Stressful experiences in relation to depth of sedation in mechanically ventilated patients

In mechanically ventilated patients, sedatives and analgesics are commonly used to ensure comfort, but there is no documented knowledge about the impact of depth of sedation on patients' perception of discomfort. The aim of this study was, therefore, to investigate the relationship between stressful experiences and intensive care sedation, including the depth of sedation. During 18 months, 313 intubated mechanically ventilated adults admitted to two general intensive care units (ICU) for more than 24 h were included. Patients (n = 250) were interviewed on the general ward 5 days after ICU discharge using the ICU Stressful Experiences Questionnaire. Patient data including sedation scores as measured by the Motor Activity Assessment Scale (MAAS) were collected from hospital records after the interview. Of the 206 patients with memories of the intensive care, 82% remembered at least one experience as quite a bit or extremely bothersome. Multivariate analyses showed that higher proportion of MAAS score 3 (indicating more periods of wakefulness), longer ICU stay and being admitted emergent were factors associated with remembering stressful experiences of the ICU as more bothersome. The findings indicate that the depth of sedation has an impact on patients' perception of stressful experiences and that light sedation compared with heavy seems to increase the risk of perceiving experiences in the ICU as more bothersome. In reducing discomfort, depth of sedation and patient comfort should be assessed regularly, non-pharmacological interventions taken into account and the use of sedatives and analgesics adapted to the individual requirements of the patient.     

瑞芬太尼在重症监护病房机械通气患者镇痛镇静中的应用研究

目的 观察瑞芬太尼对重症监护病房(ICU)机械通气患者镇痛、镇静治疗的效果,对机械通气时间、血流动力学的影响以及药物不良反应.方法 60例肿瘤术后需有创机械通气超过24 h的患者按随机数字表法分为芬太尼组(30例)及瑞芬太尼组(30例),分别给予芬太尼和瑞芬太尼持续静脉泵入镇痛、镇静,疼痛的评估选择面部表情评分法(FPS),镇静的评估选择Ramsay评分法(RS),必要时加用丙泊酚镇静治疗.两组患者在治疗期间执行每日唤醒策略,分别记录两组用药前后的FPS、RS和生命体征,加用丙泊酚及每日中断药物以唤醒的病例数,机械通气时间、住ICU时间、住ICU费用,以及不良反应发生情况.结果 两组患者均可达到满意的镇痛、镇静目标.两组间镇痛、镇静深度总体无明显差异,但用药30 min时芬太尼组FPS(分)明显高于瑞芬太尼组(3.70±1.20比2.70± 1.17,P＜0.05);两组间仅用药30 min时瑞芬太尼组平均动脉压(MAP,mm Hg,1 mm Hg=0.133 kPa)较芬太尼组明显下降(72.9±6.9比77.6±9.1,P＜0.05),其余生命体征无明显差异.芬太尼组有更多的患者需要加用丙泊酚镇静(19例比8例),并需中断药物(12例比4例,均P＜0.05);而瑞芬太尼组用药30 min和1、6、24 h时自主呼吸频率(RRs,次/min)均较芬太尼组明显降低(7.0±2.8比10.4±3.5,5.4±3.4比10.6±3.6,5.4±3.0比7.2±3.1,6.1±3.0比9.2±3.4,均P＜0.05).瑞芬太尼组机械通气时间(h)、住ICU时间(h)均较芬太尼组明显缩短(73.6±26.7比94.9±37.3,125.9±37.1比150.8±50.9,均P＜0.05),但住ICU费用(万元)则无明显差异(6.06±2.29比5.83±2.38,P＞0.05).瑞芬太尼组出现低血压的患者数比芬太尼组多(8例比2例,P＜0.05).结论 瑞芬太尼用于ICU机械通气患者与经典治疗效果相当,且起效迅速,能缩短机械通气时间,减少镇静剂的用量,无严重不良反应.     

Use of oral clonidine for sedation in ventilated paediatric intensive care patients

