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Randomized trial comparing daily interruption of sedation and nursing-implemented sedation algorithm in medical intensive care unit patients.

de Wit M, Gennings C, Jenvey WI, Epstein SK - Crit Care (2008)

Bottom Line: The Data Safety Monitoring Board convened after DIS patients were found to have higher hospital mortality; however, no causal connection between DIS and increased mortality was identified.In our cohort of patients, the use of SA was associated with reduced duration of MV and lengths of stay compared with DIS.Based on these results, DIS may not be appropriate in all mechanically ventilated patients.

View Article: PubMed Central - HTML - PubMed

Affiliation: Pulmonary and Critical Care Division, Department of Internal Medicine, School of Medicine, Virginia Commonwealth University, PO Box 980050, Richmond, VA 23298-0050, USA. mdewit@mcvh-vcu.edu

ABSTRACT

Introduction: Daily interruption of sedation (DIS) and sedation algorithms (SAs) have been shown to decrease mechanical ventilation (MV) duration. We conducted a randomized study comparing these strategies.

Methods: Mechanically ventilated adults 18 years old or older in the medical intensive care unit (ICU) were randomly assigned to DIS or SA. Exclusion criteria were severe neurocognitive dysfunction, administration of neuromuscular blockers, and tracheostomy. Study endpoints were total MV duration and 28-day ventilator-free survival.

Results: The study was terminated prematurely after 74 patients were enrolled (DIS 36 and SA 38). The two groups had similar age, gender, racial distribution, Acute Physiology and Chronic Health Evaluation II score, and reason for MV. The Data Safety Monitoring Board convened after DIS patients were found to have higher hospital mortality; however, no causal connection between DIS and increased mortality was identified. Interim analysis demonstrated a significant difference in primary endpoint, and study termination was recommended. The DIS group had longer total duration of MV (median 6.7 versus 3.9 days; P = 0.0003), slower improvement of Sequential Organ Failure Assessment over time (0.70 versus 0.23 units per day; P = 0.025), longer ICU length of stay (15 versus 8 days; P < 0.0001), and longer hospital length of stay (23 versus 12 days; P = 0.01).

Conclusion: In our cohort of patients, the use of SA was associated with reduced duration of MV and lengths of stay compared with DIS. Based on these results, DIS may not be appropriate in all mechanically ventilated patients.

Trial registration: ClinicalTrials.gov NCT00205517.

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Related in: MedlinePlus

The sedation algorithm used in this study. gtt, drop; MRICU, medical respiratory intensive care unit; prn, as necessary (pro re nata); q, every; qd, each day (quaque die); RASS, Richmond Agitation-Sedation Scale.
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Figure 1: The sedation algorithm used in this study. gtt, drop; MRICU, medical respiratory intensive care unit; prn, as necessary (pro re nata); q, every; qd, each day (quaque die); RASS, Richmond Agitation-Sedation Scale.

Mentions: Patients were randomly assigned to one of two sedation strategies: DIS or nursing-implemented SA. Sedation in all patients was managed according to the algorithm up to the time of randomization. The SA was developed locally by the medical ICU physicians, pharmacist, and nursing staff and was based on the algorithm developed by Brook and colleagues [3] and on Society of Critical Care Medicine guidelines [9]. The algorithm goals were to maximize the use of boluses, minimize the duration of continuous intravenous infusion of sedation, and treat pain with opioids (Figure 1). It included daily attempts to decrease sedation dosages. The Richmond Agitation-Sedation Scale (RASS) was used to measure sedation level, and sedation was titrated to a goal RASS score of -2 to -3 unless otherwise specified by the ICU team (Table 1) [10]. The ICU nursing staff underwent a 2-month introductory period in the use of the algorithm. After educational training, the algorithm underwent a 1-month run-in period prior to study initiation. During the trial, nurses assigned to study patients were asked daily whether they required any clarification regarding the algorithm. Nurses administered sedatives and opiates as mandated by the algorithm. Study investigators monitored compliance with the algorithm by evaluating sedation levels in patients randomly assigned to SA on two occasions per day, with the timing of the events being at the discretion of investigators and separated by at least 2 hours.


