Loading in 2 Seconds...
Loading in 2 Seconds...
Sedation Algorithm in Critically Ill Patients without Acute Brain Injury Critical Care Medicine 2005; 33 (1): 120-127.
Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.
Bernard De Jonghe, MD; Sylvie Bastuji-Garin, MD, PhD; Pascal Fangio, MD; Jean-Claude Lacherade, MD; Julien Jabot, MD; Corinne Appere-De-Vecchi, MD; Nathalie Rocha, RN; Herve Outin, MD.
Medical Intensive Care Unit, Poissy Hospital, Poisse France (BDJ, PF, JCL, JJ, CADV, NR, HO) and the Public Health Department, University of Paris XII, Henri Mondor Hospital (AP-HP), Creteil, France (SBG)
1. Assess the impact of a sedation algorithm, designed to promote high level consciousness, on the duration of mechanical ventilation.
2. Examine the relationship between the time to arousal after initiation of mechanical ventilation and the duration of mechanical ventilation.
Patients 16 years.
Requiring mechanical ventilation for 24 hours.
Acute brain injury (acute stroke, head trauma, acute encephalitis, cardiac arrest).
Transfer from another ICU.
Chronic mechanical ventilation.
Peripheral nervous system.
Time of arousal after initiation of mechanical ventilation measure by eye opening, monitored every morning. First day patients were able to open eyes either spontaneously or on verbal request for at least 2 consecutive days. Care givers blinded to result.
Mechanical ventilator weaning criteria: no longer had high grade fever, did not require catecholamines (except low dose dopamine or dobutamine), FIO2<50%, PEEP 5 cm H2O, and consciousness not severely altered.
Sedatives and analgesics were adjusted according to the decision of experiences MD or RN.
Sedatives and analgesics were adjusted by MD or RN according to an algorithm designed to achieve tolerance to the ICU environment and maintain high level of consciousness.
Midazolam and Fentanyl
Adaptation To Intensive Care Environment (ATICE)-based Sedation and Analgesia Algorithm. ATICE is measured every 3 hrs, except at night in patients with satisfactory consciousness at the end of the day. ATICE is measured more frequently in patients with worsening tolerance. The algorithm is not applied while patients are receiving neuromuscular blockers, in the prone positioning, or after an end-of-life decision has been made. IV, intravenous; VAS, visual analog scale; , increase drug dosage; , decrease drug dosage, *stricter objectives of tolerance (calmness=3, ventilator synchrony=4) may be transiently used in patients with severe acute respiratory of circulatory failure; †, during the initial 48-hr postoperative period, do not decrease fentanyl dose under 50-100 g/hr.
Age, Gender, SAPS II score w/in 24 hours of admission.
Day and time of start and end of mechanical ventilation.
Acute diagnosis, presence of LV failure, sepsis, acute renal failure, COPD.
Total daily dose fentanyl and midazolam and use of other opioids or sedation medications.
Tracheostomy, self-extubation, pressure sores, surgery, VAP.
Duration of mechanical ventilation.
Time to arousal after initiation of mechanical ventilation, ICU LOS, total medication doses, occurrence of side effects associated with over/under sedation.
Kaplan-Meier for duration of mechanical ventilation, time to arousal, ICU LOS.
Log-rank test to compare algorithm and control patients and to analyze the influence of a priori selected co-variates on mechanical ventilation duration and time to arousal. If p<0.2, multivariate Cox proportional-hazards model to in influencing independent variable.
Chi-square and Fisher’s Exact Test for categorical variables.
Mann-Whitney test for quantitative variables.
102 patients enrolled in the study
54 control group
48 algorithm group
No differences in baseline characteristics:
Conditions for extubation, except:
Highest FIO2in last 24 hours was higher in control group (38 ± 6%) vs., algorithm group (36 ± 7%) p=0.05.
Figure 2. Kaplan-Meier representation of duration of mechanical ventilation in algorithm and control patients. Mechanical ventilation was significantly shorter in the algorithm group (4.4 days [2.1-9.8]) than in the control group (10.3 days [3.5-17.2], p=0.014).
In multivariate analysis, independent predictors of duration of mechanical ventilation included:
1. Use of the algorithm
2. Presence of underlying COPD
4. Renal failure
0.48 (0.29-0.78) lower relative risk of remaining of mechanical ventilation
ICU LOS (d) 8.0 (4.0-18.1) vs. 15.0 (6.4-24.0) p=0.043
to arousal(d) 2 (2-5) vs. 4 (2-9) p=0.006
Pressure sores 9 (18.6%) vs. 20 (37.0%) p=0.04
VAP 4 (8.3%) vs. 11 (20.4%) p=0.10
Figure 3. Duration of mechanical ventilation (median, 25th and 75th percentiles) according
to time to arousal after initiation of mechanical ventilation. Time to arousal was significantly
associated with duration of mechanical ventilation (p<0.001).
Control Algorithm p Value
Daily dosage of M (mg) per day of MV, mean ± SD 79.1±52.7 55.7±45.7 0.007
Cumulative dosage of M (mg), mean ± SD 627±808 295±507 0.015
Duration in days of M administration, median (IQR) 4 (2-9) 3 (2-6) 0.12
Daily dosage of F (g) per day MV, mean ± SD 2189 ± 1744 2233 ± 1201 0.29
Cumulative dosage of F (g), mean ± SD 19834 ± 31315 13135 ± 21429 0.57
Duration in days of F administration, median (IQR) 4 (1-10) 3 (1-7) 0.18
MV, mechanical ventilation; IQR, interquartile range; M, midazolam; F, fentanyl.