Objectives We aimed to document our experience with oral clonidine when used as a sedative in combination with intravenous morphine and lorazepam in a group of mechanically ventilated children with single-organ, respiratory failure. In particular, our objectives were to establish the relationship between oral dose, plasma concentration, and sedative effect, and second, to document the side-effect profile.Design Prospective, cohort study over a 72-h period.Setting Regional paediatric intensive care unit.Patients and participants Twenty-four children were enrolled (median age 3 months) of whom ten were excluded (six due to extubation before 72 h, three sedation failures, one protocol violation).Measurements and results Plasma clonidine was measured using gas chromatography mass spectrometry, and sedation assessed using the COMFORT score. Using a dose of 3–5 g/kg every 8 h, plasma concentrations appeared to plateau at approximately 41 h giving a mean value of 1.38 ng/ml (95% confidence interval 1.0–1.8). Adequate sedation was achieved during 82% (837/1022 h) of the study period; however, this decreased to 70.3% when analysed on an intention-to-treat basis. There was a concomitant overall decrease in the average hourly requirements for both morphine (P = 0.02) and lorazepam (P = 0.003). There were no documented episodes of bradycardia, hypotension or hyperglycaemia.Conclusions Oral clonidine may be a safe and effective sedative in combination with morphine and lorazepam for young children with single-organ, respiratory failure. This agent may also exhibit opioid and benzodiazepine sparing effects in this patient group. A full pharmacokinetic study is warranted.Financial support: this study was supported, in part, by a grant from the Friends of Guys Charitable Organisation     

A systematic review and critical appraisal of guidelines and their recommendations for sedation interruptions in adult mechanically ventilated patients

ObjectiveThe objectives of the review were to (i) assess the methodological quality of all accessible and published guidelines and care bundles that offer a recommendation related to sedation interruptions, using the AGREE-II instrument, to (ii) determine what is the recommended best practice for sedation interruptions from the available guidelines, and then to have (iii) a closer inspection of the overall credibility and applicability of the recommendations using the AGREE-REX instrument. This review will benefit the outcomes of critically ill patients and the multidisciplinary team responsible for the care of mechanically ventilated adults with continuous medication infusions by providing a synthesis of the recommended action(s), actor(s), contextual information, target(s), and timing related to sedation interruptions from current best practice.Review method usedWe conducted a systematic review.Data sourcesWe applied a peer-reviewed search strategy to four electronic databases from 2010 to November 2021—MEDLINE, CINAHL, Embase, and The Cochrane Database of Systematic Reviews—and included grey literature.Review methodFindings are reported in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analyses checklist. We assessed overall quality using the validated Appraisal of Guidelines for Research and Evaluation II and AGREE Recommendation Excellence tools.ResultsWe identified 11 clinical practice guidelines and care bundles comprising 15 recommendations related to sedation interruption. There are three key findings: (i) deficiencies exist with the methodological quality of included guidelines, (ii) sedation interruption is recommended practice for the care of adult mechanically ventilated patients, and (iii) the current evidence is of low quality, which impacts overall credibility and applicability of the recommendations.ConclusionsSedation interruptions are currently best practice for adult mechanically ventilated patients; however, the available guidelines and recommendations have several deficiencies. Future research is needed to further understand the role of the nurse and other actors to enact this practice.     

The effect of an algorithm-based sedation guideline on the duration of mechanical ventilation in an Australian intensive care unit

Objective To examine the effect of an algorithm-based sedation guideline developed in a North American intensive care unit (ICU) on the duration of mechanical ventilation of patients in an Australian ICU.Design and setting The intervention was tested in a pre-intervention, post-intervention comparative investigation in a 14-bed adult intensive care unit.Patients Adult mechanically ventilated patients were selected consecutively (n = 322). The pre-intervention and post-intervention groups were similar except for a higher number of patients with a neurological diagnosis in the pre-intervention group.Intervention An algorithm-based sedation guideline including a sedation scale was introduced using a multifaceted implementation strategy.Measurements and results The median duration of ventilation was 5.6 days in the post-intervention group, compared with 4.8 days for the pre-intervention group (P = 0.99). The length of stay was 8.2 days in the post-intervention group versus 7.1 days in the pre-intervention group (P = 0.04). There were no statistically significant differences for the other secondary outcomes, including the score on the Experience of Treatment in ICU 7 item questionnaire, number of tracheostomies and number of self-extubations. Records of compliance to recording the sedation score during both phases revealed that patients were slightly more deeply sedated when the guideline was used.Conclusions The use of the algorithm-based sedation guideline did not reduce duration of mechanical ventilation in the setting of this study.     

Investigating nurses’ perceptions of their role in managing sedation in intensive care: An exploratory study

Most patients who are admitted to intensive care in need of ventilator support may also require sedation. It is a part of the nurses' role to manage sedation therapy according to patients' needs, avoiding complications of over and under sedation. The purpose of the study was to explore nurses' perceptions of their role in sedation management. A convenience sample of 107 registered nurses in the intensive care unit of a large teaching hospital was accessed and a response rate of 86% (n=92) obtained. Results showed that the nurse has a major role in sedation management in the critically ill patient. Sedation scoring is used in the assessment of the patient's sedation level and sedation is then titrated by the nurse in collaboration with medical staff to an agreed target level. However, the impact of this role depends on the experience and confidence of the nurse as knowledge and skills are required in order to provide effective sedation for patients. Recommendations from this study are to incorporate a team approach within a locally devised sedation protocol. This should be supported by an education programme aiming to improve decision-making about sedation management at the bedside.     

