The implementation of an analgesia-based sedation protocol reduced deep sedation and proved to be safe and feasible in patients on mechanical ventilation

Abstract

IntroductionDeep sedation in critically ill patients is associated with a longer duration of mechanical ventilation and a prolonged length of stay in the intensive care unit. Several protocols have been used to improve these outcomes. We implement and evaluate an analgesia-based, goal-directed, nurse-driven sedation protocol used to treat critically ill patients who receive mechanical ventilation. MethodsWe performed a prospective, two-phase (before-after), non-randomized multicenter study that involved 13 intensive care units in Chile. After an observational phase (observational group, n=155), we designed, implemented and evaluated an analgesia-based, goal-directed, nurse-driven sedation protocol (intervention group, n=132) to treat patients who required mechanical ventilation for more than 48 hours. The primary outcome was to achieve ventilator-free days by day 28. ResultsThe proportion of patients in deep sedation or in a coma decreased from 55.2% to 44.0% in the interventional group. Agitation did not change between the periods and remained approximately 7%. Ventilator-free days to day 28, length of stay in the intensive care unit and mortality were similar in both groups. At one year, post-traumatic stress disorder symptoms in survivors were similar in both groups. ConclusionsWe designed and implemented an analgesia-based, goal-directed, nurse-driven sedation protocol in Chile. Although there was no improvement in major outcomes, we observed that the present protocol was safe and feasible and that it resulted in decreased periods of deep sedation without increasing agitation.

Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU

“…Eight RCTs satisfied our research criteria (156,(168)(169)(170)(171)(172)(173)(174). We evaluated the effect of light versus deep sedation on outcomes that were considered critical by the sedation group and patient representatives: 90-day mortality, time to extubation, delirium, tracheostomy, cognitive and physical functional decline, depression, and posttraumatic stress disorder (PTSD).…”

“…The outcomes evaluated were mostly measured after ICU discharge and are different from the short-term outcomes assessed in the 2013 guideline ungraded descriptive question. Light sedation was not associated with 90-day mortality (RR, 1.01; 95% CI, 0.80-1.27; moderate quality) (168,169), but it was associated with a shorter time to extubation (MD, -0.77 d; 95% CI, -2.04 to -0.50; low quality) (168-170) and a reduced tracheostomy rate (RR, 0.57; 95% CI, 0.41-0.80; low quality) (170,171). Light sedation was not associated with a reduction in the incidence of delirium (RR, 0.96; 95% CI, 0.80-1.16; low quality) (168,172), PTSD (RR, 0.67; 95% CI, 0.12-3.79; low quality) (156,174), depression (RR, 0.76; 95% CI, 0.10-5.58; very low quality) (156,170), or self-extubation (RR, 1.29; 95% CI, 0.58-2.88; low quality) (168)(169)(170)173).…”

Posttraumatic Stress Disorder in Critical Illness Survivors

“…Greater PTSD symptoms were associated with receipt of benzodiazepines in two of four studies (14,27,31,40) and higher total dose of benzodiazepines in one of two studies (31, 54), but not with duration of benzodiazepines in one study (30). Greater PTSD symptoms were associated with receipt of benzodiazepines in two of four studies (14,27,31,40) and higher total dose of benzodiazepines in one of two studies (31, 54), but not with duration of benzodiazepines in one study (30).…”

Executive Summary: Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU

“…Light sedation was associated with a shorter time to extubation (51,54,55) and a reduced tracheostomy rate (50). Light sedation was not associated with a reduction in 90-day mortality (44, 50, 53), delirium prevalence (44,54), posttraumatic stress disorder incidence (31,50), or self-extubation (44,50,53,55). No RCTs evaluated the impact of light versus deep sedation on cognitive or physical functioning.…”