Memory in relation to depth of sedation in adult mechanically ventilated intensive care patients Monitoring sedation status over time in ICU patients: reliability and validity of the Richmond Agitation-Sedation Scale (RASS). State Behavioral Scale: A sedation assessment instrument for infants and young children supported on mechanical ventilation* Sedation algorithm in critically ill patients without acute brain injury Effect of a nursing-implemented sedation protocol on weaning outcome* Prospective evaluation of the Sedation-Agitation Scale for adult critically ill patients. The use of continuous i.v. sedation is associated with prolongation of mechanical ventilation. Effect of a scoring system and protocol for sedation on duration of patients’ need for ventilator support in a surgical intensive care unit* Effect of a nurse-implemented sedation protocol on the incidence of ventilator-associated pneumonia* A randomized trial of protocol-directed sedation management for mechanical ventilation in an Australian intensive care unit*
Objective To investigate the relationship between memory and intensive care sedation . Design and setting Prospect i ve cohort study over 18 months in two general intensive care units ( ICUs ) in district university hospitals . Patients 313 intubated mechanically ventilated adults admitted for more than 24 h , 250 of whom completed the study . Measurements Patients ( n = 250 ) were interviewed in the ward 5 days after discharge from the ICU using the ICU Memory Tool .  Patient characteristics , doses of sedative and analgesic agents , and sedation scores as measured by the Motor Activity Assessment Scale ( MAAS ) were collected from hospital records after the interview . Results Patients with no recall ( 18 % ) were significantly older , had higher baseline severity of illness , and experienced fewer periods of wakefulness ( median proportion of MAAS score 3 ; 0.37 vs. 0.70 ) than those who had memories of the ICU ( 82 % ) . Multivariate analyses showed that increasing proportion of MAAS 0–2 and older age were significantly associated with having no recall . Patients with delusional memories ( 34 % ) had significantly longer ICU stay ( median 6.6 vs. 2.2 days ) , higher baseline severity of illness , higher proportions of MAAS scores 4–6 , and more administration of midazolam than those with recall of the ICU without delusional memories . Conclusions Heavy sedation increases the risk of having no recall , and longer ICU stay increases the risk of delusional memories . The depth of sedation during total ICU stay as recorded with the MAAS may predict the probability of having memories of the ICU CONTEXT Goal -directed delivery of sedative and analgesic medications is recommended as st and ard care in intensive care units ( ICUs ) because of the impact these medications have on ventilator weaning and ICU length of stay , but few of the available sedation scales have been appropriately tested for reliability and validity . OBJECTIVE To test the reliability and validity of the Richmond Agitation-Sedation Scale ( RASS ) . DESIGN Prospect i ve cohort study . SETTING Adult medical and coronary ICUs of a university-based medical center . PARTICIPANTS Thirty-eight medical ICU patients enrolled for reliability testing ( 46 % receiving mechanical ventilation ) from July 21 , 1999 , to September 7 , 1999 , and an independent cohort of 275 patients receiving mechanical ventilation were enrolled for validity testing from February 1 , 2000 , to May 3 , 2001 . MAIN OUTCOME MEASURES Interrater reliability of the RASS , Glasgow Coma Scale ( GCS ) , and Ramsay Scale ( RS ) ; validity of the RASS correlated with reference st and ard ratings , assessment s of content of consciousness , GCS scores , doses of sedatives and analgesics , and bispectral electroencephalography . RESULTS In 290-paired observations by nurses , results of both the RASS and RS demonstrated excellent interrater reliability ( weighted kappa , 0.91 and 0.94 , respectively ) , which were both superior to the GCS ( weighted kappa , 0.64 ; P<.001 for both comparisons ) . Criterion validity was tested in 411-paired observations in the first 96 patients of the validation cohort , in whom the RASS showed significant differences between levels of consciousness ( P<.001 for all ) and correctly identified fluctuations within patients over time ( P<.001 ) . In addition , 5 methods were used to test the construct validity of the RASS , including correlation with an attention screening examination ( r = 0.78 , P<.001 ) , GCS scores ( r = 0.91 , P<.001 ) , quantity of different