Sedation and weaning from mechanical ventilation: linking spontaneous awakening trials and spontaneous breathing trials to improve patient outcomes

The use of sedation has long been integrated into critical care. Because pain, discomfort, anxiety, and agitation are commonly experienced by critically ill patients, the use of medications to alleviate and control these symptoms will continue; however, data showing that prolonged use of sedating medications imparts harm to patients obligate physicians to use agents and methods of sedation that minimize these negative side effects. Numerous observational studies and clinical trials have proven that decisions in sedation management play a crucial role in determining outcomes for mechanically ventilated ICU patients, and recent evidence supports the use of protocols that streamline efforts to discontinue sedation and mechanical ventilation in a safe and parallel fashion. Regardless of choice of sedating agent, and even when patient-targeted sedation protocols are used to minimize oversedation, the use of spontaneous awakening trials dramatically improves patient outcomes for critically ill patients. Intensive care physicians must continue to study the delivery of sedation in efforts to maximize patient comfort while minimizing patient harm.     

Parental perceptions of comfort during mechanical ventilation

There are no reports of the parental perceptions of comfort during the mechanical ventilation of children. We have assessed the quality of sedation in 28 mechanically ventilated children and compared these results to an overall parental assessment of comfort, obtained by postal questionnaire. There was no correlation between the parental assessment of comfort and the paediatric intensive care unit (PICU) staff satisfaction with the level of sedation. Parental assessment of comfort was positively correlated with the duration of ventilation, whilst PICU staff satisfaction was positively correlated with the age of the child. Parents appear to become more satisfied with the degree of comfort of their children as the duration of mechanical ventilation increases, which is an effect that may have an important bearing on communication between parents and health professionals. Our results also suggest that the commonly used sedation regime of midazolam and morphine is less effective in younger children.     

Pain management in the neonatal intensive care unit: a national survey in Italy

BACKGROUND: This study assessed current medical practice in preventative analgesia and sedation for invasive procedures in neonatal intensive care units (NICU) in Italy. METHODS: A questionnaire was sent to level II and III Italian NICUs to investigate pain management, pharmacological treatment and the use of pain scores during invasive procedures. Main outcome measures were the extent to which analgesia and sedation are currently used for invasive procedures in Italian neonatal units. RESULTS: The rate of response to the questionnaire was 88%. Written guidelines were available on acute pain control in 25% of the NICUs, and on prolonged pain control in 50%. Routine use of preventative pharmacological and nonpharmacological measures for painful procedures ranged from 13% for elective tracheal intubation to 68% for chest tube insertion. Thirty-six percent of NICUs routinely use sedation with opioids for mechanical ventilation; 14% prevent distress and pain for tracheal suctioning, 44% for heel lancing, 50% for venepuncture and percutaneous venous catheter insertion; 58% use analgesia before lumbar puncture. Validated pain assessment scores were used by 19% of NICUs. CONCLUSIONS: The need for adequate analgesia is still underestimated. Further information on the safety of analgesics in neonatology is imperative, as is an adequate education of physicians and nurses on the use of pain control guidelines as part of the standard of care in the NICU.     

Aims of sedation/analgesia

The concept of analgo-sedation in intensive care medicine has changed considerably since the last decades. Deep sedation, keeping patients artificially unconscious, is not necessary anymore, it postpones weaning from mechanical ventilation, it provokes complications, and prolongs the length of ICU stay. On the other hand, recent surveys have shown that patients recall their intensive care experience still as stressing and painful. This need more awareness of patient's pain and the readiness to give analgesics particularly before painful procedures. The frightening environment of the ICU, sleep deprivation, pain and discomfort related not only to the actual dysfunctions, but even more to the stressing procedures of care and treatment, make a certain level of sedation necessary. But patients' discomfort may also originate from many other reasons, such as hypoxaemia, hypotension, cardiac failure, drugs overdose or withdrawal, or simply from an uncomfortable body position. These sometimes non-obvious reasons have to be carefully looked for in order to treat the problem effectively. Delirium and other mental problems are common in critically ill patients. They have to be diagnosed with particular attention and treated specifically. Sedatives must be carefully adapted to the individual needs and the actual situation. Modern modes of mechanical ventilation allows lower levels of sedation. Regularly repeated assessment of the sedation level (e.g. by Ramsay score) is mandatory; a sedation protocol seems advantageous. To avoid inadvertent accumulation and overdose, it is recommended to keep the patient at a sedation level at which communication is still possible. A daily interruption of the sedation has shown to shorten the duration of mechanical ventilation and the length of ICU stay.     

