Skip to main content
Key Specialties
Cardiology Diabetology Endocrinology Gastroenterology Geriatrics and Gerontology Gynecology and Obstetrics Hematology Infectious Disease Internal Medicine Nephrology Neurology Oncology Pediatrics Respiratory Medicine Rheumatology Surgery
Congress Coverage
2024 ACC Congress 2023 ESMO Congress 2023 EASD Congress 2023 ERS Congress 2023 ESC Congress
Clinical Collections
Advances in Alzheimer’s

At a glance: The ONWARDS insulin icodec trials

A round-up of the ONWARDS phase 3 clinical trials evaluating the novel weekly insulin icodec in people with diabetes.
ADVANCED SEARCH
Log in
Top
Critical Care
Published in: Critical Care 4/2014

Open Access 01-08-2014 | Research

Early sedation and clinical outcomes of mechanically ventilated patients: a prospective multicenter cohort study

Authors: Lilian Maria Sobreira Tanaka, Luciano Cesar Pontes Azevedo, Marcelo Park, Guilherme Schettino, Antonio Paulo Nassar Jr, Alvaro Réa-Neto, Luana Tannous, Vicente Ces de Souza-Dantas, André Torelly, Thiago Lisboa, Claudio Piras, Frederico Bruzzi Carvalho, Marcelo de Oliveira Maia, Fabio Poianas Giannini, Flavia Ribeiro Machado, Felipe Dal-Pizzol, Alexandre Guilherme Ribeiro de Carvalho, Ronaldo Batista dos Santos, Paulo Fernando Guimarães Morando Marzocchi Tierno, Marcio Soares, Jorge Ibrain Figueira Salluh, for the ERICC study investigators

Published in: Critical Care | Issue 4/2014

Login to get access

Abstract

Introduction

Sedation overuse is frequent and possibly associated with poor outcomes in the intensive care unit (ICU) patients. However, the association of early oversedation with clinical outcomes has not been thoroughly evaluated. The aim of this study was to assess the association of early sedation strategies with outcomes of critically ill adult patients under mechanical ventilation (MV).

Methods

A secondary analysis of a multicenter prospective cohort conducted in 45 Brazilian ICUs, including adult patients requiring ventilatory support and sedation in the first 48 hours of ICU admissions, was performed. Sedation depth was evaluated after 48 hours of MV. Multivariate analysis was used to identify variables associated with hospital mortality.

Results

A total of 322 patients were evaluated. Overall, ICU and hospital mortality rates were 30.4% and 38.8%, respectively. Deep sedation was observed in 113 patients (35.1%). Longer duration of ventilatory support was observed (7 (4 to 10) versus 5 (3 to 9) days, P = 0.041) and more tracheostomies were performed in the deep sedation group (38.9% versus 22%, P = 0.001) despite similar PaO2/FiO2 ratios and acute respiratory distress syndrome (ARDS) severity. In a multivariate analysis, age (Odds Ratio (OR) 1.02; 95% confidence interval (CI) 1.00 to 1.03), Charlson Comorbidity Index >2 (OR 2.06; 95% CI, 1.44 to 2.94), Simplified Acute Physiology Score 3 (SAPS 3) score (OR 1.02; CI 95%, 1.00 to 1.04), severe ARDS (OR 1.44; CI 95%, 1.09 to 1.91) and deep sedation (OR 2.36; CI 95%, 1.31 to 4.25) were independently associated with increased hospital mortality.