psychoactive medication dosages 8 hours prior to assessment ( eg , lorazepam : r = - 0.31 , P<.001 ) , successful extubation ( P = .07 ) , and bispectral electroencephalography ( r = 0.63 , P<.001 ) . Face validity was demonstrated via a survey of 26 critical care nurses , which the results showed that 92 % agreed or strongly agreed with the RASS scoring scheme , and 81 % agreed or strongly agreed that the instrument provided a consensus for goal -directed delivery of medications . CONCLUSIONS The RASS demonstrated excellent interrater reliability and criterion , construct , and face validity . This is the first sedation scale to be vali date d for its ability to detect changes in sedation status over consecutive days of ICU care , against constructs of level of consciousness and delirium , and correlated with the administered dose of sedative and analgesic medications Objective : To develop and test the reliability and validity of the State Behavioral Scale for use in describing sedation/agitation levels in young intubated patients supported on mechanical ventilation . Design : In this prospect i ve , psychometric evaluation , pairs of trained pediatric critical care nurse evaluators simultaneously and independently assessed a convenience sample of pediatric intensive care unit patients along eight state/behavioral dimensions and a numeric rating scale ( NRS ) of 0 ( extremely se date d ) to 10 ( extremely agitated ) . The eight dimensions were derived from the sedation/agitation literature and expert opinion and included respiratory drive , response to ventilation , coughing , best response to stimulation , attentiveness to careprovider , tolerance to care , consolability , and movement after consoled , each with 3–5 levels . Setting : An 18-bed pediatric medical – surgical intensive care unit and 26-bed pediatric cardiovascular intensive care unit in a university-affiliated academic children ’s hospital . Patients : A total of 91 intubated mechanically ventilated patients 6 wks to 6 yrs of age provided a median of two observations ( interquartile range , 1–3 ) for a total of 198 sets of observations . Excluded were postoperative patients or those receiving neuromuscular blockade . Interventions : Patients were observed for 1 min , and then incremental levels of stimulation were applied until patient response . After 2 mins of consoling , the state behavioral assessment and NRS were completed . Measurements : Weighted kappa and intraclass coefficients were generated to assess interrater reliability of the eight dimension and NRS ratings . Distinct state behavior profiles were empirically identified from the dimension ratings using hierarchical cluster analysis using a squared Euclidean distance measure and between-groups linkage . Construct validity of these profiles was assessed by comparing group mean NRS scores using one-way analysis of variance . Main Results : Weighted kappa scores for all 198 dimension ratings ranged from .44 to .76 , indicating moderate to good interrater reliability . The intraclass coefficient of .79 was high for NRS ratings . Cluster analysis revealed five distinct state profiles , with mean NRS ratings of 1.1 , 2.5 , 4.0 , 5.3 , and 7.6 , all of which differed significantly from each other ( F = 75.8 , p < .001 ) , supporting the profiles ’ construct validity . Conclusions : Based on empirically derived state behavior profiles , we have constructed the State Behavioral Scale to allow systematic description of the sedation – agitation continuum in young pediatric patients supported on mechanical ventilation . Further studies including prospect i ve validation and describing the effect of State Behavioral Scale implementation on clinical outcomes , including the quality of sedation and length of mechanical ventilation , are warranted Objective : To determine whether use of a sedation algorithm to promote a high level of tolerance to the intensive care environment and preserve consciousness affected time to arousal and duration of mechanical ventilation in patients without acute brain injury . Design : Two-phase , prospect i ve , controlled study . Setting : University-affiliated medical intensive care unit . Patients : Patients without acute brain injury requiring mechanical ventilation for at least 24 hrs . Interventions : During the control phase , sedatives and analgesics were adjusted according to the physician ’s decision . During the algorithm phase , sedatives and analgesics were adjusted according to an algorithm developed by a multidisciplinary team including nurses and physicians . The algorithm was