Introduction of sedation protocol for intubated patients in a medical intensive care unit.
Onyenekwe JC, Hanlon K, Peters M, Smoot CA, Jennings JH, Swiderek JL, and Digiovine B. Introduction of 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. Analgesia and sedation are commonly required for these patients to tolerate mechanical ventilation and invasive procedures. Traditionally, continuous infusions of sedatives, typically benzodiazepines, have been used in this patient population. However, benzodiazepines are associated with delirium as well as increased morbidity and mortality. Limiting sedation has been associated with fewer days on mechanical ventilation, decreased intensive care unit (ICU) length of stay and decreased mortality. No standard of care for the management of sedation in the ICU has been established. In 2013, the American College of Critical Care Medicine published guidelines on the management of pain, agitation and delirium in the ICU. However, there is little data validating the recommended analgesic approach to sedation. These guidelines were used to create our pain, agitation and delirium (PAD) protocol. Our goal was to determine if our protocol led to more consistent pain and delirium assessment. 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 continuous fentanyl with midazolam only as rescue. Our PAD protocol is analgesic centered with medication dosing to maintain Critical Care Pain Observation Tool (CPOT) score of 1-2 starting with intermittent narcotics. Pain scores included the universal pain assessment tool with either a visual analogue scale or Wong-Baker FACES pain rating scale and CPOT. Delirium was assessed with the Confusion Assessment Method for the ICU (CAMICU). Assessment of pain and delirium were compared between groups. 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 mean percentage of ventilator days in which pain was assessed with any tool was significantly higher in the post group (80.4 vs 59.7, p < 0.001). Delirium was also assessed significantly more in the post group (82.1% vs 0.85%, p < 0.001). Conclusion: The introduction of a sedation protocol focused on addressing pain, agitation and delirium in mechanically ventilated adult ICU patients significantly increased the assessment of pain and delirium.