Conclusions

Early deep sedation is associated with adverse outcomes and constitutes an independent predictor of hospital mortality in mechanically ventilated patients.
Appendix
Available only for authorised users
Literature
1.
Puntillo KA, Max A, Timsit JF, Vignoud L, Chanques G, Robleda G, Roche-Campo F, Mancebo J, Divatia JV, Soares M, Ionescu DC, Grintescu IM, Vasiliu IL, Maggiore SM, Rusinova K, Owczuk R, Egerod I, Papathanassoglou ED, Kyranou M, Joynt GM, Burghi G, Freebairn RC, Ho KM, Kaarlola A, Gerritsen RT, Kesecioglu J, Sulaj MM, Norrenberg M, Benoit DD, Seha MS, et al: Determinants of procedural pain intensity in the intensive care unit: the Europain Study. Am J Respir Crit Care Med. 2014, 189: 39-47.PubMed
2.
Barr J, Fraser GL, Puntillo K, Ely EW, Gélinas C, Dasta JF, Davidson JE, Devlin JW, Kress JP, Joffe AM, Coursin DB, Herr DL, Tung A, Robinson BR, Fontaine DK, Ramsay MA, Riker RR, Sessler CN, Pun B, Skrobik Y, Jaeschke R: Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit. Crit Care Med. 2013, 41: 263-306.CrossRefPubMed
3.
Arroliga AC, Thompson BT, Ancukiewicz M, Gonzales JP, Guntupalli KK, Park PK, Wiedemann HP, Anzueto A, Acute Respiratory Distress Syndrome Network: Use of sedatives, opioids, and neuromuscular blocking agents in patients with acute lung injury and acute respiratory distress syndrome. Crit Care Med. 2008, 36: 1083-1088.CrossRefPubMed
4.
Arabi Y, Haddad S, Hawes R, Moore T, Pillay M, Naidu B, Issa A, Yeni B, Grant C, Alshimemeri A: Changing sedation practices in the intensive care unit – protocol implementation, multifaceted multidisciplinary approach and teamwork. Middle East J Anesthesiol. 2007, 19: 429-447.PubMed
5.
Patel RP, Gambrell M, Speroff T, Scott TA, Pun BT, Okahashi J, Strength C, Pandharipande P, Girard TD, Burgess H, Dittus RS, Bernard GR, Ely EW: Delirium and sedation in the intensive care unit: survey of behaviors and attitudes of 1384 healthcare professionals. Critical Care Med. 2009, 37: 825-832.CrossRef
6.
Salluh JI, Soares M, Teles JM, Ceraso D, Raimondi N, Nava VS, Blasquez P, Ugarte S, Ibanez-Guzman C, Centeno JV, Laca M, Grecco G, Jimenez E, Árias-Rivera S, Duenas C, Rocha MG, DECCA (Delirium Epidemiology in Critical Care) Study Group: Delirium epidemiology in critical care (DECCA): an international study. Crit Care. 2010, 14: R210-PubMedCentralCrossRefPubMed
7.
Granja C, Gomes E, Amaro A, Ribeiro O, Jones C, Carneiro A, Costa-Pereira A, JMIP Study Group: Understanding posttraumatic stress disorder-related symptoms after critical care: the early illness amnesia hypothesis. Crit Care Med. 2008, 36: 2801-2809.CrossRefPubMed
8.
Jackson JC, Girard TD, Gordon SM, Thompson JL, Shintani AK, Thomason JW, Pun BT, Canonico AE, Dunn JG, Bernard GR, Dittus RS, Ely EW: Long-term cognitive and psychological outcomes in the awakening and breathing controlled trial. Am J Respir Crit Care Med. 2010, 182: 183-191.PubMedCentralCrossRefPubMed
9.
Nelson BJ, Weinert CR, Bury CL, Marinelli WA, Gross CR: Intensive care unit drug use and subsequent quality of life in acute lung injury patients. Crit Care Med. 2000, 28: 3626-3630.CrossRefPubMed
10.
Dasta JF, Kane-Gill SL, Pencina M, Shehabi Y, Bokesch PM, Wisemandle W, Riker RR: A cost-minimization analysis of dexmedetomidine compared with midazolam for long-term sedation in the intensive care unit. Crit Care Med. 2010, 38: 497-503.CrossRefPubMed
11.
Awissi DK, Bégin C, Moisan J, Lachaine J, Skrobik Y: I-SAVE study: impact of sedation, analgesia, and delirium protocols evaluated in the intensive care unit: an economic evaluation. Ann Pharmacother. 2012, 46: 21-28.CrossRefPubMed
12.
Mascia MF, Koch M, Medicis JJ: Pharmacoeconomic impact of rational use guidelines on the provision of analgesia, sedation, and neuromuscular blockade in critical care. Crit Care Med. 2000, 28: 2300-2306.CrossRefPubMed
13.
Salluh JI, Dal-Pizzol F, Mello PV, Friedman G, Silva E, Teles JM, Lobo SM, Bozza FA, Soares M, Brazilian Research in Intensive Care Network: Delirium recognition and sedation practices in critically ill patients: a survey on the attitudes of 1015 Brazilian critical care physicians. J Crit Care. 2009, 24: 556-562.CrossRefPubMed
