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Daily interruption of sedative infusions and complications of critical illness in mechanically ventilated patients. Critical Care Med 2004 Vol.32 No.6 R3 曾耀賢. Critical patients /c MV: frequent require sedation and analgesia BZD, propofol and Haldol for sedation Opiates for analgesia

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Daily interruption of sedative infusions and complications of critical illness in mechanically ventilated patients


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Daily interruption of sedative infusions and complications of critical illness in mechanically ventilated patients

Critical Care Med 2004 Vol.32 No.6

R3 曾耀賢

slide2
Critical patients /c MV: frequent require sedation and analgesia
    • BZD, propofol and Haldol for sedation
    • Opiates for analgesia
  • However, the strategies of these drugs are variable
    • Developed protocol to minimize detrimental effects of overdose or accumulation
  • Daily interruption of continuous sedation
    • Daily interruption until patients was awake
    • Reduction of average duration of MV: 2.4 days
    • Reduction in average ICU length of stay: 3.5 days
slide3
Daily interruption of sedation
    • MV and critical illness: more easy to cause nosocomial complications (VAP)
    • Long duration of MV & ICU LOS: more complications of critical illness
    • Seven complications:
      • Ventilator-associated pneumonia
      • Upper gastrointestinal hemorrhage
      • Bactremia
      • Barotrauma
      • Venous thromboembolic disease
      • Cholestasis
      • Sinusitis

Determine whether the strategy was associated with a reduction in these complications

methods
Methods
  • Patients and Study Design
    • From database of our previous published, prospective, randomized-controlled study
    • 128 patients database: provided to investigator to evaluate and ensure accurate assignment
    • Investigator were not involved in original study; no documentation of study was present; all charts were reviewed independently
methods5
Methods
  • Data Collection and Definition of Variables
    • Demographic data
      • Age, gender, BW, Acute physiology & chronic healthy evaluation II severity of illness score
    • Use of a ventilator strategy utilizing permissive hypercapnia
      • Hypoventilation to allow Pco2 ≧ 50mmHg
    • ICU LOS
    • Duration of mechanical ventilation
methods6
Methods
  • Data Collection and Definition of Variables
    • To establish the presence of the identified seven complications associated with MV & clinical illness
      • Predefined clinical criteria
      • Complications were selected based on
        • Clinical importance
        • Frequency
        • Reliability of disclosure from a retrospective chart review
        • Complications: required to be new & distinct
methods7
Methods
  • Data Collection and Definition of Variables
    • Ventilation associated pneumonia:
      • new lung opacity,
      • ≧2 criteria (BT <36 or >38℃; WBC <4K or >10K; purulent secretion)
    • UGI bleeding:
      • confirm by UE; mesenteric angiography;
      • combination of grossly visualized blood from NG and subsequent blood transfusion
methods8
Methods
  • Data Collection and Definition of Variables
    • Bacteremia:
      • positive blood culture;
      • positive of CNS required serial demonstration
    • Barotrauma:
      • pneumothorax requiring chest tube insertion
    • Venous thromboembolic disease
      • Venous thrombosis by Doppler, venography, infused CT
methods9
Methods
  • Data Collection and Definition of Variables
    • Pulmonary embolus
      • Proven by pulmonary angiogram, infused spiral CT
    • Cholestasis
      • Elevated ALKP, Bil T; imaging study; need for procedural intervention
    • Sinusitis
      • Gross purulence from nares or sinus fluid present
      • Sinus CT scan and subsequent endoscopic drainage
methods10
Methods
  • Data Collection and Definition of Variables
    • Deep venous thrombosis prophylaxis was defined as
      • Daily administration of subcutaneous unfractionated or LMWH or
      • Intermittent pneumatic compression devices for period ≧75% of time spent in the ICU
    • Stress ulcer prophylaxis was defined as
      • Daily PPI, H2 blocker or sucralfate for period ≧75% of time spent in the ICU
results
Results
  • 126 patients had medical records available
    • 66 patients in the sedative interruption group
    • 60 patients in the control group
results13
Results
  • Similar in the two groups
    • Demographic characteristic
    • Acute physiology and chronic healthy evaluation II scores
    • Frequency of use of permissive hypercapnia ventilation strategy
results14
Results
  • Incidence of prophylaxis is similar
    • Deep venous thrombosis prophylaxis
      • 90.2 % in daily sedation interruption group
      • 92.5 % in the control group
      • p = 1.0
    • Gastric stress ulcer prophylaxis
      • 90.5 % in daily sedation interruption group
      • 96.3 % in the control group
      • p = 1.0
results15
Results
  • Outcome
    • After blinded assessment for all complications
      • Sedative interruption group experienced
        • 13 complications in 12 patients (2.8%)
      • Control group experienced
        • 26 complications in 19 patients (6.2%)
      • p = 0.04 (generalized estimating equation)
results16
Results
  • Outcome
    • Six of the seven complications

