Effect of sedation with dexmedetomidine vs lorazepam on acute brain dysfunction in mechanically ventilated patients: the MENDS randomized controlled trial. Cost of ICU sedation: comparison of empirical and controlled sedation methods. Daily interruption of sedative infusions and complications of critical illness in mechanically ventilated patients* Effect of a nursing-implemented sedation protocol on the duration of mechanical ventilation. Sedation algorithm in critically ill patients without acute brain injury The Effect of ICU Sedation Guidelines and Pharmacist Interventions on Clinical Outcomes and Drug Cost Impact of a clinical pharmacist-enforced intensive care unit sedation protocol on duration of mechanical ventilation and hospital stay* Impact of systematic evaluation of pain and agitation in an intensive care unit* The use of continuous i.v. sedation is associated with prolongation of mechanical ventilation. Efficacy and safety of a paired sedation and ventilator weaning protocol for mechanically ventilated patients in intensive care (Awakening and Breathing Controlled trial): a randomised controlled trial A randomized trial of intermittent lorazepam versus propofol with daily interruption in mechanically ventilated patients* Introduction of sedative, analgesic, and neuromuscular blocking agent guidelines in a medical intensive care unit: Physician and nurse adherence 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* The Impact of Bispectral Index Monitoring on Sedation Administration in Mechanically Ventilated Patients Pharmacoeconomic impact of rational use guidelines on the provision of analgesia, sedation, and neuromuscular blockade in critical care Changing sedation practices in the intensive care unit--protocol implementation, multifaceted multidisciplinary approach and teamwork. Implementation of an institutional program to improve clinical and financial outcomes of mechanically ventilated patients: One-year outcomes and lessons learned* A prospective evaluation of empiric versus protocol-based sedation and analgesia.
CONTEXT Lorazepam is currently recommended for sustained sedation of mechanically ventilated intensive care unit ( ICU ) patients , but this and other benzodiazepine drugs may contribute to acute brain dysfunction , ie , delirium and coma , associated with prolonged hospital stays , costs , and increased mortality . Dexmedetomidine induces sedation via different central nervous system receptors than the benzodiazepine drugs and may lower the risk of acute brain dysfunction . OBJECTIVE To determine whether dexmedetomidine reduces the duration of delirium and coma in mechanically ventilated ICU patients while providing adequate sedation as compared with lorazepam . DESIGN , SETTING , PATIENTS , AND INTERVENTION Double-blind , r and omized controlled trial of 106 adult mechanically ventilated medical and surgical ICU patients at 2 tertiary care centers between August 2004 and April 2006 . Patients were se date d with dexmedetomidine or lorazepam for as many as 120 hours . Study drugs were titrated to achieve the desired level of sedation , measured using the Richmond Agitation-Sedation Scale ( RASS ) . Patients were monitored twice daily for delirium using the Confusion Assessment Method for the ICU ( CAM-ICU ) . MAIN OUTCOME MEASURES Days alive without delirium or coma and percentage of days spent within 1 RASS point of the sedation goal . RESULTS Sedation with dexmedetomidine result ed in more days alive without delirium or coma ( median days , 7.0 vs 3.0 ; P = .01 ) and a lower prevalence of coma ( 63 % vs 92 % ; P < .001 ) than sedation with lorazepam . Patients se date d with dexmedetomidine spent more time within 1 RASS point of their sedation goal compared with patients se date d with lorazepam ( median percentage of days , 80 % vs 67 % ; P = .04 ) . The 28-day mortality in the dexmedetomidine group was 17 % vs 27 % in the lorazepam group ( P = .18 ) and cost of care was similar between groups . More patients in the dexmedetomidine group ( 42 % vs 31 % ; P = .61 ) were able to complete post-ICU neuropsychological testing , with similar scores in the tests evaluating global cognitive , motor speed , and attention functions . The 12-month time to death was 363 days in the dexmedetomidine group vs 188 days in the lorazepam group ( P = .48 ) . CONCLUSION In mechanically ventilated ICU patients managed with individualized targeted sedation , use of a dexmedetomidine infusion result ed in more days alive without delirium or coma and more time at the targeted level of sedation than with a lorazepam infusion . TRIAL REGISTRATION clinical trials.gov Identifier : NCT00095251 A r and omised crossover study was undertaken to compare the quality and cost of controlled versus empirical sedation with midazolam in critically ill patients . Patients ( n = 40 ) entering the ICU were enrolled provided they satisfied the strict entry criteria . During 90 hours of midazolam