Sedation in the intensive care unit

Analgesics and sedatives are commonly prescribed in the ICU environment for patient comfort, however, recent studies have shown that these medications can themselves lead to adverse patient outcomes. Interventions that facilitate a total dose reduction in analgesic and sedative medications e.g. the use of nurse controlled protocol guided sedation, the combination of spontaneous awakening and breathing trials, and the use of short acting medications, are associated with improved outcomes such as decreased time of mechanical ventilation and ICU length of stay. This purpose of this review is to provide an overview of the pharmacology of commonly prescribed analgesics and sedatives, and to discuss the evidence regarding best prescribing practices of these medications, to facilitate early liberation from mechanical ventilation and to promote animation in critically ill patients.     

Attitudes of patients, housestaff, and nurses toward postoperative analgesic care

A survey was carried out among housestaff and nurses involved with postoperative patient care to assess their knowledge of analgesics and their attitudes toward postoperative analgesic care. Only one-fifth of the respondents prescribed for complete pain relief. There were some misconceptions about adding other drugs to narcotic analgesics as well as fear of the addictive properties of these narcotics. The respondents lacked confidence about their knowledge of narcotic analgesics. Fear of respiratory depression was less prominent. Nine percent of the physicians and 31% of the nurses believed that response to a placebo indicates factitious pain. Fifty-four percent of the physicians and 74% of the nurses believed that patients receive adequate pain relief. Eighty-one patients were questioned on their beliefs about pain and its relief. Sixty-six of these were monitored postoperatively to assess the effectiveness of pain relief, which was judged by the authors to be ineffective (i.e., moderate to severe pain at the peak of analgesia) in 41%. Seventy-five percent of the patients reported that their overall postoperative pain relief had been adequate. There was no correlation between the amount of analgesic required postoperatively and either the degree to which patients believed pain builds character or the degree to which they rated themselves sensitive to pain. This study emphasizes the need for better and more comprehensive training of housestaff and nurses in analgesic care.     

Burns pain management: The role of nurse–patient communication

BackgroundNursing is an embodiment of knowledge, clinical work, and interpersonal communication. Effective nursing care has a distinct influence on the overall satisfaction and experience of the patient. Communication is said to be indispensable in the delivery of quality healthcare. Effective communication between nurses and patients has proven to yield better results with pain control and improved psychological status of patients.ObjectivesThe aim of the study is to explore nurses’ perceptions on the role of communication in the management of burns pain.MethodsA qualitative design with purposive sampling was carried out to recruit 11 registered nurses from a Reconstructive Plastic Surgery and Burns Center in Ghana. To identify the participants’ perception on the role of nurse–patient communication in the management of burns pain, a face to face semi-structured interviews were conducted using an interview guide to collect data.ResultsThematic analysis was done with various themes emerging. Helping patients manage pain, early detection of patient’s distress, improved patient participation in their care were some of the positive effects of nurse–patient communication whiles reduced level of cooperation during caregiving, and endurance of pain by the patient were the results of poor nurse–patient communication. Language and time factor were the barriers that were identified to hinder effective communication between nurses and patients.ConclusionsDue to the subjective nature of pain, the current study highlights the need for increased communication for an effective assessment and management of pain among patients with burns. It is, therefore, imperative that nurses be well trained in communication with an emphasis on patient-centered communication.     

Time to wake up the patients in the ICU: a crazy idea or common sense?

With the first generation of ventilators, it was often necessary to sedate patients to avoid dyssynchrony between patient and ventilator. The standard treatment of patients in need of mechanical ventilation has therefore traditionally included sedation. Modern ventilators are able to simulate the patients breathing efforts to a higher degree, and therefore, deep sedation is no longer necessary. In the last decade, support has grown for a reduction in the use of sedation. The focus has been placed on the correlation between the depth of sedation and the length of mechanical ventilation. It has been shown that a daily wake up trial reduced the time that patients were dependent on mechanical ventilation. Additionally, it has been shown that combining both a spontaneous breathing trial and a daily wake up trial reduced the mechanical ventilation time compared to a spontaneous breathing trial alone. We have recently shown in a randomized study that the use of no sedation, compared to the standard treatment with sedation and a daily wake up trial, reduced the time that patients required mechanical ventilation, the length of the patients' stay in the intensive care unit, and the total length of the hospital stay. All evidence indicates that the use of sedative drugs should be reduced, patients should be mobilized, and each patient's needs should be evaluated on a daily basis to optimize the care of each individual patient.     