Toward less sedation in the intensive care unit: a prospective observational study

Purpose

Excessive sedation is associated with prolonged mechanical ventilation and longer intensive care unit (ICU) and hospital stays. We evaluated the feasibility of using minimal sedation in the ICU.

Methods

Prospective observational study in a university hospital 34-bed medico-surgical department of intensive care. All adult patients who stayed in the ICU for more than 12 hours over a 2-month period were included. Intensive care unit admission diagnoses, severity scores, use of sedatives and/or opiates, duration of mechanical ventilation, length of ICU stay, and 28-day mortality were recorded for each patient.

Results

Of the 335 patients (median age, 61 years) admitted during the study period, 142 (42%) received some sedation, most commonly with midazolam and propofol. Sedative agents were administered predominantly for short periods of time (only 10% of patients received sedation for >24 hours). One hundred fifty-five patients (46%) received mechanical ventilation, generating 15?240 hours of mechanical ventilation, of these, only 2993 (20%) hours were accompanied by a continuous sedative infusion. Self-extubation occurred in 6 patients, but only 1 needed reintubation.

Conclusions

In a mixed medical-surgical ICU, minimal use of continuous sedation seems feasible without apparent adverse effects.     

ICU患者在机械通气中应用异丙酚镇静的观察与护理

目的观察异丙酚在ICU机械通气患者的镇静效果及护理.方法选择40例在ICU接受气管插管、机械通气患者按住院号单双分成2组,观察组20例在上机后使用异丙酚,对照组20例给与其它镇静剂,观察2组机械通气时间、在ICU住院的时间.结果观察组的机械通气时间、在ICU住院时间,明显少于对照组（P＜0.01,P＜0.05）.结论异丙酚用于ICU机械通气患者的镇静不仅能安全有效镇静,而且能减少机械通气时间和在ICU住院时间,使用异丙酚应严格无菌技术操作以防止发生医源性感染.     

Effects of nurse-led sedation protocols on mechanically ventilated intensive care adults: A systematic review and meta-analysis

ObjectivesThe objective of the study was to compare nurse-led sedation protocols with physician-led usual care in intensive care units (ICUs) in treating mechanically ventilated adult patients.Review method usedThis is a systematic review and meta-analysis.Data sourcesPubMed, Cochrane Library, EMBASE, CINAHL, China National Knowledge Infrastructure, and China Wanfang databases were interrogated for articles published before May 2020.Review methodAs per Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, eight randomised controlled trials (RCTs) and six preintervention and postintervention studies published in English and Chinese met the inclusion criteria for the meta-analysis. Two reviewers independently extracted data into a tabular format using predefined data fields. Disagreements were resolved by consensus. The quality of the included RCTs and preintervention and postintervention studies was assessed using the Cochrane Quality Assessment Tool and Risk Of Bias In Non-randomised Studies of Interventions assessment tool.ResultsEight RCTs were of intermediate methodological quality, and six preintervention and postintervention studies exhibited a low to moderate risk of bias. Compared with usual care, nurse-led sedation protocols resulted in significantly decreased durations of mechanical ventilation (days) (standardised mean difference = ?1.765; 95% confidence interval [CI] = ?2.461, ?1.068); P < 0.001; I² = 97.7%); decreased length of ICU stay (days) (standardised mean difference = ?1.463; 95% CI = -2.181, ?0.745; P < 0.001; I² = 97.3%); reduced ICU mortality (relative risk [RR] = 0.854; 95% CI = 0.747, 0.983; P = 0.027), I² = 0%); and decreased incidence of ventilator-associated pneumonia (RR = 0.438; 95% CI = 0.292, 0.657; P < 0.001; I² = 41.4%), delirium (RR = 0.522; 95% CI = 0.338, 0.807; P = 0.003; I² = 26.6%), and extubation failure (RR = 0.498; 95% CI = 0.266, 0.932; P = 0.029; I² = 45.1%).ConclusionsAlthough pre–post intervention study design cannot establish causality, the present findings raise the considerable possibility that a sedation protocol can be safely implemented by nurses to reduce mortality in ICUs and sedation-related adverse events in patients on mechanical ventilation compared with physician-led usual care.     

