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The incidence of sub-optimal sedation in the ICU: a systematic review.

Jackson DL, Proudfoot CW, Cann KF, Walsh TS - Crit Care (2009)

Bottom Line: Study aims, design, population, comparisons made, and data on the incidence of sub-optimal, optimal, over-sedation or under-sedation were extracted.Across all included studies, a substantial incidence of sub-optimal sedation was reported, with a greater tendency toward over-sedation.Our review suggests that improvements in the consistent definition and measurement of sedation may improve the quality of care of patients within the ICU.

View Article: PubMed Central - HTML - PubMed

Affiliation: GE Healthcare, Pollards Wood, Nightingales Lane, Chalfont St, Giles, Bucks, HP8 4SP, UK. Daniel.Jackson@ge.com.

ABSTRACT

Introduction: Patients in intensive care units (ICUs) are generally sedated for prolonged periods. Over-sedation and under-sedation both have negative effects on patient safety and resource use. We conducted a systematic review of the literature in order to establish the incidence of sub-optimal sedation (both over- and under-sedation) in ICUs.

Methods: We searched Medline, Embase and CINAHL (Cumulative Index to Nursing and Allied Health Literature) online literature databases from 1988 to 15 May 2008 and hand-searched conferences. English-language studies set in the ICU, in sedated adult humans on mechanical ventilation, which reported the incidence of sub-optimal sedation, 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 papers of all included studies were retrieved and were again reviewed twice against inclusion criteria. Data were doubly extracted. Study aims, design, population, comparisons made, and data on the incidence of sub-optimal, optimal, over-sedation or under-sedation were extracted.

Results: There was considerable variation between included studies in the definition of optimal sedation and in the scale or method used to assess sedation. Across all included studies, a substantial incidence of sub-optimal sedation was reported, with a greater tendency toward over-sedation.

Conclusions: Our review suggests that improvements in the consistent definition and measurement of sedation may improve the quality of care of patients within the ICU.

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Incidence of sub-optimal sedation across included studies. The plot shows the percentage of measurements, patients, or time in which patients were sub-optimally sedated according to each included study's definition of optimal sedation and measurements reported. Studies are grouped by study design. Where more than one group was reported by a study (for example, a comparison of two different treatment arms), separate points are shown for each group. RCT, randomised controlled trial.
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Figure 3: Incidence of sub-optimal sedation across included studies. The plot shows the percentage of measurements, patients, or time in which patients were sub-optimally sedated according to each included study's definition of optimal sedation and measurements reported. Studies are grouped by study design. Where more than one group was reported by a study (for example, a comparison of two different treatment arms), separate points are shown for each group. RCT, randomised controlled trial.

Mentions: The remaining included studies comprised studies of sedative drugs [21-26,29,31-34,36,37,39-42,45-50], studies investigating different sedation devices or scales [27,28,38,51,52], and studies looking at the introduction of a sedation guideline or protocol [3,35,53,54]. Studies varied by design and aim, by sedatives used, by scales and definitions of sub-optimal sedation used, and by the way incidence was reported (as a proportion of measurements, patients, or time). While these studies did not necessarily have the incidence of sub-optimal sedation as their primary focus, the data in such studies were considered to be of interest to the inclusive scope of this review. Although studies of sedative drugs or of the introduction of guidelines or protocols may not give an accurate estimate of the incidence of sub-optimal sedation within routine clinical practice, they nevertheless show that it does occur and can give an impression of the extent to which it may be a problem, even in settings that could be reasonably expected to be more controlled than in routine practice. The incidence of sub-optimal sedation reported in these studies is summarised in Figure 3 (separated by study and treatment arm where relevant). The reported incidence varied from 1% [39] to 75% [28], with the majority reporting an incidence of over 20%. The incidence of over- and under-sedation was similarly variable, and figures of between 2.8% and 44% for over-sedation [28,33,51] and between 2% and 31% for under-sedation [23,51] were reported. A further study [2] that looked at the introduction of a sedation guideline did not record the incidence of sub-optimal sedation but recorded the median Ramsay scale values. These were 4 during the day and 5 at night, in contrast to the study's stated aim of Ramsay levels of 2 to 3 during the day and 3 to 4 at night; this study again noted a possible tendency toward over-sedation of patients. Importantly, there was no change in this tendency before and after reinforcement of the guideline, suggesting that this was insufficient to improve sedation practice [3].