based on regular assessment s of consciousness and tolerance to the intensive care unit environment using the Adaptation to Intensive Care Environment instrument and was design ed to achieve tolerance and maintain a high level of consciousness . St and ard practice s , including weaning from the ventilator , were the same during both study phases . Measurements and Main Results : A total of 102 patients were enrolled ( control group , n = 54 ; algorithm group , n = 48 ) . Median duration of mechanical ventilation was significantly shorter in the algorithm group ( 4.4 days [ interquartile range , 2.1–9.8 ] ) compared with the control group ( 10.3 days [ 3.5–17.2 ] , p = .014 ) , representing a 57.3 % reduction . In Cox multivariate analysis , the risk of remaining on mechanical ventilation was 0.48 times ( 95 % confidence interval , 0.29–0.78 ) lower for algorithm patients compared with controls . The median time to arousal was also significantly shorter in patients in the algorithm group ( 2 days [ 2–5 ] ) compared with the control group ( 4 days [ 2–9 ] , p = .006 ) . Conclusions : The use of a sedation algorithm to promote tolerance to the intensive care environment and preserve consciousness in patients without acute brain injury result ed in a marked decrease in the duration of mechanical ventilation . This reduction was at least partly attributable to a shorter time to arousal after initiation of mechanical ventilation Objective : To evaluate the effect of the implementation of a nursing-driven protocol of sedation on duration of intubation . Design : Before- and -after prospect i ve study . Setting : 18-bed medical-surgical intensive care unit . Patients : Patients receiving mechanical ventilation longer than 48 hrs who were ready to wean . Interventions : During the observational period , sedatives and analgesics were adjusted according to physicians ’ orders . During the intervention period , sedatives and analgesics were adjusted by nurses according to an algorithm-based sedation guideline , including a sedation scale . Measurements and Main Results : A total of 356 patients were included in the study ( 176 patients in the observational period and 189 patients in the intervention period ) . There were no significant differences in the duration of intubation between the two periods ( median , 7 [ interquartile range , 5–13 ] days vs. 7 [ interquartile range , 5–9 ] days ) . In a Kaplan-Meier analysis , the probability of successful extubation was higher during the intervention period than during the observational period ( log-rank = 0.02 ) . During the intervention period , patients were more awake without a significant increment in the nurse workload ; however , there was no significant decrease in the total doses of sedatives and analgesics administered . Conclusions : The implementation of a nursing-driven protocol of sedation may improve the probability of successful extubation in a heterogeneous population of mechanically ventilated patients OBJECTIVE Subjective scales to assess agitation and sedation in adult intensive care unit ( ICU ) patients have rarely been tested for validity or reliability . We revised and prospect ively tested the  Sedation-Agitation Scale ( SAS ) for interrater reliability and compared it with the Ramsay scale and the Harris scale to test construct validity . DESIGN A convenience sample of ICU patients was simultaneously and independently examined by pairs of trained evaluators by using the revised SAS , Ramsay , and Harris Scales . SETTING Multidisciplinary 34-bed ICU in a nonuniversity , academic medical center . PATIENTS Forty-five ICU patients ( surgical and medical ) were examined a total of 69 times by evaluator pairs . MEASUREMENTS AND MAIN RESULTS The mean patient age was 63.2 yrs , 36 % were female , and 71 % were intubated . When classified by using SAS , 45 % were anxious or agitated ( SAS 5 to 7 ) , 26 % were calm ( SAS 4 ) , and 29 % were se date d ( SAS 1 to 3 ) . Interrater correlation was high for SAS ( r2 = .83 ; p < .001 ) and the weighted kappa score for interrater agreement was 0.92 ( p < .001 ) . Of 41 assessment s scored as Ramsay 1 , 49 % scored SAS 6 , 41 % were SAS 5 , 5 % were SAS 4 , and 2 % each were SAS 3 or 7 . SAS was highly correlated with the Ramsay ( r2 = .83 ; p < .001 ) and Harris ( r2 = .86 ; p < .001 ) scales . CONCLUSIONS SAS is both reliable ( high interrater agreement ) and valid ( high correlation with the Harris and Ramsay scales ) in assessing agitation and sedation in adult ICU patients .  