Management of the sedated patient

A sedation strategy aimed at minimizing alteration of consciousness once comfort, analgesia and adaptation to the ventilator have been ensured is feasible in critically-ill patients requiring mechanical ventilation, even if, in patients with severe ARDS or ICH, the high dosages of sedatives and analgesics transiently required to provide perfect adaptation to the ventilator often preclude preservation of consciousness. The main components of a sedation algorithm include a clear objective of sedation-analgesia, regular assessments of patient status using validated clinical tools and a precise yet simple dosage adaptation schedule. Development and implementation of a sedation algorithm requires a multidisciplinary approach and an important input from both physicians and nurses. However, several methodologically-correct interventional studies have shown that using an algorithm to administrate sedatives and analgesics results in a significant reduction of MV duration, reaching 50% in some studies. This might translate into a real benefit for the patient point of view provided that preserving patient's comfort remains a constant concern for the caregivers. There is no reliable evidence to date to use propofol rather than midazolam as a sedative agent. Indeed, the way the sedative drug is used, as part of a sedation algorithm, is very likely more important than the selection of the drug itself. Analgesia-based sedation, promoting the use of morphinics alone before the adjunction of hypnotics, represents a new alternative to the traditional combined administration of hypnotics and morphinics. However data on the impact of analgesia-based sedation on patients' outcomes remain sparse to date.     

Continuous epidural infusion for postoperative mechanical ventilation

We evaluated in analgesic and sedative effects of continuous epidural infusion of two analgesic regimens in ventilated patients following esophagectomy. Forty-six patients, divided into two treatment groups, received postoperative continuous epidural infusion of morphine, or that of a combination of bupivacaine and morphine. Assessments were made with the following indices: pain relief score, somnolence score, patient ventilator coordination score, and the number of supplemental administrations of analgesics and sedatives. No significant differences occurred in somnolence scores or patient ventilator coordination scores between the two groups, which revealed satisfactory sedation for mechanical ventilation. Patients receiving the combination of bupivacaine and morphine had significantly less pain postoperatively, requiring a smaller number of supplemental administrations of analgesics and sedatives (P 0.05). It is concluded that: 1) continuous epidural infusion of analgesics gives potent analgesia and sedation of ventilated patients following esophagectomy; 2) the combination of bupivacaine and morphine gives pain relief superior to morphine alone.(Sakura S, Sumi M, Saito Y et al.: Continuous epidural infusion for postoperative mechanical ventilation. J Anesth 4: 219–225, 1990)     

Review articles: the effects of perioperative and intensive care unit sedation on brain organ dysfunction

Analgesia and sedation are routinely administered to patients in procedural suites, operating rooms, and intensive care units to permit invasive procedures, prevent pain and anxiety, reduce stress and oxygen consumption, allow mechanical ventilation, and for numerous other patient comfort and safety reasons. Increasing research and evidence, however, has implicated commonly prescribed sedative medications as risk factors for untoward events and worse patient outcomes, including brain organ dysfunction manifested as delirium and coma. The effect of sedatives on outcomes is also influenced by the depth of sedation, making it imperative to reduce total exposure to this class of medications. Juxtaposing the widespread necessity and use of sedation with the cost of acute and long-term cognitive dysfunction to patients and society, physicians must now strive to balance patients' demands and requisite for comfort with their own oath to do no harm. Fortunately, our methods of sedation and choice of medications can likely mitigate this cognitive risk. In this review, we detail the effects of perioperative and intensive care unit sedation on the development of delirium and cognitive impairment and provide an evidence-based approach towards analgesia and sedation paradigms to improve patient outcomes.     

Pain management

Analgesia and hypnosis are two separate entities and should result in distinct assessment and management for patients admitted to an intensive care unit (ICU). Those patients are exposed to moderate-severe pain and they are likely to remember pain as one bothersome experience. Any cause of patient discomfort is sought with the priority given to pain and adequate analgesia. Assessing pain must rely upon the use of clinical scoring systems, although these instruments are still underused in ICU. Satisfactory levels of analgesia by continuous infusion of opioids during times without stimulation do not guarantee against pain reactions during procedures (endotracheal suctioning, mobilization, wound care and dressing change, removal of chest tube). The concept of multimodal analgesia should be extended to the ICU since it may reduce the opioids requirements. In order to facilitate systematic pain and sedation assessment and to adjust daily drug dosages accordingly, it appears crucial to promote educational programs and elaboration of protocols/guidelines in ICU. Protocols/guidelines may help caregivers to rationally use sedatives and opioids and possibly reduce mechanical ventilation and ICU length of stay.     