The incidence of sub-optimal sedation in the ICU: a systematic review.

Jackson DL, Proudfoot CW, Cann KF, Walsh TS - Crit Care (2009)

Incidence of sub-optimal sedation across included studies. The plot shows the percentage of measurements, patients, or time in which patients were sub-optimally sedated according to each included study's definition of optimal sedation and measurements reported. Studies are grouped by study design. Where more than one group was reported by a study (for example, a comparison of two different treatment arms), separate points are shown for each group. RCT, randomised controlled trial.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC2811948&req=5

Figure 3: Incidence of sub-optimal sedation across included studies. The plot shows the percentage of measurements, patients, or time in which patients were sub-optimally sedated according to each included study's definition of optimal sedation and measurements reported. Studies are grouped by study design. Where more than one group was reported by a study (for example, a comparison of two different treatment arms), separate points are shown for each group. RCT, randomised controlled trial.
Mentions: The remaining included studies comprised studies of sedative drugs [21-26,29,31-34,36,37,39-42,45-50], studies investigating different sedation devices or scales [27,28,38,51,52], and studies looking at the introduction of a sedation guideline or protocol [3,35,53,54]. Studies varied by design and aim, by sedatives used, by scales and definitions of sub-optimal sedation used, and by the way incidence was reported (as a proportion of measurements, patients, or time). While these studies did not necessarily have the incidence of sub-optimal sedation as their primary focus, the data in such studies were considered to be of interest to the inclusive scope of this review. Although studies of sedative drugs or of the introduction of guidelines or protocols may not give an accurate estimate of the incidence of sub-optimal sedation within routine clinical practice, they nevertheless show that it does occur and can give an impression of the extent to which it may be a problem, even in settings that could be reasonably expected to be more controlled than in routine practice. The incidence of sub-optimal sedation reported in these studies is summarised in Figure 3 (separated by study and treatment arm where relevant). The reported incidence varied from 1% [39] to 75% [28], with the majority reporting an incidence of over 20%. The incidence of over- and under-sedation was similarly variable, and figures of between 2.8% and 44% for over-sedation [28,33,51] and between 2% and 31% for under-sedation [23,51] were reported. A further study [2] that looked at the introduction of a sedation guideline did not record the incidence of sub-optimal sedation but recorded the median Ramsay scale values. These were 4 during the day and 5 at night, in contrast to the study's stated aim of Ramsay levels of 2 to 3 during the day and 3 to 4 at night; this study again noted a possible tendency toward over-sedation of patients. Importantly, there was no change in this tendency before and after reinforcement of the guideline, suggesting that this was insufficient to improve sedation practice [3].

Bottom Line: Study aims, design, population, comparisons made, and data on the incidence of sub-optimal, optimal, over-sedation or under-sedation were extracted.Across all included studies, a substantial incidence of sub-optimal sedation was reported, with a greater tendency toward over-sedation.Our review suggests that improvements in the consistent definition and measurement of sedation may improve the quality of care of patients within the ICU.

View Article: PubMed Central - HTML - PubMed

Affiliation: GE Healthcare, Pollards Wood, Nightingales Lane, Chalfont St, Giles, Bucks, HP8 4SP, UK. Daniel.Jackson@ge.com.

ABSTRACT

Introduction: Patients in intensive care units (ICUs) are generally sedated for prolonged periods. Over-sedation and under-sedation both have negative effects on patient safety and resource use. We conducted a systematic review of the literature in order to establish the incidence of sub-optimal sedation (both over- and under-sedation) in ICUs.

Methods: We searched Medline, Embase and CINAHL (Cumulative Index to Nursing and Allied Health Literature) online literature databases from 1988 to 15 May 2008 and hand-searched conferences. English-language studies set in the ICU, in sedated adult humans on mechanical ventilation, which reported the incidence of sub-optimal sedation, 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 papers of all included studies were retrieved and were again reviewed twice against inclusion criteria. Data were doubly extracted. Study aims, design, population, comparisons made, and data on the incidence of sub-optimal, optimal, over-sedation or under-sedation were extracted.

Results: There was considerable variation between included studies in the definition of optimal sedation and in the scale or method used to assess sedation. Across all included studies, a substantial incidence of sub-optimal sedation was reported, with a greater tendency toward over-sedation.

Conclusions: Our review suggests that improvements in the consistent definition and measurement of sedation may improve the quality of care of patients within the ICU.

Show MeSH