sedation , patients received r and omly allocated 10-hour periods of controlled or empirical sedation . With empirical sedation , the mean dose of midazolam  and the cost of sedation were almost double those with controlled sedation . The quality of sedation was superior with the controlled method . In a separate study on 352 patients , a cost-benefit analysis of controlled sedation with midazolam or propofol infusion or bolus injections of morphine plus diazepam showed that the quality of sedation achieved with propofol was superior to the other two regimens and that , with morphine plus diazepam , the quality of sedation was unacceptably poor . Although the direct purchase price of propofol was higher than that of other agents , the total cost of sedation with propofol was lower than that for midazolam for short-term intensive care ( less than 24 hours ) and comparable to midazolam for longer-term use . However , indirect benefits of sedation with propofol include a much shorter ICU stay with the attendant reduced nursing costs and greater throughout the patients , and this more than compensates for the higher purchase price of the agent Objective : In critically ill patients receiving mechanical ventilation , daily interruption of sedative infusions decreases duration of mechanical ventilation and intensive care unit length of stay . Whether this sedation strategy reduces the incidence of complications commonly associated with critical illness is not known . Design : Blinded , retrospective chart review . Setting : University-based hospital in Chicago , IL . Patients : One hundred twenty-eight patients receiving mechanical ventilation and continuous infusions of sedative drugs in a medical intensive care unit . Interventions : None . Measurements and Main Results : We performed a blinded , retrospective evaluation of the data base from our previous trial of 128 patients r and omized to daily interruption of sedative infusions vs. sedation as directed by the medical intensive care unit team without this strategy . Seven distinct complications associated with mechanical ventilation and critical illness were identified : a ) ventilator-associated pneumonia ; b ) upper gastrointestinal hemorrhage ; c ) bacteremia ; d ) barotrauma ; e ) venous thromboembolic disease ; and f ) cholestasis or g ) sinusitis requiring surgical intervention . The incidence of complications was evaluated for each patient ’s hospital course . One hundred twenty-six of 128 charts were available for review . Patients undergoing daily interruption of sedative infusions experienced 13 complications ( 2.8 % ) vs. 26 ( 6.2 % ) in those subjected to conventional sedation techniques ( p = .04 ) . Conclusions : Daily interruption of sedative infusions in critically ill patients undergoing mechanical ventilation reduces intensive care unit length of stay and , in turn , decreases the incidence of complications of critical illness associated with prolonged intubation and mechanical ventilation OBJECTIVE To compare a practice of protocol -directed sedation during mechanical ventilation implemented by nurses with traditional non- protocol -directed sedation administration . DESIGN R and omized , controlled clinical trial . SETTING Medical intensive care unit ( 19 beds ) in an urban teaching hospital . PATIENTS Patients requiring mechanical ventilation ( n = 321 ) . INTERVENTIONS Patients were r and omly assigned to receive either protocol -directed sedation ( n = 162 ) or non- protocol -directed sedation ( n = 159 ) . MEASUREMENTS AND MAIN RESULTS The median duration of mechanical ventilation was 55.9 hrs ( 95 % confidence interval , 41.0 - 90.0 hrs ) for patients managed with protocol -directed sedation and 117.0 hrs ( 95 % confidence interval , 96.0 - 155.6 hrs ) for patients receiving non- protocol -directed sedation . Kaplan-Meier analysis demonstrated that patients in the protocol -directed sedation group had statistically shorter duration s of mechanical ventilation than patients in the non- protocol -directed sedation group ( chi-square = 7.00 , p = .008 , log rank test ; chi-square = 8.54 , p = .004 , Wilcoxon 's test ; chi-square = 9.18 , p = .003 , -2 log test ) . Lengths of stay in the intensive care unit ( 5.7+/-5.9 days vs. 7.5+/-6.5 days ; p = .013 ) and hospital ( 14.0+/-17.3 days vs. 19.9+/-24.2 days ; p < .001 ) were also significantly shorter among patients in the protocol -directed sedation group . Among the 132 patients ( 41.1 % ) receiving continuous intravenous sedation , those in the protocol -directed sedation group ( n = 66 ) had a significantly shorter duration of continuous intravenous sedation than those in the non- protocol -directed sedation group ( n = 66 ) ( 3.5+/-4.0 days vs. 5.6+/-6.4 days ; p = .003 ) . Patients in the protocol -directed sedation group also had a significantly lower tracheostomy rate compared with patients in the non- protocol -directed sedation group ( 10 of 162 patients [ 6.2 % ] vs. 