Changing sedation practices in the intensive care unit--protocol implementation, multifaceted multidisciplinary approach and teamwork

INTRODUCTION: Sedation protocols have demonstrated effectiveness in improving ICU sedation practices. However, the importance of multifaceted multidisciplinary approach on the success of such protocols has not been fully examined. METHODS: The study was conducted in a tertiary care medical-surgical ICU as a prospective, 4-pronged, observational study describing a quality improvement initiative that employs 2 types of controlled comparisons: a "before and after" comparison related to intense education of ICU clinicians and nurses about sedation and analgesia in the ICU, and a comparison of protocolized versus non-protocolized care. Patients were assigned alternatively to receive sedation by a goal-directed protocol using the Riker Sedation-Agitation Scale (SAS) or by standard practice. A multifaceted multidisciplinary educational program was initiated including the use of point of use reminders, directed educational efforts, and opinion leaders. This included several lectures and in-services and the routine availability of at least one member of this group to answer questions. We included all consecutive patients receiving mechanical ventilation, who were judged by their treating team to require intravenous sedation. MEASUREMENTS AND MAIN RESULTS: The following data was collected: demographics, Acute Physiology and Chronic Health Evaluation (APACHE) II score and Simplified Acute Physiology score (SAPS) II, daily doses of analgesics and sedatives, duration of mechanical ventilation, ICU length of stay (LOS) and ventilator associated pneumonia (VAP) incidence. To examine the effect of the multifaceted multidisciplinary approach, we compared the first 3 months to the second 3 months in the following 4 groups: G1 no protocol group in the first 3 months, G2 protocol group in first 3 months, G3 no protocol group in the second 3 months, G4 protocol group in the second 3 months. After ICU day 3, SAS in the groups G2, G3 and G4 became higher than in G1 reflecting "lighter" levels of sedation. There were significant reductions in the use of analgesics and sedatives in the protocol group after 3 months. This was associated with a reduction in VAP rate and trends towards shorter mechanical ventilation duration and hospital length of stay (LOS). CONCLUSIONS: The implementation of a multifaceted multidisciplinary approach including the use of point of use reminders, directed educational efforts, and opinion leaders along with sedation protocol led to significant changes in sedation practices and improvement in patients' outcomes. Such approach appears to be critical for the success of ICU sedation protocol.     

Sedation in the critically ill patient

Critically ill patients who require intensive care need effective analgesia and sedation to control potentially unpleasant symptoms, such as pain and anxiety. Analgesics and sedatives are also used to allow patients to tolerate nursing procedures and tracheal intubation as well as to aid mechanical ventilation. Metabolism of traditional opioids is dependent on organ function, which is abnormal among critically ill patients. The use of a score system to ensure sufficient but not excessive sedation should be mandatory. Sufentanil and remifentanil are more predictable opioids that are suitable for either sedation or analgesia in critically ill patients to achieve an adequate Ramsay score from 2 to 4.     

Pain control after surgery: a survey of current practice.

A questionnaire was sent to 302 qualified nurses in an attempt to elicit their current practice of administering postoperative analgesics, knowledge of the drugs, opinions regarding prescribing habits and comments on how pain control could be improved; 211 nurses replied (70% response). Knowledge was good but practice poor in that 56% give less than six doses postoperatively and the majority of nurses do not give analgesics until the patient is in pain; 66% thought the amount of analgesic given was a poor indication of pain experienced; 62% felt that prescribing by doctors was inconsistent and 90% thought it could be improved. Deficiencies in communication between anaesthetists, nurses and patients were highlighted. The nurses wished for more involvement in pain management and for more education of patients preoperatively. A selection of comments is included and possible simple methods for improving pain control are discussed.     

Meta-analysis of randomised controlled trials on daily sedation interruption for critically ill adult patients

Sedation is often used to improve comfort, reduce anxiety and stress and to facilitate nursing care of critically ill patients in the intensive care unit. This meta-analysis examined the benefits and risks of daily sedation interruption in critically ill adult patients. A total of five randomised controlled trials, comparing daily sedation interruption with no interruption in 699 critically ill patients, from the Cochrane controlled trials register, Embase and MEDLINE databases (1966 to April 2010) were identified and subject to meta-analysis. With the limited data available, daily sedation interruption was not associated with a significant reduction in duration of mechanical ventilation, length of intensive care unit and hospital stay, or mortality. Daily sedation interruption was associated with a reduced risk of requiring tracheostomy (odds ratio 0.57, 95% confidence interval 0.35 to 0.92, P = 0.02; F = 3%) but not an increased risk of removal of the endotracheal tube by the patients (odds ratio 1.3, 95% confidence interval 0.41 to 4.10, P = 0.65; F = 49%). The current evidence suggests that daily sedation interruption appears to be safe, but the significant heterogeneity and small sample sizes of the existing studies suggest that large randomised controlled studies with long-term survival follow-up are needed before daily sedation interruption can be recommended as a standard sedation practice for critically ill adult patients.     