occurred more

frequently in

control group

results17
Results
  • Kaplan-Meier analysis of time from intubation or from ICU admission to first complication
discussion
Discussion
  • Pain and anxiety are common among patients in ICU, it may be attributed to
    • Discomfort of procedures (intubation, MV)
    • Isolation from familiar surroundings
    • Lack of control or autonomy
    • Uncertainty regarding prognosis
discussion20
Discussion
  • Sedatives and analgesics are frequently administered during MV
    • Alleviate pain and anxiety
    • Decrease excessive oxygen consumption
    • Facilitate nursing care
  • So, bedside nursing role of careful monitoring of sedatives and analgesia in extremely important
discussion21
Discussion
  • The use of sedation protocols mandating daily interruption of continuous infusions or a nursing-directed protocol targeting
    • Reduction in sedative dosing  shorten duration of MV & ICU LOS
    • Such reductions in sedation without increasing adverse events (removal of ETT or CVP)
discussion22
Discussion
  • Determine whether a protocol of daily interruption of sedative infusion affect incidence of common complications
  • Complications are routinely studied individually
  • study complications in aggregate  create a risk of possible interrelationship not immediately recognized
  • Comparison between groups was analyzed using the general estimating equation
    • Permits comparisons of the sum of complications while accounting for the possibility of interrelationships between multiple complications among individual patients
discussion23
Discussion
  • Kaplan-Meier curves: data for the time to first complication
    • Disparity later in the ICU course  more ICU time, more increase the chance of complication
    • Unlike general estimating equation: evaluate the sum of all complications & potential interrelationship
    • K-M curve evaluate only the first complication in each patient

 No differences between these two group

discussion24
Discussion
  • Some complications (VAP) have been clearly linked to duration of MV
    • Cook et al.: cumulative risk of VAP increase over time, risk of VAP per day
      • 3.3% at MV day 52.3% at day 101.3% at day 15
    • Bacteremia: associated with venous catheters
      • More present when intubation and MV
      • Understandable if higher rate in control group
discussion25
Discussion
  • Critical patients are frequent immobilized
    • Subjected to procedures involving invasive instrument
    • More venous thromboembolic events, even prophylaxis
  • At least 4 complications: direct result of invasive instrumentation
    • Bacteremia (venous catheters)
      • Shorten duration of MV & ICU LOS  reduce the need and duration of venous catheter placement
    • VAP (endotracheal intubation)
discussion26
Discussion
  • At least 4 complications: direct result of invasive instrumentation
    • Barotrauma
      • Reducing intubation time  reduce incidence?
      • Lacking convincing data to support
    • Iatrogenic pneumothorax during central catheter placement
    • NG and supine positioning  sinusitis

 Shortening ventilator and ICU time  decrease the need for these invasive devices

discussion27
Discussion
  • This study has limitations worth nothing
    • Described complications were not prospectively defined and followed in the original investigation
    • To minimized bias
      • Database was reviewed blinded
      • Investigators had never seen the database before this study
    • Didn’t prospectively seek to identify complications in the original study
      • Possible some were undetected
      • However, potential difference in incidence of undetected complications seed unlikely
discussion28
Discussion
  • Many of complications are routinely sought, or
  • Only identified by the need for an intervention
    • Barotrauma leading to chest tube placement
    • Cholecystitis or sinusitis leading to surgery
  • Further reducing the likelihood of underrecognition of these complications
  • Retrospective evaluation based on medical chart
    • Inherent limitations
    • in CVP manipulation or MV setting: not reliably
conclusion
Conclusion
  • Common complications of critical illness reduce
    • when intubated, mechanically ventilated patients by protocol of daily sedative interruption
    • Improved outcomes are likely the result of reduced duration of MV and ICU LOS