed since major data on NMBA were published [16][17][18]. The question of whether NMBA is effective is still unknown.…”

Section: Introductionmentioning

confidence: 99%

Neuromuscular blockade in acute respiratory distress syndrome: a systematic review and meta-analysis of randomized controlled trials

Patolia

Guervilly

2020

j intensive care

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Background: Neuromuscular blocking agent (NMBA) has been proposed by medical guidelines for early severe acute respiratory distress syndrome (ARDS) because of its survival benefits. However, new studies have provided evidence contradicting these results. Method: A search was performed of the Pubmed, Scopus, Clinicaltrials.gov, and Virtual Health Library databases for randomized controlled trials (RCT) evaluating 28-day mortality in ARDS patients treated with NMBA within 48 h. An English language restriction was applied. Relevant data were extracted and pooled into risk ratios (RR), mean differences (MD), and corresponding 95% confidence intervals (CI) using random-effect model. Sensitivity and metaregression analysis were performed. Results: From 2675 studies, we included five RCTs in the analysis, for a total of 1461 patients with a mean PaO 2 / FIO 2 of 104 ± 35 mmHg. The cisatracurium group had the same risk of death at 28 days (RR, 0.90; 95% CI, 0.78-1.03; I 2 = 50%, p = 0.12) and 90 days (RR, 0.81; 95% CI, 0.62-1.06; I 2 = 56%, p = 0.06) as the control group (no cisatracurium). The secondary outcomes of mechanical ventilation duration and ventilator-free days were not different between the two groups. Cisatracurium had a significantly lower risk of barotrauma than the control group with no difference in intensive care unit (ICU)-induced weakness. The PaO 2 /FIO 2 ratio was higher in the cisatracurium group but not until 48 h. Meta-regression analysis of the baseline PaO 2 /FIO 2 ratio, positive endexpiratory pressure (PEEP) revealed no heterogeneity. Subgroup analysis excluding the trial using high PEEP and light sedation strategy yielded an improvement in all mortality outcomes. Conclusion: NMBA improves oxygenation only after 48 h in moderate, severe ARDS patients and has a lower barotrauma risk without affecting ICU weakness. However, NMBA does not reduce ventilator-free days, duration of mechanical ventilation or, most importantly, the mortality risk regardless of the severity of ARDS.

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Targeting light versus deep sedation for patients receiving mechanical ventilation

Cited by 6 publications

References 24 publications

Pain Assessment with the BPS and CCPOT Behavioral Pain Scales in Mechanically Ventilated Patients Requiring Analgesia and Sedation

Pain Assessment with the BPS and CCPOT Behavioral Pain Scales in Mechanically Ventilated Patients Requiring Analgesia and Sedation

Modifiable risk factors of ventilator-associated pneumonia in non-intensive care unit versus intensive care unit

Neuromuscular blockade in acute respiratory distress syndrome: a systematic review and meta-analysis of randomized controlled trials

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