Sedation protocol for intubated patients in a medical intensive care unit.
Hanlon K, Onyenekwe J, Peters M, Smoot T, Schuldt S, Swiderek J, DiGiovine B, and Jennings J. Sedation protocol for intubated patients in a medical intensive care unit. Am J Respir Crit Care Med 2018; 197.
Am J Respir Crit Care Med
Critically ill mechanically ventilated patients frequently experience pain, agitation and delirium, requiring the use of a variety of medications including benzodiazepines. However, benzodiazepines are associated with delirium as well as increased morbidity and mortality. In 2013, the American College of Critical Care Medicine published guidelines on the management of pain, agitation and delirium in the intensive care unit (ICU), noting that pain should be treated prior to treating agitation so as to minimize the use of benzodiazepines. However, there is little data validating the recommended approach. The guidelines were used to create a pain, agitation and delirium (PAD) protocol at Henry Ford Hospital. We are now reviewing our experience to assess whether our protocol has reduced benzodiazepine use, days on mechanical ventilation and ICU length of stay (LOS). Methods: We conducted a single-center retrospective analysis of all intubated patients in our medical ICU from January 2014 to June 2016. Patients intubated for > 30 days or who died on the ventilator were excluded. In the pre-protocol (pre) group (January 2014 to October 2015) sedation consisted of both fentanyl and midazolam, either in intermittent dosing or as continuous infusion with daily sedation vacations. Patients in the post-protocol (post) group (October 2015 to June 2016) received fentanyl with midazolam only as rescue. We studied outcomes between these groups including ventilator days, ICU LOS and unplanned extubation rates. Results: We identified a total of 1673 patients, 1057 in the pre group and 616 in the post group. Compared to the pre group, the median total dose of midazolam was significantly lower in the post group (0 mg [CI 0-92] vs 20.3 mg [CI 0-218], p < 0.001), while the total median dose of fentanyl was higher (741 mcg [CI 0-4743] vs 4071 mcg [CI 0-24120], p < 0.001). Delirium was significantly higher in the post group (57% vs 27%, p<0.001), although this was likely related to increased assessment. The decrease in midazolam use did not significantly impact unplanned extubation rates, ventilator days or ICU LOS between the groups. Conclusion: The introduction of a sedation protocol focused on addressing pain, agitation and delirium in mechanically ventilated adult ICU patients significantly decreased benzodiazepine use without increasing adverse outcomes