Quality improvement report: Effect of a scoring system and protocol for sedation on duration of patients' need for ventilator support in a surgical intensive care unit

Brattebø, Guttorm; Hofoss, Dag; Flaatten, Hans; Muri, Anne Kristine; Gjerde, Stig; Plsek, Paul E.

doi:10.1136/bmj.324.7350.1386

Cited by 193 publications

(34 citation statements)

References 11 publications

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“…Indeed recent data from sedation studies have guided management of this important aspect of critical care. Target-based (27), protocolized sedation (28), with the incorporation of daily wake up trials (3, 29) have been shown to be associated with lower exposure to sedatives and analgesics and with improved outcomes and thus have been recommended as the “new standard of care” in sepsis management guidelines (30). Despite data being available for over 5 yr, recent large-scale sedation surveys from the United States (Ely EW, unpublished observations), Canada (31), and Europe (32) continue to show modest adherence at best to these standards and have shown that many ICU patients continue to be deeply sedated.…”

Section: Discussionmentioning

confidence: 99%

Presence of electroencephalogram burst suppression in sedated, critically ill patients is associated with increased mortality

Watson

Shintani

Tyson

et al. 2008

Critical Care Medicine

150

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Objectives This study investigates the possibility of a relationship between oversedation and mortality in mechanically ventilated patients. The presence of burst suppression, a pattern of severely decreased brain wave activity on the electroencephalogram, may be unintentionally induced by heavy doses of sedatives. Burst suppression has never been studied as a potential risk factor for death in patients without a known neurologic disorder or injury. Design: Post hoc analysis of a prospectively observational cohort study. Setting Medical intensive care units of a tertiary care, university-based medical center. Patients A total of 125 mechanically ventilated, adult, critically ill patients. Measurements and Main Results A validated arousal scale (Richmond Agitation-Sedation Scale) was used to measure sedation level, and the bispectral index monitor was used to capture electroencephalogram data. Burst suppression occurred in 49 of 125 patients (39%). For analysis, the patients were divided into those with burst suppression (49 of 125, 39%) and those without burst suppression (76 of 125, 61%). All baseline variables were similar between the two groups, with the overall cohort demonstrating a high severity of illness (Acute Physiology and Chronic Health Evaluation II scores of 27.4 ± 8.2) and 98% receiving sedation. Of those with burst suppression, 29 of 49 (59%) died within 6 months compared with 25 of 76 (33%) who did not demonstrate burst suppression. Using time-dependent Cox regression to adjust for clinically important covariates (age, Charlson comorbidity score, baseline dementia, Acute Physiology and Chronic Health Evaluation II, Sequential Organ Failure Assessment, coma, and delirium), patients who experienced burst suppression were found to have a statistically significant higher 6-month mortality [Hazard’s ratio = 2.04, 95% confidence interval, 1.12–3.70, p = 0.02]. Conclusion The presence of burst suppression, which was unexpectedly high in this medical intensive care unit population, was an independent predictor of increased risk of death at 6 months. This association should be studied prospectively on a larger scale in mechanically ventilated, critically ill patients.

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Section: Discussionmentioning

confidence: 99%

Presence of electroencephalogram burst suppression in sedated, critically ill patients is associated with increased mortality

Watson

Shintani

Tyson

et al. 2008

Critical Care Medicine

150

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“…We found that sedation protocols are increasingly popular in Australasia, consistent with the results of international studies. 11,13,27 Although protocols have had dramatic beneficial effects on duration of mechanical ventilation and length of ICU stay in the United States and Europe, 21,22,38 recent Australian studies 19,20 had different findings. Differences in open or closed ICU models, nurse to patient ratios, nurses' education and autonomy, specialist medical training, and professional collaboration may be important factors in the international variation in outcomes for use of sedation protocols.…”

Section: Opinions On Sedation Managementmentioning

confidence: 99%

“…18 Interestingly, studies of the implementation of sedation protocols in Australian ICUs 19,20 indicate less beneficial patient outcomes (ie, ventilation time and ICU length of stay) than do similar European and American studies. 21,22 Therefore, we investigated doctors' and nurses' current practices and explored their opinions on sedation management of patients receiving mechanical ventilation in Australian and New Zealand ICUs to extrapolate potential explanations for these international differences in outcomes.…”

mentioning

confidence: 99%

Sedation Management in Australian and New Zealand Intensive Care Units: Doctors’ and Nurses’ Practices and Opinions

O’Connor

Bucknall

Manias

2010

American Journal of Critical Care

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Objective To explore the use of sedatives and analgesics, tools for scoring level of sedation, sedation and pain protocols, and daily interruptions in sedation in Australian and New Zealand intensive care units and to examine doctors' and nurses' opinions about the sedation management of critically ill patients. Methods A cross-sectional Internet-based survey design was used. In total, 2146 members of professional critical care organizations in Australia and New Zealand were e-mailed the survey during a 4-month period in 2006 through 2007. Results Of 348 members (16% response rate) who accessed the survey, 246 (71%) completed all sections. Morphine, fentanyl, midazolam, and propofol were the most commonly used medicines. Newer medicines, such as dexmedetomidine and remifentanil, and inhalant medications, such as nitrous oxide and isoflurane, were rarely used by most respondents. Respondents used protocols to manage sedatives (54%) and analgesics (51%), and sedation assessment tools were regularly used by 72%. A total of 62% reported daily interruption of sedation; 23% used daily interruption for more than 75% of patients. A disparity was evident between respondents' opinions on how deeply patients were usually sedated in practice and how deeply patients should ideally be sedated. Conclusions Newer medications are used much less than are traditional sedatives and analgesics. Sedation protocols are increasingly used in Australasia, despite equivocal evidence supporting their use. Similarly, daily interruption of sedation is common in management of patients receiving mechanical ventilation. Research is needed to explore contextual and personal factors that may affect sedation management.

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“…Variable effectiveness within the ICU11 may be traced to published ICU reports whereby audit and feedback is undertaken in different ways: at the point-of-patient care in two,23 24 weekly in two,15 18 monthly in four,14 16–17 22 at a single time in one19 and not specified in two20 21 studies. Across reports, feedback is delivered through various channels including electronic, print and verbal processes.…”

Section: Introductionmentioning

confidence: 99%

A qualitative study of the variable effects of audit and feedback in the ICU

Sinuff

Muscedere

Rozmovits³

et al. 2015

BMJ Qual Saf

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Quality improvement report: Effect of a scoring system and protocol for sedation on duration of patients' need for ventilator support in a surgical intensive care unit

Abstract: Relatively simple changes in sedation practice had significant effects on length of ventilator support. The change process was well received by the staff and increased their interest in identifying other areas for improvement.

Cited by 193 publications

References 11 publications

Presence of electroencephalogram burst suppression in sedated, critically ill patients is associated with increased mortality

Presence of electroencephalogram burst suppression in sedated, critically ill patients is associated with increased mortality

Sedation Management in Australian and New Zealand Intensive Care Units: Doctors’ and Nurses’ Practices and Opinions

A qualitative study of the variable effects of audit and feedback in the ICU

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