SAS provides additional information by stratifying agitation into three categories ( compared with one for the Ramsay scale ) without sacrificing validity or reliability STUDY OBJECTIVE To determine whether the use of continuous i.v . sedation is associated with prolongation of the duration of mechanical ventilation . DESIGN Prospect i ve observational cohort study . SETTING The medical ICU of Barnes-Jewish Hospital , a university-affiliated urban teaching hospital . PATIENTS Two hundred forty-two consecutive ICU patients requiring mechanical ventilation . INTERVENTIONS Patient surveillance and data collection . MEASUREMENTS AND RESULTS The primary outcome measure was the duration of mechanical ventilation . Secondary outcome measures included ICU and hospital lengths of stay , hospital mortality , and acquired organ system derangements . A total of 93 ( 38.4 % ) mechanically ventilated patients received continuous i.v . sedation while 149 ( 61.6 % ) patients received either bolus administration of i.v . sedation ( n=64 ) or no i.v . sedation ( n=85 ) following intubation . The duration of mechanical ventilation was significantly longer for patients receiving continuous i.v . sedation compared with patients not receiving continuous i.v . sedation ( 185+/-190 h vs 55.6+/-75.6 h ; p<0.001 ) . Similarly , the lengths of intensive care ( 13.5+/-33.7 days vs 4.8+/-4.1 days ; p<0.001 ) and hospitalization ( 21.0+/-25.1 days vs 12.8+/-14.1 days ; p<0.001 ) were statistically longer among patients receiving continuous i.v . sedation . Multiple linear regression analysis , adjusting for age , gender , severity of illness , mortality , indication for mechanical ventilation , use of chemical paralysis , presence of a tracheostomy , and the number of acquired organ system derangements , found the adjusted duration of mechanical ventilation to be significantly longer for patients receiving continuous i.v . sedation compared with patients who did not receive continuous i.v . sedation ( 148 h [ 95 % confidence interval : 121 , 175 h ] vs 78.7 h [ 95 % confidence interval : 68.9 , 88.6 h ] ; p<0.001 ) . CONCLUSION We conclude from these preliminary observational data that the use of continuous i.v . sedation may be associated with the prolongation of mechanical ventilation . This study suggests that strategies targeted at reducing the use of continuous i.v . sedation could shorten the duration of mechanical ventilation for some patients . Prospect i ve r and omized clinical trials , using well- design ed sedation guidelines and protocol s , are required to determine whether patient-specific outcomes ( eg , duration of mechanical ventilation , patient comfort ) can be improved compared with conventional sedation practice Problem : Need for improved sedation strategy for adults receiving ventilator support . Design : Observational study of effect of introduction of guidelines to improve the doctors ’ and nurses ’ performance . The project was a prospect i ve improvement and was part of a national quality improvement collaborative . Background and setting : A general mixed surgical intensive care unit in a university hospital ; all doctors and nurses in the unit ; all adult patients ( > 18 years ) treated by intermittent positive pressure ventilation for more than 24 hours . Key measures for improvement : Reduction in patients ’ mean time on a ventilator and length of stay in intensive care over a period of 11 months ; anonymous reporting of critical incidents ; staff perceptions of ease and of consequences of changes . Strategies for change : Multiple measures ( protocol development , educational presentations , written guidelines , posters , flyers , emails , personal discussion s , and continuous feedback ) were tested , rapidly assessed , and adopted if beneficial . Effects of change : Mean ventilator time decreased by 2.1 days ( 95 % confidence interval 0.7 to 3.6 days ) from 7.4 days before intervention to 5.3 days after . Mean stay decreased by 1.0 day ( −0.9 to 2.9 days ) from 9.3 days to 8.3 days . No accidental extubations or other incidents were identified . Lessons learnt : 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 Objective : To determine whether the use of a nurse-implemented sedation protocol could reduce the incidence of  ventilator-associated pneumonia in critically ill patients . Design : Two-phase ( before – after ) , prospect i ve , controlled study . Setting : University-affiliated , 11-bed medical intensive care unit . Patients : Patients requiring mechanical ventilation for ≥48 hrs and sedative infusion with midazolam or propofol alone .  