21 of 159 patients [ 13.2 % ] , p = .038 ) . CONCLUSIONS The use of protocol -directed sedation can reduce the duration of mechanical ventilation , the intensive care unit and hospital lengths of stay , and the need for tracheostomy among critically ill patients with acute respiratory failure 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 measure the effect of evidence -based intensive care unit ( ICU ) sedation guidelines and interventions by a pharmacist to promote these guidelines on the weaning time from mechanical ventilation and sedation drug cost . DESIGN : Before-after study . SETTING : A 15-bed medical-surgical ICU at a tertiary-care teaching hospital . PATIENTS : 100 patients ( 2 groups of 50 consecutive patients ) on mechanical ventilation ( assist or pressure control mode for ≥6 h ) who were successfully discharged from the ICU . METHODS : ICU sedation guidelines were developed through physician , nursing , and pharmacy consensus using a physician survey and literature overview as points of reference and were implemented into practice . Prospect ively , data on the time required to wean patients from mechanical ventilation ( successful trial of T-piece , pressure support , or intermittent m and atory ventilation leading to extubation ) and total drug costs for sedation were measured and compared between groups . All prospect i ve ICU pharmacist interventions pertaining to sedation were documented . RESULTS : New sedation guidelines promoted lorazepam use in preference to midazolam and suggested propofol for patients not successfully se date d with high-dose lorazepam , haloperidol , or morphine . Over the 2-month collection periods , there was no difference in the median weaning time between the pre- ( 16 h , range 2–607 ) and post- ( 18 h , range 1–284 ) guideline groups . Total sedation drug costs decreased from $ 4515 to $ 1152 ( $ US ) ( p = 0.081 ) . Median sedation drug costs decreased from $ 11.27 ( range $ 0–1340 ) to $ 3.55 ( range $ 0–250 ) , with the amount ( mg ) of midazolam and propofol used decreasing by 86 % and 100 % , respectively . The ICU pharmacist successfully recommended a change from midazolam to lorazepam in 12 of 50 patients , 5 of whom had received midazolam for more than 24 hours . CONCLUSIONS : High compliance with ICU sedation guidelines promoting lorazepam rather than midazolam or propofol in mechanically ventilated patients led to a 75 % decrease in sedation drug costs and did not adversely affect the clinicians ' ability to wean patients from mechanical ventilation Objective : While the use of a protocol to guide sedation and analgesia therapy in the intensive care unit has been shown to improve patient outcomes , compliance is often poor . We hypothesized that a formal , consistent intervention by pharmacists to promote adherence to our institution 's sedation guidelines would improve clinical outcomes . The purpose of this study was to document the impact of daily pharmacist interventions on clinical outcomes of intensive care unit patients prescribed continuous sedative therapy .  Design : Before-after study . Setting : Two medical intensive care units ( total of 18 beds ) at a university medical center . Patients : Patients were 156 mechanically ventilated patients prescribed a continuous infusion of sedative medication while in the medical intensive care unit . Interventions : In the retrospective group , data were collected on all mechanically ventilated patients receiving continuous sedative infusions over a 3-month period . In the prospect i ve group , a pharmacist evaluated all mechanically ventilated patients on continuous sedation daily and made recommendations to adhere to the institution 's previously approved sedation guidelines . Measurements and Main Results : Data were collected for 78 control and 78 intervention patients . The groups were well matched in terms of baseline demographics . The mean duration of mechanical ventilation was reduced from 338 ± 348 hrs ( 14 days ) in the pre-intervention group to 178 ± 178 hrs ( 7.4 days ) in the postintervention group ( p < .001 ) . Duration s of both intensive care unit stay ( 380 ± 325 hrs vs. 238 ± 206 hrs , p = .001 ) and hospital stay ( 537 ± 350 hrs vs. 369 ± 274 hrs , p = .001 ) were also significantly reduced in the post intervention group . Conclusions : The institution of a daily pharmacist-enforced intervention directed at improving sedation guideline adherence result ed in a significant decrease in the duration of mechanical ventilation in patients receiving continuous sedation Objective : To measure the impact of implementation of the systematic evaluation of pain and agitation by nurses  using the Behavioral Pain Scale ( BPS ) , the Numerical Rating Scale ( NRS ) for pain , and the Richmond Agitation Sedation Scale ( RASS ) associated with medical staff education in analgesia and sedation management in intensive care unit ( ICU ) patients . Design : Two-phase , prospect