Randomized trial comparing daily interruption of sedation and nursing-implemented sedation algorithm in medical intensive care unit patients.

de Wit M, Gennings C, Jenvey WI, Epstein SK - Crit Care (2008)

The sedation algorithm used in this study. gtt, drop; MRICU, medical respiratory intensive care unit; prn, as necessary (pro re nata); q, every; qd, each day (quaque die); RASS, Richmond Agitation-Sedation Scale.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC2481461&req=5

Figure 1: The sedation algorithm used in this study. gtt, drop; MRICU, medical respiratory intensive care unit; prn, as necessary (pro re nata); q, every; qd, each day (quaque die); RASS, Richmond Agitation-Sedation Scale.
Mentions: Patients were randomly assigned to one of two sedation strategies: DIS or nursing-implemented SA. Sedation in all patients was managed according to the algorithm up to the time of randomization. The SA was developed locally by the medical ICU physicians, pharmacist, and nursing staff and was based on the algorithm developed by Brook and colleagues [3] and on Society of Critical Care Medicine guidelines [9]. The algorithm goals were to maximize the use of boluses, minimize the duration of continuous intravenous infusion of sedation, and treat pain with opioids (Figure 1). It included daily attempts to decrease sedation dosages. The Richmond Agitation-Sedation Scale (RASS) was used to measure sedation level, and sedation was titrated to a goal RASS score of -2 to -3 unless otherwise specified by the ICU team (Table 1) [10]. The ICU nursing staff underwent a 2-month introductory period in the use of the algorithm. After educational training, the algorithm underwent a 1-month run-in period prior to study initiation. During the trial, nurses assigned to study patients were asked daily whether they required any clarification regarding the algorithm. Nurses administered sedatives and opiates as mandated by the algorithm. Study investigators monitored compliance with the algorithm by evaluating sedation levels in patients randomly assigned to SA on two occasions per day, with the timing of the events being at the discretion of investigators and separated by at least 2 hours.

Bottom Line: The Data Safety Monitoring Board convened after DIS patients were found to have higher hospital mortality; however, no causal connection between DIS and increased mortality was identified.In our cohort of patients, the use of SA was associated with reduced duration of MV and lengths of stay compared with DIS.Based on these results, DIS may not be appropriate in all mechanically ventilated patients.

View Article: PubMed Central - HTML - PubMed

Affiliation: Pulmonary and Critical Care Division, Department of Internal Medicine, School of Medicine, Virginia Commonwealth University, PO Box 980050, Richmond, VA 23298-0050, USA. mdewit@mcvh-vcu.edu

ABSTRACT

Introduction: Daily interruption of sedation (DIS) and sedation algorithms (SAs) have been shown to decrease mechanical ventilation (MV) duration. We conducted a randomized study comparing these strategies.

Methods: Mechanically ventilated adults 18 years old or older in the medical intensive care unit (ICU) were randomly assigned to DIS or SA. Exclusion criteria were severe neurocognitive dysfunction, administration of neuromuscular blockers, and tracheostomy. Study endpoints were total MV duration and 28-day ventilator-free survival.

Results: The study was terminated prematurely after 74 patients were enrolled (DIS 36 and SA 38). The two groups had similar age, gender, racial distribution, Acute Physiology and Chronic Health Evaluation II score, and reason for MV. The Data Safety Monitoring Board convened after DIS patients were found to have higher hospital mortality; however, no causal connection between DIS and increased mortality was identified. Interim analysis demonstrated a significant difference in primary endpoint, and study termination was recommended. The DIS group had longer total duration of MV (median 6.7 versus 3.9 days; P = 0.0003), slower improvement of Sequential Organ Failure Assessment over time (0.70 versus 0.23 units per day; P = 0.025), longer ICU length of stay (15 versus 8 days; P < 0.0001), and longer hospital length of stay (23 versus 12 days; P = 0.01).

Conclusion: In our cohort of patients, the use of SA was associated with reduced duration of MV and lengths of stay compared with DIS. Based on these results, DIS may not be appropriate in all mechanically ventilated patients.

Trial registration: ClinicalTrials.gov NCT00205517.

Show MeSH
Related in: MedlinePlus