Singapore SPICE: sedation practices in intensive care evaluation in Singapore – a prospective cohort study of the public healthcare system

Abstract

INTRODUCTIONA study was conducted to describe the sedation practices of intensive care units (ICUs) in Singapore in terms of drug use, sedation depth and the incidence of delirium in both early (< 48 hours) and late (> 48 hours) periods of ICU admission.METHODS A prospective multicentre cohort study was conducted on patients who were expected to be sedated and ventilated for over 24 hours in seven ICUs (surgical ICU, n = 4; medical ICU, n = 3) of four major public hospitals in Singapore. Patients were followed up to 28 days or until ICU discharge, with four-hourly sedation monitoring and daily delirium assessment by trained nurses. The Richmond Agitation and Sedation Scale (RASS) and Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) were used. RESULTSWe enrolled 198 patients over a five-month period. The mean Acute Physiology and Chronic Health Evaluation (APACHE) II score was 25.3 ± 9.2, and 90.9% were emergency hospital admissions. Patients were followed up for 1,417 ICU patient days, of which 396 days were in the early period and 1,021 days were in the late period. 7,354 RASS assessments were performed. Propofol and fentanyl were the sedative agents of choice in the early and late periods, respectively. Patients were mostly in the light sedation range, especially in the late period. At least one episode of delirium was seen in 23.7% of patients.CONCLUSION Sedation practices in Singapore ICUs are characterised by light sedation depth and low incidence of delirium, possibly due to the drugs used.

Sedation and Delirium in the Intensive Care Unit—A Practice-Based Approach

“…In particular, the study by Lee et al 56 is a subgroup analysis of the SPICE cohort in Singapore. 55 In summary, sedation use in Singapore ICU ranged from between 25.8-70.3%; the use of fentanyl and propofol also predominated. Benzodiazepine use was bundled approach that adheres to analgesia first with no sedation or the practice of balanced, multimodal sedation-when necessary-is essential to help patients remain alert, cooperative and delirium-free as well as to lower their mortality and duration of mechanical ventilation, facilitate early mobilisation and increase cognitive well-being.…”

Sedating critically ill patients

“…sedation practices in intensive care evaluation [SPICE]) in Singapore public hospital ICUs to overcome the knowledge gap on this topic. (9) Data was compared with that from Malaysia and Australia/New Zealand (ANZ), since a uniform protocol, ANZ SPICE, was used. (10,11) The Singapore data showed lower proportions of ICU patients in the deep sedation range.…”

“…CAM-ICU-positive delirium (at least one episode) was seen in 23.7% of their study cohort, far lower than the 44%-50.7% incidence in the other two SPICE studies. (9)(10)(11) At the risk of simplifying cause and effect, there was a higher frequency of benzodiazepine use in both the ANZ and Malaysian studies, while propofol and fentanyl were the most commonly used agents locally. Moreover, the local regimen's target was in the range of light sedation.…”

“…(13) Creating or finding the best assessment regimens is also vitally important. These must be practical to be implemented across very heterogeneous ICU settings, as rightly evinced by Ng et al (9) Strategies to decrease overall exposure to sedation, (14) such as sedation hold/interruption, have failed to show benefit in terms of reducing the duration of mechanical ventilation or ICU stay, according to a study by the SLEAP Investigators and Canadian Critical Care Trials Group. (15) Current practices have moved away from continuous deep sedation, and with more suitable agents available, ICU patients will hopefully be at less risk of developing the morbidity associated with agitation and delirium.…”

“…However, a skilled human is still needed to orchestrate this complex task through the act of titration. Hence, more studies, such as the study by Ng et al, (9) are needed to focus interest and resources and to further develop cutting-edge sedation practices and technology in our local ICUs.…”