Interventions : During the control phase , sedatives were adjusted according to the physician ’s decision . During the protocol phase , sedatives were adjusted according to a protocol developed by a multidisciplinary team including nurses and physicians . The protocol was based on the Cambridge scale , and sedation level was adjusted every 3 hrs by the nurses . St and ard practice s , including weaning from the ventilator and diagnosis of VAP , were the same during both study phases . Measurements and Main Results : A total of 423 patients were enrolled ( control group , n = 226 ; protocol group , n = 197 ) . The incidence of VAP was significantly lower in the protocol group compared with the control group ( 6 % and 15 % , respectively , p = .005 ) . By univariate analysis ( log-rank test ) , only use of a nurse-implemented protocol was significantly associated with a decrease of incidence of VAP ( p < .01 ) . A nurse-implemented protocol was found to be independently associated with a lower incidence of VAP after adjustment on Simplified Acute Physiology Score II in the multivariate Cox proportional hazards model ( hazard rate , 0.81 ; 95 % confidence interval , 0.62–0.95 ; p = .03 ) . The median duration of mechanical ventilation was significantly shorter in the protocol group ( 4.2 days ; interquartile range , 2.1–9.5 ) compared with the control group ( 8 days ; interquartile range , 2.2–22.0 ; p = .001 ) , representing a 52 % relative reduction . Extubation failure was more frequently observed in the control group compared with the protocol group ( 13 % and 6 % , respectively , p = .01 ) . There was no significant difference in in-hospital mortality ( 38 % vs. 45 % in the protocol vs. control group , respectively , p = .22 ) . Conclusions : In patients receiving mechanical ventilation and requiring sedative infusions with midazolam or propofol , the use of a nurse-implemented sedation protocol decreases the rate of VAP and the duration of mechanical ventilation Objective : To compare protocol -directed sedation management with traditional non- protocol -directed practice in mechanically ventilated patients . Design : R and omized , controlled trial . Setting : General intensive care unit ( 24 beds ) in an Australian metropolitan teaching hospital . Patients : Adult , mechanically ventilated patients ( n = 312 ) . Interventions : Patients were r and omly assigned to receive sedation directed by formal guidelines ( protocol group , n = 153 ) or usual local clinical practice ( control , n = 159 ) . Measurements and Main Results : The median ( 95 % confidence interval ) duration of ventilation was 79 hrs ( 56–93 hrs ) for patients in the protocol group compared with 58 hrs ( 44–78 hrs ) for patients who received control care ( p = .20 ) . Lengths of stay ( median [ range ] ) in the intensive care unit ( 94 [ 2–1106 ] hrs vs. 88 ( 14–962 ) hrs , p = .58 ) and hospital ( 13 [ 1–113 ] days vs. 13 ( 1–365 ) days , p = .97 ) were similar , as were the proportions of subjects receiving a tracheostomy ( 17 % vs. 15 % , p = .64 ) or undergoing unplanned self-extubation ( 1.3 % vs. 0.6 % , p = .61 ) . Death in the intensive care unit occurred in 32 ( 21 % ) patients in the protocol group and 32 ( 20 % ) control subjects ( p = .89 ) , with a similar overall proportion of deaths in hospital ( 25 % vs. 22 % , p = .51 ) . A Cox proportional hazards model , after adjustment for age , gender , Acute Physiology and Chronic Health Evaluation II score , diagnostic category , and doses of commonly used drugs , estimated that protocol sedation management was associated with a 22 % decrease ( 95 % confidence interval 40 % decrease to 2 % increase , p = .07 ) in the occurrence of successful weaning from mechanical ventilation . Conclusions : This r and omized trial provided no evidence of a substantial reduction in the duration of mechanical ventilation or length of stay , in either the intensive care unit or the hospital , with the use of protocol -directed sedation compared with usual local management . Qualified high-intensity nurse staffing and routine Australian intensive care unit nursing responsibility for many aspects of ventilatory practice may explain the contrast between these findings and some recent North American studies
AIMS Assess the effects of protocol -directed sedation management on the duration of mechanical ventilation and other relevant patient outcomes in mechanically ventilated intensive care unit patients .
BACKGROUND Sedation is a core component of critical care .
Sub-optimal sedation management incorporates both under- and over-sedation and has been linked to poorer patient outcomes .