Transcript Sedation Algorithm in Critically Ill Patients without

Sedation Algorithm in Critically Ill
Patients without Acute Brain Injury
Critical Care Medicine 2005; 33 (1): 120-127.
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)
Purpose of the Study
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.
Methods
Study Population
Inclusion Criteria
Patients  16 years.
Requiring mechanical ventilation for  24 hours.
Exclusion criteria
Acute brain injury (acute stroke, head trauma, acute encephalitis,
cardiac arrest).
Transfer from another ICU.
Chronic mechanical ventilation.
Tracheostomy.
Peripheral nervous system.
Moribund State.
Study Design
Control Group
6 months
No Algorithm
9 months
Algorithm
Development
Algorithm group
6 months
Algorithm Implemented
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.
Methods
Control Group
Sedatives and analgesics were adjusted according to the
decision of experiences MD or RN.
Algorithm Group
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.
Medication
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.
Methods
Data Collection
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.
Methods
Statistical analysis
Primary endpoint:
Duration of mechanical ventilation.
Secondary endpoints:
Time to arousal after initiation of mechanical
ventilation, ICU LOS, total medication doses,
occurrence of side effects associated with
over/under sedation.
Methods
Statistical analysis
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 covariates on mechanical ventilation duration and time to
arousal. If p<0.2, multivariate Cox proportionalhazards model to in influencing independent variable.
Chi-square and Fisher’s Exact Test for categorical
variables.
Mann-Whitney test for quantitative variables.
Results
Baseline characteristics
102 patients enrolled in the study
54 control group
48 algorithm group
No differences in baseline characteristics:
Patient demographics
Admission diagnosis
Survival
Conditions for extubation, except:
Highest FIO2 in last 24 hours was higher in control group (38 ±
6%) vs., algorithm group (36 ± 7%) p=0.05.
Results
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).
Results
In multivariate analysis, independent
predictors of duration of mechanical
ventilation included:
1.Use of the algorithm
2. Presence of underlying COPD
3. Sepsis
4. Renal failure
Results
0.48 (0.29-0.78) lower relative risk of remaining of mechanical ventilation
Algorithm
ICU LOS (d)
Median time
to arousal(d)
Pressure sores
VAP
Control
8.0 (4.0-18.1)
vs. 15.0 (6.4-24.0)
p=0.043
2 (2-5)
9 (18.6%)
4 (8.3%)
vs.
vs.
vs.
p=0.006
p=0.04
p=0.10
4 (2-9)
20 (37.0%)
11 (20.4%)
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).
Results
Control
Daily dosage of M (mg) per day of MV, mean ± SD
Cumulative dosage of M (mg), mean ± SD
Duration in days of M administration, median (IQR)
Daily dosage of F (g) per day MV, mean ± SD
Cumulative dosage of F (g), mean ± SD
Duration in days of F administration, median (IQR)
Algorithm
79.1±52.7
55.7±45.7
627±808
295±507
4 (2-9)
3 (2-6)
2189 ± 1744
2233 ± 1201
19834 ± 31315 13135 ± 21429
4 (1-10)
3 (1-7)
MV, mechanical ventilation; IQR, interquartile range; M, midazolam; F, fentanyl.
p Value
0.007
0.015
0.12
0.29
0.57
0.18
Conclusion
• “The use of a sedation algorithm designed
to promote preserved consciousness led to a
marked decrease in the duration of
mechanical ventilation in patients without
brain injury.”