14.
Shinotsuka CR, Salluh JI: Perceptions and practices regarding delirium, sedation and analgesia in critically ill patients: a narrative review. Rev Bras Ter Intensiva. 2013, 25: 155-161.PubMedCentralCrossRefPubMed
15.
Mehta S, Burry L, Cook D, Fergusson D, Steinberg M, Granton J, Herridge M, Ferguson N, Devlin J, Tanios M: Daily sedation interruption in mechanically ventilated critically ill patients cared for with a sedation protocol: a randomized controlled trial. JAMA. 2012, 308: 1985-1992.CrossRefPubMed
16.
Jakob SM, Ruokonen E, Grounds RM, Sarapohja T, Garratt C, Pocock SJ, Bratty JR, Takala J, Dexmedetomidine for Long-Term Sedation Investigators: Dexmedetomidine vs midazolam or propofol for sedation during prolonged mechanical ventilation: two randomized controlled trials. JAMA. 2012, 307: 1151-1160.CrossRefPubMed
17.
Riker RR, Shehabi Y, Bokesch PM, Ceraso D, Wisemandle W, Koura F, Whitten P, Margolis BD, Byrne DW, Ely EW, Rocha MG, SEDCOM (Safety and Efficacy of Dexmedetomidine Compared With Midazolam) Study Group: Dexmedetomidine vs. midazolam for sedation of critically ill patients: a randomized trial. JAMA. 2009, 301: 489-499.CrossRefPubMed
18.
Azevedo LC, Park M, Salluh JI, Rea-Neto A, Souza-Dantas VC, Varaschin P, Oliveira MC, Tierno PF, Dal-Pizzol F, Silva UV, Knibel M, Nassar AP, Alves RA, Ferreira JC, Teixeira C, Rezende V, Martinez A, Luciano PM, Schettino G, Soares M, ERICC (Epidemiology of Respiratory Insufficiency in Critical Care) investigators: Clinical outcomes of patients requiring ventilator support in Brazilian intensive care units: a multicenter, prospective, cohort study. Crit Care. 2013, 17: R63-PubMedCentralCrossRefPubMed
19.
Charlson ME, Pompei P, Alex KL, MacKenzie CR: A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis. 1987, 40: 373-383.CrossRefPubMed
20.
Moreno RP, Metnitz PG, Almeida E, Jordan B, Bauer P, Campos RA, Iapichino G, Edbrooke D, Capuzzo M, Le Gall JR, SAPS 3 Investigators: SAPS 3 – from evaluation of the patient to evaluation of the intensive care unit. Intensive Care Med. 2005, 31: 1345-1355.PubMedCentralCrossRefPubMed
21.
Vincent JL, Moreno R, Takala J, Willatts S, De Mendonça A, Bruining H, Reinhart CK, Suter PM, Thijs LG: The SOFA (Sepsis-Related Organ Failure Assessment) score to describe organ dysfunction/failure. On behalf of the Working Group on Sepsis-Related Problems of the European Society on Intensive Care Medicine. Intensive Care Med. 1996, 22: 707-710.CrossRefPubMed
22.
Levy MM, Fink MP, Marshall JC, Abraham E, Angus D, Cook D, Cohen J, Opal SM, Vincent JL, Ramsay G, SCCM/ESICM/ACCP/ATS/SIS: International Sepsis Definitions Conference. Crit Care Med. 2003, 31: 1250-1256.CrossRefPubMed
23.
Rosolem MM, Rabello LS, Lisboa T, Caruso P, Costa RT, Leal JV, Salluh JI, Soares M: Critically ill patients with cancer and sepsis: clinical course and prognostic factors. J Crit Care. 2012, 27: 301-307.CrossRefPubMed
24.
Ranieri VM, Rubenfeld GD, Thompson BT, Ferguson ND, Caldwell E, Fan E, Camporota L, Slutsky AS, Definition Task Force ARDS: Acute respiratory distress syndrome: the Berlin Definition. JAMA. 2012, 307: 2526-2533.PubMed
25.
Ely EW, Truman B, Shintani A, Thomason JW, Wheeler AP, Gordon S, Francis J, Speroff T, Gautam S, Margolin R, Sessler CN, Dittus RS, Bernard GR: Monitoring sedation status over time in ICU patients. Reliability and validity of the Richmond Agitation–Sedation Scale (RASS). JAMA. 2003, 289: 2983-2991.CrossRefPubMed
26.
Devlin JW, Roberts R: Pharmacology of commonly used analgesics and sedatives in the ICU: benzodiazepines, propofol, and opioids. Crit Care Clin. 2009, 25: 431-449. viiCrossRefPubMed
27.
28.
Pandharipande PP, Pun BT, Herr DL, Maze M, Girard TD, Miller RR, Shintani AK, Thompson JL, Jackson JC, Deppen SA, Stiles RA, Dittus RS, Bernard GR, Ely EW: Effect of sedation with dexmedetomidine vs lorazepam on acute brain dysfunction in mechanically ventilated patients: the MENDS randomized controlled trial. JAMA. 2007, 298: 2644-2653.CrossRefPubMed
29.
