Favorable Outcomes After Implementing a Nurse-Driven Sedation Protocol

Background In patients receiving mechanical ventilation, prolonged exposure to sedative and analgesic medications contributes to negative clinical outcomes. Objective To reduce exposure to sedative and analgesic medications among patients receiving mechanical ventilation by implementing a nurse-driven sedation protocol. Methods This quality improvement project followed a plan-do-study-act cycle. Nurses were educated on the protocol, and 30 patient medical records were reviewed both before and after protocol implementation. Data were extracted on intensive care unit length of stay, duration of mechanical ventilation, duration of continuous sedation, presence of delirium, pain, level of sedation, and performance and documentation of spontaneous awakening trials. Data were analyzed using descriptive statistics, the χ2 test, and calculated percent change. Results Forty-four nurses completed protocol education. The mean (SD) duration of mechanical ventilation decreased by 26% (from 5 [3.7] days to 3.7 [3.2] days), and the mean (SD) intensive care unit length of stay decreased by 27% (from 6.3 [4.3] days to 4.6 [3.7] days). The mean (SD) duration of continuous sedation decreased by 35% (from 6419 [7241] minutes to 4178 [4507] minutes). Spontaneous awakening trials documented increased by 35% (from 57% to 77%), and spontaneous awakening trials performed increased by 92% (from 40% to 77%), a statistically significant change (P = .004). Conclusion These preliminary data suggest that implementation of a nurse-driven sedation protocol resulted in favorable outcomes by decreasing duration of mechanical ventilation, intensive care unit length of stay, and duration of continuous sedation and increasing the number of spontaneous awakening trials performed.

Impact of Propofol Bolus Administration on the Nociceptive Flexion Reflex Threshold and Bispectral Index in Children—A Case Series

We analyzed the impact of propofol administration during continuous sedation and analgesia on the nociceptive flexion reflex threshold (NFRT) and Bispectral Index (BIS) in ventilated children. We examined patients who received propofol before planned endotracheal suctioning. Patients were clinically assessed using the modified Face, Legs, Activity, Cry, Consolability (mFLACC) scale and COMFORT-B (Comfort Behavior) scale. We continuously recorded the NFRT and BIS. We recorded 23 propofol administrations in eight patients with an average age of 8.6 ± 3.5 years. The median (minimum-maximum) scores for the mFLACC scale and COMFORT-B scale were 0 (0–5) and 6 (6–17), respectively, before the bolus. The administration of a weight-adjusted propofol bolus of 1.03 ± 0.31 mg/kg resulted in an increase in NFRT and burst-suppression ratio; BIS and electromyogram values decreased. Changes from baseline (95% CI) after propofol bolus administration were BIS −23.9 (−30.8 to −17.1), EMG -10.5 dB (−13.3 to −7.7), SR 14.8 % (5.6 to 24.0) and NFRT 13.6 mA (5.5 to 21.7). Further studies are needed to determine whether sedated children may benefit from objective pain and sedation monitoring with BIS and NFRT.

Role of sleep on respiratory failure after extubation in the ICU

Background Sleep had never been assessed immediately after extubation in patients still in the ICU. However, sleep deprivation may alter respiratory function and may promote respiratory failure. We hypothesized that sleep alterations after extubation could be associated with an increased risk of post-extubation respiratory failure and reintubation. We conducted a prospective observational cohort study performed at the medical ICU of the university hospital of Poitiers in France. Patients at high-risk of extubation failure (> 65 years, with any underlying cardiac or lung disease, or intubated > 7 days) were included. Patients intubated less than 24 h, with central nervous or psychiatric disorders, continuous sedation, neuroleptic medication, or uncooperative were excluded. Sleep was assessed by complete polysomnography just following extubation including the night. The main objective was to compare sleep between patients who developed post-extubation respiratory failure or required reintubation and the others. Results Over a 3-year period, 52 patients had complete polysomnography among whom 12 (23%) developed post-extubation respiratory failure and 8 (15%) required reintubation. Among them, 10 (19%) had atypical sleep, 15 (29%) had no deep sleep, and 33 (63%) had no rapid eye movement (REM) sleep. Total sleep time was 3.2 h in median [interquartile range, 2.0–4.4] in patients who developed post-extubation respiratory failure vs. 2.0 [1.1–3.8] in those who were successfully extubated (p = 0.34). Total sleep time, and durations of deep and REM sleep stages did not differ between patients who required reintubation and the others. Reintubation rates were 21% (7/33) in patients with no REM sleep and 5% (1/19) in patients with REM sleep (difference, − 16% [95% CI − 33% to 6%]; p = 0.23). Conclusions Sleep assessment by polysomnography after extubation showed a dramatically low total, deep and REM sleep time. Sleep did not differ between patients who were successfully extubated and those who developed post-extubation respiratory failure or required reintubation.

A systematic review of quality improvement initiatives for continuous sedation until death

Background: Extensive debate surrounds the practice of continuous sedation until death within end-of-life care. Aim: To provide insight into existing initiatives to support the practice of continuous sedation until death and assess their feasibility and effectiveness. Design: Systematic review and narrative synthesis, registered on PROSPERO (CRD42020149630). Data sources: Records were searched through MEDLINE, EMBASE, CENTRAL, CINAHL, and Web of Science from inception to April 16 2020. Peer-reviewed studies reporting original data on initiatives to support the practice of continuous sedation were included for review. Results: Twenty-one studies met the criteria and were included. Initiatives were focused on assessment tools of consciousness and discomfort (9), the use of guidelines and protocols (8), and expert consultation (3). All initiatives were reported as useful, acceptable, and feasible. Studies on the use of monitoring devices showed that a small proportion of patients were found to be awake, despite the patient being unresponsive according to the observer-based sedation scales. However, the wide range of values of these monitoring devices for comfortable and adequately sedated patients seems to hamper its overall implementation in daily clinical practice. Physicians reported changes in practice conform to guideline recommendations but the shift was modest at best. Expert consultation was regarded as supportive when sufficient expertise is lacking and helpful in avoiding possibly unnecessary sedations. Conclusions: The reviewed initiatives may contribute to improvement of continuous sedation until death, though their evidence base is rather limited. More insight is needed into their feasibility, preconditions for effective implementation and impact in actual practice.