Predictors of mortality of mechanically ventilated patients in internal medicine wards

Purpose

Budget restrictions have led to shortage of intensive care unit (ICU) beds in several countries. Consequently, ventilated patients are often kept on the wards. This study examined survival likelihood among patients ventilated on the wards and the predictive value of commonly used severity-of-illness scores.

Methods

This study is a prospective observation and characterization of consecutive, mechanically ventilated patients in 3 internal medicine wards of a single hospital who were denied ICU admission. Outcome measures are as follows: 28-day mortality, survival to hospital discharge, and 3 months postdischarge.

Results

Eighty-six patients were examined. The patients were 78.9 ± 8.9 years old; 53% were independent preadmission. Respiratory insufficiency due to infection was the main reason for mechanical ventilation (58%). Charlson and acute physiology scores (APS) averaged 4 ± 2.2 and 91.8 ± 26.7, respectively. Twenty-eight-day mortality was 71%, whereas in-hospital mortality was 74% and 3 months postdischarge mortality was 79%. Survivors were significantly younger than nonsurvivors (74.4 ± 8.5 years vs 80.4 ± 8.6 years, P < .01), were more likely to be ventilated for cardiac causes (41% vs 11%, P = .04), and had significantly higher initial mean blood pressure (79.4 mm Hg vs 58.2 mm Hg, P = .02) and blood albumin levels (29.8 g/L vs 25.7 g/L, P = .05). Death rate was 10 times more likely, with an APS greater than 90 on the day of intubation as compared with an APS less than 90.

Conclusion

Mortality in patients ventilated on the ward was high, especially in the subgroup of patients with an APS score greater than 90. The early calculation of APS may assist in focusing therapeutic efforts on patients with better survival chances.     

Severe agitation among ventilated medical intensive care unit patients: frequency,characteristics and outcomes

Objective To determine the frequency, characteristics and outcomes of severe agitation among ventilated medical intensive care unit (MICU) patients.Design Prospective cohort study.Setting Eighteen-bed MICU in 964-bed tertiary care center.Patients All ventilated patients, aged 18 years or older and admitted for more than 24 h between January 1, 2001 and May 8, 2001.Interventions None.Measurements Data were collected daily by concurrent chart abstractions. Variables included sociodemographic, clinical, laboratory, pharmacologic and non-pharmacologic interventions, ventilator settings and adverse events. Severe agitation, the main outcome variable, was defined as two or more Motor Activity Assessment Scale (MAAS) scores above 4 in a 24-h period and sedative and/or narcotic doses above the established sedation and analgesia protocol or a combination of two or more sedatives.Results Twenty-three (16.1%) of 143 enrolled patients exhibited severe agitation. Agitated patients were younger (hazard ratio [HR] 1.32), more likely to be admitted from an outside hospital ICU (HR 2.48), had lower pH (HR 1.55) and PaO₂/FIO₂ less than 200 mmHg (HR 2.59). Agitated patients had longer MICU stays (median 12 versus 5 days, p<0.0001) and more ventilator days (median 14 versus 6, p<0.0001). Agitated patients were more likely to self-extubate (26% versus 6%, p=0.002). Benzodiazepines, narcotics and neuromuscular blocking agents were administered more frequently and at higher doses, but haloperidol was not.Conclusion Severe agitation occurs commonly in critically ill patients and is associated with adverse events including longer ICU stays, duration of mechanical ventilation and self-extubation.Electronic Supplementary Material Supplementary material is available in the online version of this article at http://dx.doi.org/10.1007/s00134-004-2193-9This research was partially supported by Nursing Education and Research Fund. Presented in part at the 2002 Annual Meeting of Society of Critical Care Medicine, San Diego, California.     