医护患三方对基础护理认知的调查分析

目的了解医生、护士和患者对基础护理的认知现状,探讨三方观点的异同,并提出相应对策.方法采用自行设计的问卷,分层抽样调查483名医生和1 740例患者、普查1 226名护士对基础护理的认识现状.结果 分别有67.3%医生和59.1%护士认为为患者做生活护理会树立护士形象;医、护、患三方多数认为应由护士与家人共同来照顾患者...     

Weaning from mechanical ventilation: an open issue

Weaning from mechanical ventilation represents one of the main challenges facing ICU physicians. Difficult weaning affects about 25% of critical patients undergoing mechanical ventilation. Its duration correlates on one hand with pathophysiological aspects of the underlying disease and, on the other hand, with other factors such as the development of neuromyopathy of the critically ill patient, prolonged use of sedative-hypnotic drugs and, most of all, physicians' reluctance to identify the correct timing of therapeutic steps for weaning and subsequent extubation. The goal of adopting weaning protocols is to overcome problems due to an exclusively clinical opinion. Protocols have to be used together with daily clinical evaluation of the patient and the procedure must be carried out by an ICU team of both medical and nursing staff. Attempts to wean a patient from a ventilator and extubate him should be made through a spontaneous breathing trial (SBT) with T-tube or pressure support ventilation (PSV) with pressure support of 7-8 cmH(2)O +/- PEEP =/> 4 cmH(2)O. Proper recourse to non invasive mechanical ventilation (NIMV) and an accurate timing for tracheostomy are effective tools which can be used by physicians to facilitate weaning and to improve patient outcomes.     

危重症专职护理小组干预提高COPD呼吸衰竭患者序贯机械通气治疗效果

目的探讨危重症专职护理小组在慢性阻塞性肺疾病(COPD)呼吸衰竭患者序贯机械通气治疗中的作用。方法将序贯机械通气治疗的102例COPD呼吸衰竭患者分为两组。对照组(n=51)实施常规护理干预;干预组(n=51)由危重症专职护理小组实施护理干预。比较两组干预前后血气指标、治疗效果、护理质量。结果干预后干预组血气分析结果显著优于对照组(均P0.05);干预组入住ICU时间、住院时间及机械通气时间较对照组显著缩短(P0.05,P0.01),护理质量评分较对照组显著上升(均P0.01)。结论将危重症专职护理小组干预运用于COPD呼吸衰竭患者序贯机械通气治疗中有助于提高临床疗效,有利于改善患者预后。     

Strategies for postoperative pain relief in neurosurgical intensive care unit

Despite advances in neurosurgical and neuroanesthesiological practice, postoperative pain continues to be undertreated. There are many modalities that may provide safe and effective postoperative analgesia. We discuss mainly systemic (e.g. opioids, nonsteroidal antiinflammatory agents) analgesic options. They still remain the most widely used method for providing pain relief in acute surgical situations. The exact choice or combination of analgesics utilized for a particular patient will depend on the risk benefit profile and patient preferences. Especially is crucial to promptly involve the analgesics when an opioid tolerant patient requires aggressive pain treatment. But, opioid analgesia alone may not fully relieve all aspects of acute postoperative pain. Combinations of drugs acting on different mechanisms of nociceptive modulation will decrease the incidence of adverse effects and offer additive and/or sinergistic effects. Analgesic concentrations of ketamine infusions remain a valuable addition to opioid administration. Complementary medicine techniques used as adjuvant therapies have the potential to improve pain management and improve postoperative distress. Neuromuscular blocking agents (NMB) in the intensive care unit (ICU) patient facilitate intubation and ventilatory support, decrease oxygen consumption, facilitate bedside procedures and diagnostics, and potentially decrease intracranial pressure. Ideally, analgesics, sedatives and/or muscle relaxants should be combined into a multimodal approach to facilitate patient recovery after surgery. Although a great deal is known about specific drugs and dosage requirements, further research is needed that clearly examines optimal scheduling regimens if we are to maximize patient care. The most important rule of pain management is that pain is what the patient says it is.