i ve , controlled study . Setting : Twelve-bed medical-surgical ICU in a university hospital . Patients : Consecutive patients staying > 24 hrs in ICU . Interventions :  BPS , NRS , and RASS were measured twice daily , at rest , by independent observers during 21 wks ( control group ) and after 4 wks of training , by nurses during 29 wks ( intervention group ) . In the intervention group , the treating physician was alerted in case of pain defined by BPS > 5 or NRS > 3 or in case of agitation defined by RASS > 1 . Measurements and Main Results : A total of 230 patients were included ( control group , n = 100 ; intervention group , n = 130 ) . Baseline characteristics were not significantly different . The incidence of pain and agitation decreased significantly in the intervention group : 63 % vs. 42 % ( p = .002 ) and 29 % vs. 12 % ( p = .002 ) , respectively . Rate of severe pain and agitation events defined by NRS > 6 and RASS > 2 , respectively , also decreased significantly . There were significantly more therapeutic changes in the intervention group in the way of an escalation but also in the way of a de-escalation for analgesic and psychoactive drugs . Compared with the control group , there was a marked decrease in the duration of mechanical ventilation ( 120 [ interquartile range 48–312 ] vs. 65 ( 24–192 ) hrs , p = .01 ) and nosocomial infections rate ( 17 % vs. 8 % , p < .05 ) in the intervention group . There was no significant difference in median length of stay ( 9 [ 4 , 15 ] vs. 7 [ 4 , 13 ] days ) and mortality in ICU ( 12 vs. 15 % ) . Conclusions : Systematic evaluation of pain and agitation , and analgesics and sedatives need was associated with a decrease in incidence of pain and agitation , duration of mechanical ventilation and nosocomial infections 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 BACKGROUND Approaches to removal of sedation and mechanical ventilation for critically ill patients vary widely . Our aim was to assess a protocol that paired spontaneous awakening trials (SATs)-ie , daily interruption of sedatives-with spontaneous breathing trials ( SBTs ) . METHODS In four tertiary-care hospitals , we r and omly assigned 336 mechanically ventilated patients in intensive care to management with a daily SAT followed by an SBT  ( intervention group ; n=168 )  or with sedation per usual care plus a daily SBT ( control group ; n=168 ) . The primary endpoint was time breathing without assistance . Data were analysed by intention to treat . This study is registered with Clinical Trials.gov , number NCT00097630 . FINDINGS One patient in the intervention group did not begin their assigned treatment protocol because of withdrawal of consent and thus was excluded from analyses and lost to follow-up . Seven patients in the control group discontinued their assigned protocol , and two of these patients were lost to follow-up . Patients in the intervention group spent more days breathing without assistance during the 28-day study period than did those in the control group ( 14.7 days vs 11.6 days ; mean difference 3.1 days , 95 % CI 0.7 to 5.6 ; p=0.02 ) and were discharged from intensive care ( median time in intensive care 9.1 days vs 12.9 days ; p=0.01 ) and the hospital earlier ( median time in the hospital 14.9 days vs 19.2 days ; p=0.04 ) . More patients in the intervention group self-extubated than in the control group ( 16 patients vs six patients ; 6.0 % difference , 95 % CI 0.6 % to 11.8 % ; p=0.03 ) , but the number of patients who required reintubation after self-extubation was similar ( five patients vs three patients ; 1.2 % difference , 95 % CI -5.2 % to 2.5 % ; p=0.47 ) , as were total reintubation rates ( 13.8%vs 12.5 % ; 1.3 % difference , 95 % CI -8.6 % to 6.1 % ; p=0.73 ) . At any instant during the year after enrolment , patients in the intervention group were less likely to die than were patients in the control group ( HR 0.68 , 95 % CI 0.50 to 0.92 ; p=0.01 ) . For every seven patients treated with the intervention , one life was saved ( number needed to treat was 7.4 , 95 % CI 4.2 to 35.5 ) . INTERPRETATION Our results suggest that a wake up and breathe protocol that pairs daily spontaneous awakening trials ( ie , interruption of sedatives ) with daily spontaneous breathing trials results in better outcomes for mechanically ventilated patients in intensive care than current st and ard approaches and should become routine practice Objective : To compare duration of mechanical ventilation for patients r and omized to receive lorazepam by intermittent bolus administration vs. continuous infusions of propofol using protocol s that include scheduled daily interruption of sedation . Design : A r and omized open-label trial enrolling patients from October 2001 to March 2004 . Setting : Medical intensive care units of two tertiary care medical centers . Patients : Adult patients expected to require mechanical ventilation for > 48 hrs and who required ≥10 mg of lorazepam or a continuous infusion of a sedative to achieve adequate sedation . Interventions : Patients were r and omized to receive lorazepam by intermittent bolus administration or propofol by continuous infusion to maintain a Ramsay score of 2–3 . Sedation was interrupted on a daily basis for both groups . Measurements and Main Results : The primary outcome was median ventilator days . Secondary outcomes included 28-day ventilator-free survival , intensive care unit and hospital length of stay , and hospital mortality . Median ventilator days were significantly lower in the daily interruption propofol group compared with the intermittent bolus lorazepam group ( 5.8 vs. 8.4 , p = .04 ) . The difference was largest for hospital survivors ( 4.4 vs. 9.0 , p = .006 ) . There was a trend toward greater ventilator-free survival for patients in the daily interruption propofol group ( median 18.5 days for propofol vs. 10.2 for lorazepam , p = .06 ) . Hospital mortality was not different . Conclusions : For medical patients requiring > 48 hrs of mechanical ventilation , sedation with propofol results in significantly fewer ventilator days compared with intermittent lorazepam when sedatives are interrupted daily Objective : To determine physician and nurse adherence with sedative , analgesic , and neuromuscular blocking agent guidelines in the management of mechanically ventilated patients in a medical intensive care unit . Design : Prospect i ve cohort study . Subjects : One hundred consecutively admitted patients to a medical intensive care unit who required mechanical ventilatory support . A sample of 29 nurses , residents , and attending physicians were interviewed regarding their attitudes and perceptions of the guidelines . Measurement : Data were collected from concurrent medical records and included the following : demographic characteristics ; clinical variables ; physician prescriptions of sedative , analgesic , and /or neuromuscular blocking agents ; nurse administration of these medications ; documentation of monitoring ; and assessment of patient hemodynamic status and behaviors . A semistructured interview was elicited from both nurses and physicians about their rationale for the use or nonuse of the guidelines . Results : Patients ranged in age from 24 to 87 yrs , mean 60.7 ( ±15.3 ) yrs .  Admission Acute Physiology and Chronic Health Evaluation III scores ranged from 36 to 192 , mean 93.8 ( ±30.5 ) and median 88 . Length of mechanical ventilatory support ranged from 1 to 112 days , mean 14.8 ( ±20.0 ) days , and median 8 days ; medical intensive care unit length of stay ranged from 1 to 46 days , with a mean of 9.8 ( ±8.1 ) days and a median of 8 days . Of the 100 patients , 47 % died , 28 % returned home , and 25 % were discharged to a nursing facility . Eighty‐five patients were administered one or more sedative , analgesic , and /or neuromuscular blocking agent , range 1‐9 drugs , mean 2.5 ( ±1.5 ) drugs . Physicians prescribed 14 different medications ; the most commonly administered drug was lorazepam ( n = 71 ) , followed by morphine ( n = 39 ) . Physicians and nurses had partial or total adherence to the guidelines in 58 % of patients . The initial choice of the drug followed the guidelines in 60 % of patients ; the overall guideline was followed in 23 % of patients . The most common rationale s for nonadherence to the guidelines stated by both physicians and nurses were patient‐specific factors , resident guideline learning curve , and physician medication preferences . Conclusion : Most patients required treatment for agitated behaviors . The majority of treatment regimens partially or totally adhered to the guidelines . Factors such as patient‐specific disease states , resident guideline learning curve , and physician preferences of medications may have decreased adherence . Improving adherence to the guidelines is essential to assess their effectiveness in improving clinical outcomes 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 The aim of this prospect i ve r and omised controlled trial was to assess the effectiveness of the Bispectral Index ( BIS ) monitor in supporting clinical sedation management decisions in mechanically ventilated intensive care unit patients . Fifty adult mechanically ventilated surgical and general intensive care unit patients receiving sedative infusions of morphine and midazolam  were r and omly allocated to receive BIS monitoring ( n=25 ) or st and ard sedation management ( n=25 ) . In the BIS group , sedation was titrated to maintain a BIS value of greater than 70 . In the st and ard management group , sedative needs were titrated based on subjective assessment and clinical signs . There was no statistically significant difference in the amount of sedation administered  ( morphine P = 0.67 and midazolam P = 0.85 ) . However , there was a statistically significant difference in sedation administration over time . Patients in the