Impact of obesity in mechanically ventilated patients: a prospective study

Objective  To analyze the influence of severe obesity on mortality and morbidity in mechanically ventilated intensive care unit (ICU) patients. Design  Prospective, multi-center exposed/unexposed matched epidemiologic study. Setting  Hospital setting. Patients  Severely obese patients (body mass index (BMI) ≥ 35 kg/m²), mechanically ventilated for at least 2 days were matched with unexposed nonobese patients (BMI < 30 kg/m²) for center, gender, age (±5 years), and the simplified acute physiology (SAPS) II score (±5 points). We recorded tracheal intubation, catheter placement, nosocomial infections, development of pressure ulcers, ICU and hospital outcome. Results  Eighty-two severely obese patients (mean BMI, 42 ± 6 kg/m²) were compared to 124 nonobese patients (mean BMI, 24 ± 4 kg/m²). The ICU course was similar in both the groups, except for the difficulties during tracheal intubation (15 vs. 6%) and post-extubation stridor (15% vs. 3%), which were significantly more frequent in obese patients (P < 0.05). The ICU mortality rate did not differ between obese and nonobese patients (24 and 25%, respectively); nor did the risk-adjusted hospital mortality rate (0.76, 95% confidence interval 0.41–1.16 in obese patients versus 0.82, 95% confidence interval 0.54–1.13 in nonobese patients). Conditional logistic regression confirmed that mortality was not associated with obesity. Conclusion  The only difference in morbidity of obese patients who were mechanically ventilated was increased difficulty with tracheal intubation and a higher frequency of post-extubation stridor. Obesity was not associated either with increased ICU mortality or with hospital mortality. Electronic supplementary material  The online version of this article (doi:) contains supplementary material, which is available to authorized users. This article is discussed in the editorial available at doi: . The authors have no financial interest in any aspect of this report.     

模拟昼夜节律的镇静在重症监护病房机械通气患者中的应用

目的 观察模拟昼夜节律的镇静方案在重症监护病房(ICU)机械通气患者撤除镇静后昼夜节律的形成、机械通气时间及ICU停留时间等方面是否具有优势.方法 采用前瞻性随机对照方法,将120例收入ICU的机械通气患者用信封法完全随机分为昼夜节律组(CR)、每日中断组(DI)、持续输注组(CS)、按需镇静组(DS)4组,每组30例,因DS组不良反应多,入组10例后去除该组,最终入组患者共90例.记录患者的年龄、性别、体重、急性生理学与慢性健康状况评分系统Ⅱ(APACHEⅡ)评分、镇静药物剂量、每日清醒时间、机械通气持续时间、ICU停留时间、并发症(呼吸机相关性肺炎、需置入胸引管的气压伤)和不良反应(患者意外拔管、再次插管、气管切开、死亡),并测定生化指标,10:00和22:00各记录1次在岗护士人数.结果 CR、DI、CS3组患者性别比例、年龄、体重、APACHEⅡ评分、ICU停留时间、机械通气时间差异无统计学意义.CS组镇静药物总剂量(mg:5466.7±620.4)、平均镇静药物剂量(mg·h-1·kg-1:2.19±0.61)均明显高于CR组(4344.5±816.0、1.00±0.51 )、DI组(4154.3±649.4、1.23±0.62),差异均有统计学意义(均P＜0.01);CR组与DI组无差异.CR组每日清醒时间(h:4.40±1.30)较DI组(0.59±0.26)、CS组(0.15±0.02)均明显延长(均P＜0.05).各组并发症的发生未见统计学差异;DI组不良反应的发生(2例次)较CR组(1例)、CS组(0例)明显增加(P=0.0477).撤除镇静后,CR组昼夜节律正常者较CS组明显增加(19比9,P=0.0339).CR、DI、CS 3组间白天在岗护士人数两两比较差异均有统计学意义(1.65、1.41、1.14,均P＜0.01),夜间则无差异.各组生化指标未见差异.结论 模拟昼夜节律的镇静方案有助于ICU机械通气患者脱离镇静后昼夜节律的形成,且不增加不良反应及并发症发生率,不延长机械通气时间及ICU停留时间,具有一定临床适用性.     

早期渐进性活动训练促进重症监护病房机械通气患者神经肌肉功能恢复的效果观察

目的探讨早期渐进性活动训练促进重症监护病房(intensive care unit,ICU)机械通气患者神经肌肉功能恢复的效果。方法将98例ICU机械通气患者随机分为实验组和对照组,每组各49例,实验组患者在镇静中断后每天实施两次早期渐进性活动训练;对照组患者每天两次接受床上被动或主动全范围关节活动。采用功能独立性评分表(functional independence measure,FIM)对两组患者分别在拔除气管插管时、转出ICU时和出院时进行评定,并比较两组患者住院期间并发症发生情况。结果实验组患者在拔除气管插管时FIM总分及自理能力、括约肌控制、转移方面得分明显高于对照组,两组比较,均P<0.05,差异具有统计学意义;实验组患者在转出ICU时和出院时在FIM总分及5个方面得分明显高于对照组,两组比较,均P<0.05,差异具有统计学意义。实验组患者呼吸机相关性肺炎(ventilator associated pneumonia,VAP)、下肢深静脉栓塞(deep vein thrombosis,DVT)的发生率明显低于对照组,两组比较,均P<0.05,差异具有统计学意义。结论早期渐进性活动训练能促进ICU机械通气患者神经肌肉功能恢复,并可降低相关并发症的发生率。