PURPOSE: The critically ill patient often requires invasive procedures and interventions that may be life-saving, yet are distressing and painful. There are broad indications for analgesia and sedation in the intensive care setting. However, the liberal use of such agents can produce negative effects on patient outcomes. Sedation protocols have proven to reduce the duration of mechanical ventilation, length of stay and the need for tracheostomy in ventilated patients. The objective of this study is to explore the impact of a nurse driven sedation protocol versus non-protocolized sedation on total drug used.
METHODS: This is a retrospective analysis of 260 cases from a mixed medical and surgical ICU from July 2008 through May 2009. A sedation protocol was instituted in January 2009 and followed guidelines put forth by the Society of Critical Care Medicine. Run-in time of one month was allowed to encourage better utilization of the protocol. Patients ventilated for more than one day were studied and those needing paralysis, with status epilepticus, and drug or alcohol withdrawal were excluded from analysis. The total doses of sedative and analgesic agent used (narcotics, benzodiazepine and diprivan) per patient were tallied while they were on mechanical ventilation. Total doses were normalized to equivalent doses of morphine and lorazepam based in published pharmacologic potencies of the narcotics and benzodiazepines. Total equivalent doses of medication per vent day were compared before an after the introduction of the sedation protocol.
RESULTS: Overall, there were 24 patients before the sedation protocol and 15 after the protocol who were studied. Total before and after doses for narcotics were 59.3 mg versus 40.6 mg (p value 0.22), for benzodiazepine 8.8 mg versus 6.9 mg (p value 0.28) and for diprivan 899.4 mg versus 359.4 mg (p value 0.09).
CONCLUSIONS: Although the numbers did not reach statistical significance, there was a trend toward less total drug used in the post protocol patients and the reduction in diprivan use closely approached significance. Several other studies have compared continuous infusion versus intermittent dosing head to head with mixed results on outcomes.
CLINICAL IMPLICATIONS: A well-utilized sedation protocol may lead to an overall reduction in sedative and analgesic drug used and this reduction may be the reason for any of the observed benefits. 1.Brook, A.,et al,Crit Care Med,1999 27(12:p.2609-2615 2.Jacobi,J.et al,Crit Care Med,2002 30(1):p.119-146
DISCLOSURE: The following authors have nothing to disclose: Melissa Devlin, Gerardo Carino
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