BIS group received increasing amounts of sedation over time whilst those in the control group received decreasing amounts of sedation over time . The same inverse relationship existed for both sedative agents ( morphine P=0.005 , midazolam P=0.03 ) . Duration of mechanical ventilation was comparable in the two groups . We conclude that the use of BIS monitoring did not reduce the amount of sedation used , the length of mechanical ventilation time or the length of ICU stay Objective To determine the cost-effectiveness and safety of a set of rational use guidelines for analgesia , sedation , and neuromuscular blockade in critically ill ventilated patients when compared with similar factors in st and ard prescribing . Design Prospect i ve cost-benefit analysis . Setting Medical and surgical intensive care units ( ICU ) of a 350-bed tertiary care university hospital . Patients Patients admitted to our ICUs who required mechanical ventilation and continuous analgesics , sedatives , and /or neuromuscular junction blockers ( NMJBs ) .  There were 72 patients in the baseline and 84 patients in the follow-up groups . Interventions Prospect i ve tracking of eligible baseline patients was followed by the development and introduction of guidelines and an academic detailing process to promote the use of guidelines . Several months after the introduction of guidelines , a second group of eligible follow-up patients was tracked . The use and effectiveness of analgesics , sedatives , and NMJBs  , as well as cost and outcomes , were followed in both groups . Data were subsequently review ed and analyzed . Measurements and Main Results We recorded data by means of Paradox and Excel data bases and included demographics , costs , outcomes ( including adverse drug reactions , functional status , ventilator time in hours , lengths of stay ) , and mortality rates . Data were subsequently analyzed via the Winks statistical data analysis program . Both groups were similar with regard to demographics . There was a statistically significant increase in severity of illness in the follow-up group without a statistically significant increase in mortality . Direct drug costs , ventilator time , and lengths of stay were reduced in the follow-up group . In addition , the use of NMJBs was reduced from 30 % in the baseline group to 5 % in the follow-up group . Conclusions Rational use guidelines result ed in safe , cost-effective improvements in the provision of continuous analgesia , sedation , and neuromuscular blockade to critically ill patients requiring ventilator management when compared with similar factors in baseline prescribing strategies INTRODUCTION Sedation protocol s have demonstrated effectiveness in improving ICU sedation practice s. However , the importance of multifaceted multidisciplinary approach on the success of such protocol s has not been fully examined . METHODS The study was conducted in a tertiary care medical-surgical ICU as a prospect i ve , 4-pronged , observational study describing a quality improvement initiative that employs 2 types of controlled comparisons : a " before and after " comparison related to intense education of ICU clinicians and nurses about sedation and analgesia in the ICU , and a comparison of protocol ized versus non- protocol ized care . Patients were assigned alternatively to receive sedation by a goal -directed protocol using the Riker Sedation-Agitation Scale ( SAS ) or by st and ard practice . A multifaceted multidisciplinary educational program was initiated including the use of point of use reminders , directed educational efforts , and opinion leaders . This included several lectures and in-services and the routine availability of at least one member of this group to answer questions . We included all consecutive patients receiving mechanical ventilation , who were judged by their treating team to require intravenous sedation .  MEASUREMENTS AND MAIN RESULTS The following data was collected : demographics , Acute Physiology and Chronic Health Evaluation ( APACHE ) II score and Simplified Acute Physiology score ( SAPS ) II , daily doses of analgesics and sedatives , duration of mechanical ventilation , ICU length of stay ( LOS ) and ventilator associated pneumonia ( VAP ) incidence . To examine the effect of the multifaceted multidisciplinary approach , we compared the first 3 months to the second 3 months in the following 4 groups : G1 no protocol group in the first 3 months , G2 protocol group in first 3 months , G3 no protocol group in the second 3 months , G4 protocol group in the second 3 months . After ICU day 3 , SAS in the groups G2 , G3 and G4 became higher than in G1 reflecting " lighter " levels of sedation . There were significant reductions in the use of analgesics and sedatives in the protocol group after 3 months . This was associated with a reduction in VAP rate and trends towards shorter mechanical ventilation duration and hospital length of stay ( LOS ) . CONCLUSIONS The implementation of a multifaceted multidisciplinary approach including the use of point of use reminders , directed educational efforts , and opinion leaders along with sedation protocol led to significant changes in sedation practice s and improvement in patients ' outcomes . Such approach appears to be critical for the success of ICU sedation protocol Objective To determine the effect of an institutional approach to the care of patients requiring mechanical ventilation for longer than three consecutive days in five adult intensive care units ( ICU ) on clinical and financial outcomes . Design A multidisciplinary team was selected from five adult ICUs to design the approach . Planning occurred from August 1999 to September 2000 . The process was called outcomes management ( OM ) and included an evidence -based clinical pathway , protocol s for weaning and sedation use , and the selection of four advanced practice nurses ( called outcomes managers ) to manage and monitor the program . Setting The project was completed in a 550-bed mid-Atlantic academic medical center . The ICUs included the following : coronary care , medical ICU , neuroscience ICU , surgical trauma ICU , and thoracic cardiovascular ICU . Patients The sample included 595 pre-OM patients and 510 post-OM patients mechanically ventilated for greater than three consecutive days . Interventions Full implementation of the OM approach occurred in March 2001 . Retrospective baseline ( 18 months pre-OM ) and prospect i ve ( 12 months OM ) clinical and financial data were compared . Measurements and Main Results Statistically significant differences in clinical outcomes were demonstrated in the managed patients compared with those managed before the institutional approach . Outcomes include ventilator duration ( median days declined from ten to nine ; p = .0001 ) , ICU length of stay ( median days declined from 15 to 12 ; p = .0008 ) , hospital length of stay ( median days declined from 22 to 20 ; p = .0001 ) , and mortality rate ( declined from 38 % to 31 % , p = .02 ) . More than $ 3,000,000 cost savings were realized in the OM group . Conclusions This institutional approach to the care of patients ventilated > 3 days improved all clinical and financial outcomes of interest . To date , few similar initiatives have demonstrated similar results . The approach and lessons learned in this process improvement project may be helpful to other institutions attempting to improve outcomes in this vulnerable population STUDY OBJECTIVE To compare empiric and protocol -based therapies of sedation and analgesia in terms of pharmacologic cost , effects on mechanical ventilation and intensive care unit ( ICU ) stay , and quality of sedation and analgesia . DESIGN Prospect i ve study . SETTING A 24-bed medical-surgical-neurologic ICU . PATIENTS Seventy-two patients evaluated during empiric therapy and 86 during protocol -based therapy .  INTERVENTION Assessment of data collected for 4 months before and 5 months after an evidence -based sedation and analgesia protocol was implemented . MEASUREMENTS AND MAIN RESULTS Protocol adherence rate was 83.7 % . The hourly cost ( Canadian dollars ) of sedation was less with protocol -based therapy ( $ 5.68 + /- 4.27 vs $ 7.69 + /- 5.29 , p<0.01 ) likely due to increased lorazepam use . Pharmacologic cost savings may be negated since sedation duration tended to be longer ( 122.7 + /- 142.8 vs 88.0 + /- 94.8 hrs , p<0.1 ) and extubation may have been delayed ( 61.6 + /- 97.4 vs 39.1 + /- 54.7 hrs , p=0.13 ) with protocol use . Duration of ICU stay after sedation was discontinued was not significantly different before and after protocol implementation . With the protocol , however , the percentage of modified Ramsay sedation scores representing discomfort decreased from 22.4 to 11 % ( p<0.001 ) and the percentage at a score of 4 increased from 17.2 % to 29.6 % ( p<0.01 ) . The percentage of modified visual analog measurements representing pain decreased from 9.6 to 5.9 % ( p<0.05 ) with the protocol . When data were stratified according to duration of sedation , the benefits and delayed extubation associated with protocol -based therapy were limited to patients requiring long-term sedation . CONCLUSION Compliance with this protocol reduced drug costs and enhanced the quality of sedation and analgesia for patients requiring long-term sedation . Protocol -based therapy with lorazepam may have delayed extubation but did not delay ICU discharge
Introduction Patients in intensive care units ( ICUs ) often receive sedation for prolonged periods .
In order to better underst and the impact of sub-optimal sedation practice on outcomes , we performed a systematic review , including observational studies and controlled trials which were conducted in se date d patients in the ICU and which compared the impact of changes in or different protocol s for sedation management on economic and patient safety outcomes .