A systematic review of the impact of sedation practice in the ICU on resource use, costs and patient safety

Abstract

IntroductionPatients in intensive care units (ICUs) often receive sedation for prolonged periods. In order to better understand the impact of sub-optimal sedation practice on outcomes, we performed a systematic review, including observational studies and controlled trials which were conducted in sedated patients in the ICU and which compared the impact of changes in or different protocols for sedation management on economic and patient safety outcomes.MethodsWe searched Medline, Embase and CINAHL online literature databases from 1988 to 15th May 2008 and hand searched conferences. English-language studies set in the ICU, in sedated adult humans on mechanical ventilation, which reported the impact of sedation practice on cost and resource use and patient safety outcomes, were included. All abstracts were reviewed twice by two independent reviewers, with all conflicts resolved by a third reviewer, to check that they met the review inclusion criteria. Full-text papers of all included studies were retrieved and again reviewed twice against inclusion criteria. Data were doubly extracted from studies. Study aims, design, population, and outcomes including duration of mechanical ventilation, length of stay in ICU and hospital, costs and rates of mortality and adverse events were extracted. Due to heterogeneity between study designs and outcomes reported, no quantitative data synthesis such as meta-analysis was possible.ResultsIncluded studies varied in design, patient population and aim, with the majority being before-after studies. Overall, studies showed that improvements in sedation practice, such as the introduction of guidelines and protocols, or daily interruption of sedation, were associated with improvements in outcomes including ICU and hospital length of stay, duration of mechanical ventilation, and costs. Mortality and the incidence of nosocomial infections were also reduced.ConclusionsSystematic interventions to improve sedation practice and maintain patients at an optimal sedation level in the ICU may improve patient outcomes and optimize resource usage.

Memories and prevalence of posttraumatic stress disorder in intensive care units

“…The significant correlation found between the duration of ICU stay and delusional memories corroborates data from other studies that found a correlation between the probability of patients developing delirium and the consolidation of traumatic memories or delusions (D. L. Jackson, Proudfoot, Cann, & Walsh, 2010;Samuelson et al, 2007). In turn, these associations functioned as precipitating the onset of PTSD (Capuzzo et al, 2004, C. Jones et al, 2003Ringdal et al, 2009;Samuelson et al, 2007), which did not occur in this study.…”

Remifentanil/midazolam versus fentanyl/midazolam for analgesia and sedation of mechanically ventilated neonates and young infants: a randomized controlled trial

“…Thus, these drugs can accumulate in the peripheral compartments during prolonged use and may cause prolonged sedation with an unpredictable extubation time after cessation of a continuous infusion [3]. Prolonged sedation and mechanical ventilation may have several negative consequences like Intensive Care Med (2012) 38:1017-1024 DOI 10.1007/s00134-012-2532-1 an increased risk of lung injury, hemodynamic interference, or gastrointestinal motility disturbances [4,5].…”

Sedation and ParalysisDiscussion

“…14 However, implementation of these protocols has not been shown to be associated with a significant decrease in mortality rate. 14,[16][17][18] In a recent systematic review 20 of the topic, Jackson et al conclude that implementation of sedation management protocols in critically ill patients is strongly associated with a decrease in duration of mechanical ventilation, stay in ICU, and, probably, incidence of ventilator-associated pneumonia, without an increase in adverse events. Mehta et al recently published the results of a randomized controlled trial investigating whether daily interruption of sedation decreases the time to extubation in mechanically ventilated patients.…”