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Sedative Selection in the ICU: Advantages and Potential Pitfalls FREE TO VIEW

Steven Campbell; Naeem Ali; Jessica Kynyk; Matthew Exline
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Ohio State University, Columbus, OH

Chest. 2014;146(4_MeetingAbstracts):723A. doi:10.1378/chest.1987490
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SESSION TITLE: Hot Topics in Pulmonary & Critical Care

SESSION TYPE: Original Investigation Slide

PRESENTED ON: Sunday, October 26, 2014 at 01:30 PM - 03:00 PM

PURPOSE: The efficacy of protocol-directed sedation regimens for adults in the ICU is well established. Propofol provides effective sedation with a more rapid and predictable emergence time than benzodiazepines, and is associated with shorter duration of mechanical ventilation. However, there is a paucity of data examining the impact of sedation medication choices in an ICU environment. Our objective was to determine if different sedation regimens had any impact with respect to total time on a ventilator, performing dose optimization, and achieving target Richmond Agitation Sedation Scale (RASS) scores. We also looked at failed extubation rates by sedative choice.

METHODS: Over a ten month period all mechanically ventilated patients at a tertiary care academic hospital had quality data abstracted. Continuous sedation regimen was logged (benzodiazepine, narcotic, or propofol). They were evaluated for sedation optimization/interruption trials and time at goal RASS.

RESULTS: 988 intubated patients representing 6359 patient-days of which 3245 patients-days featured the use of a continuous sedative drip. 2087 (64%) patient-days were on a regimen containing propofol, 819 (25%) had a benzodiazepine, and 1648 (51%) had a narcotic (patients could be on multiple drips). When compared to benzodiazepine and narcotic drips, eligible patients on a propofol based regimen were more likely to have protocol-directed dose optimization (92% versus 79% and 78% respectively, p<0.0001) and fewer ventilator days (3.5±0.5 versus 5.2±0.9 and 5.9±0.7, p<0.0001). Patients on propofol and narcotic drips were more likely to be at targeted RASS levels compared to benzodiazepine drips (37% and 43% respectively versus 21.5%, p<0.0001). There were a total of 953 extubations, of patients receiving continuous sedation on day of extubation 68 (7.1%) failed within 48 hours, 32 (47%, p=0.01) were on propofol alone.

CONCLUSIONS: Patients treated with a propofol based regimen were more likely to be dose optimized, at their target RASS, and extubated sooner. However, being on a sedation regimen containing propofol at time of extubation puts patients at a significantly higher risk of being re-intubated. This could be a selection bias as these patients were less sedated and perhaps more likely to be extubated early, or this could be due to an effect of propofol altering respiratory physiology.

CLINICAL IMPLICATIONS: As we move towards propofol based sedation regimens, further studies are needed to assess its potential impact on failing extubation.

DISCLOSURE: The following authors have nothing to disclose: Steven Campbell, Naeem Ali, Jessica Kynyk, Matthew Exline

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