Daily Sedation Interruption in Mechanically Ventilated Critically Ill Patients Cared for With a Sedation Protocol A Randomized Controlled Trial Daily Sedation Interruption in Ventilated Patients

Mehta S, Burry L, Cook D, et al. — Wed, 21 Nov 2012 00:00:00 GMT

Context

Protocolized sedation and daily sedation interruption are 2 strategies to minimize sedation and reduce the duration of mechanical ventilation and intensive care unit (ICU) stay. We hypothesized that combining these strategies would augment the benefits.

Objective

To compare protocolized sedation with protocolized sedation plus daily sedation interruption in critically ill patients.

Design, Setting, and Patients

Randomized controlled trial of 430 critically ill, mechanically ventilated adults conducted in 16 tertiary care medical and surgical ICUs in Canada and the United States between January 2008 and July 2011.

Intervention

Continuous opioid and/or benzodiazepine infusions and random allocation to protocolized sedation (n = 209) (control) or to protocolized sedation plus daily sedation interruption (n = 214). Using validated scales, nurses titrated infusions to achieve light sedation. For patients receiving daily interruption, nurses resumed infusions, if indicated, at half of previous doses. Patients were assessed for delirium and for readiness for unassisted breathing.

Main Outcome Measure

Time to successful extubation. Secondary outcomes included duration of stay, doses of sedatives and opioids, unintentional device removal, delirium, and nurse and respiratory therapist clinical workload (on a 10-point visual analog scale [VAS]).

Results

Median time to successful extubation was 7 days in both the interruption and control groups (median [IQR], 7 [4-13] vs 7 [3-12]; interruption group hazard ratio, 1.08; 95% CI, 0.86-1.35; P = .52). Duration of ICU stay (median [IQR], 10 [5-17] days vs 10 [6-20] days; P = .36) and hospital stay (median [IQR], 20 [10-36] days vs 20 [10-48] days; P = .42) did not differ between the daily interruption and control groups, respectively. Daily interruption was associated with higher mean daily doses of midazolam (102 mg/d vs 82 mg/d; P = .04) and fentanyl (median [IQR], 550 [50-1850] vs 260 [0-1400]; P < .001) and more daily boluses of benzodiazepines (mean, 0.253 vs 0.177; P = .007) and opiates (mean, 2.18 vs 1.79; P < .001). Unintentional endotracheal tube removal occurred in 10 of 214 (4.7%) vs 12 of 207 patients (5.8%) in the interruption and control groups, respectively (relative risk, 0.82; 95% CI, 0.36-1.84; P = .64). Rates of delirium were not significantly different between groups (53.3% vs 54.1%; relative risk, 0.98; 95% CI, 0.82-1.17; P = .83). Nurse workload was greater in the interruption group (VAS score, 4.22 vs 3.80; mean difference, 0.41; 95% CI, 0.17-0.66; P = .001).

Conclusion

For mechanically ventilated adults managed with protocolized sedation, the addition of daily sedation interruption did not reduce the duration of mechanical ventilation or ICU stay.

Trial Registration

clinicaltrials.gov Identifier: NCT00675363

Hospitals Slash Central Line Infections With Program That Empowers Nurses

Kuehn BM. — Wed, 24 Oct 2012 00:00:00 GMT

It's been 31 months since a patient in the intensive care unit has developed a central line–associated bloodstream infection (CLABSI) at the Peterson Regional Medical Center in Kerrville, Tex, said nurse educator Theresa Hickman, RN, during a press briefing in September.

The Changing Landscape of ICU Sedation

Kress JP, Hall JB. — Wed, 21 Nov 2012 00:00:00 GMT

Intubation and mechanical ventilation are essential components of modern intensive care. However, they are also uncomfortable and often intolerable for the patient. Therefore, intensive care clinicians typically prescribe sedation for ventilated patients, hoping to ensure comfort and yet avoid excess or prolonged unconsciousness. Two decades ago, the typical approach was to provide sedation via continuous infusion, with a focus on ensuring comfort and with little awareness of the adverse effects of excessive sedative use in the intensive care unit (ICU). However, as reports emerged showing such infusions could unnecessarily prolong the duration of mechanical ventilation and intensive care, a variety of evidence-based sedation algorithms for mechanically ventilated patients evolved.

JAMA: Nursing Care Topic Collection

Daily Sedation Interruption in Mechanically Ventilated Critically Ill Patients Cared for With a Sedation Protocol A Randomized Controlled Trial Daily Sedation Interruption in Ventilated Patients

Hospitals Slash Central Line Infections With Program That Empowers Nurses

The Changing Landscape of ICU Sedation