Jackson DL, Proudfoot CW, Cann KF, Walsh T: A systematic review of the impact of sedation practice in the ICU on resource use, costs and patient safety. Crit Care. 2010, 14: R59-PubMedCentralCrossRefPubMed
30.
Shehabi Y, Bellomo R, Reade MC, Bailey M, Bass F, Howe B, McArthur C, Seppelt IM, Webb S, Weisbrodt L, Sedation Practice in Intensive Care Evaluation (SPICE) Study Investigators; ANZICS Clinical Trials Group: Early intensive care sedation predicts long-term mortality in ventilated critically ill patients. Am J Respir Crit Care Med. 2012, 186: 724-731.CrossRefPubMed
31.
Shehabi Y, Chan L, Kadiman S, Alias A, Ismail WN, Tan MA, Khoo TM, Ali SB, Saman MA, Shaltut A, Tan CC, Yong CY, Bailey M, Sedation Practice in Intensive Care Evaluation (SPICE) Study Group Investigators: Sedation depth and long-term mortality in mechanically ventilated critically ill adults: a prospective longitudinal multicentre cohort study. Intensive Care Med. 2013, 39: 910-918.PubMedCentralCrossRefPubMed
32.
Pun BT, Balas MC, Davidson J: Implementing the, PAD guidelines: top ten points to consider. Semin Respir Crit Care Med. 2013, 2013: 223-235.
33.
Mansouri P, Javadpour S, Zand F, Ghodsbin F, Sabetian G, Masjedi M, Tabatabaee HR: Implementation of a protocol for integrated management of pain, agitation, and delirium can improve clinical outcomes in the intensive care unit: a randomized clinical trial. J Crit Care. 2013, 28: 918-922.CrossRefPubMed
34.
Payen JF, Chanques G, Mantz J, Hercule C, Auriant I, Leguillou JL, Binhas M, Genty C, Rolland C, Bosson JL: Current practices in sedation and analgesia for mechanically ventilated critically ill patients: a prospective multicenter patient-based study. Anesthesiology. 2007, 106: 687-695. quiz 891–892CrossRefPubMed
35.
Finfer S, Chittock DR, Su SY, Blair D, Foster D, Dhingra V, Bellomo R, Cook D, Dodek P, Henderson WR, Hébert PC, Heritier S, Heyland DK, McArthur C, McDonald E, Mitchell I, Myburgh JA, Norton R, Potter J, Robinson BG, Ronco JJ, NICE-SUGAR Study Investigators: Intensive versus conventional glucose control in critically ill patients. N Engl J Med. 2009, 360: 1283-1297.CrossRefPubMed
36.
Ho BCH, Bellomo R, McGain F, Jones D, Naka T, Wan L, Braitberg G: The incidence and outcome of septic shock patients in the absence of early goal directed therapy. Crit Care. 2006, 10: R80-PubMedCentralCrossRefPubMed
37.
Bucknall TK, Manias E, Presneill JJ: A randomized trial of protocol-directed sedation management for mechanical ventilation in an Australian intensive care unit. Crit Care Med. 2008, 36: 1444-1450.CrossRefPubMed
38.
Judson JA, Fisher MM: Intensive care in Australia and New Zealand. Crit Care Clin. 2006, 22: 407-423. vii–viiiCrossRefPubMed
39.
Bellomo R, Stow PJ, Hart GK: Why is there such a difference in outcome between Australian intensive care units and others?. Curr Opin Anaesthesiol. 2007, 20: 100-105.CrossRefPubMed
40.
41.
Teasdale G, Knill-Jones R, van der Sande J: Observer variability in assessing impaired consciousness and coma. J Neurol Neurosurg Psychiatry. 1978, 41: 603-610.PubMedCentralCrossRefPubMed
42.
Sessler CN, Gosnell MS, Grap MJ, Brophy GM, O’Neal PV, Keane KA, Tesoro EP, Elswick RK: The Richmond Agitation–Sedation Scale. Validity and reliability in adult intensive care unit patients. Am J Respir Care Med. 2012, 166: 1338-1344.CrossRef
43.
Benítez-Rosario MA, Castillo-Padrós M, Garrido-Bernet B, González-Guillermo T, Martínez-Castillo LP, González A, Members of the Asocación Canaria de Cuidados Paliativos (CANPAL) Research Network: Appropriateness and reliability testing of the modified Richmond agitation–sedation scale in Spanish patients with advanced cancer. J Pain Symptom Manage. 2013, 45: 1112-1119.CrossRefPubMed
44.
Ely EW, Shintani A, Truman B, Speroff T, Gordon SM, Harrell FE, Inouye SK, Bernard GR, Dittus RS: Delirium as a predictor of mortality in mechanically ventilated patients in the intensive care unit. JAMA. 2004, 291: 1753-1762.CrossRefPubMed
45.
Shehabi Y, Riker RR, Bokesch PM, Wisemandle W, Shintani A, Ely EW, SEDCOM (Safety and Efficacy of Dexmedetomidine Compared With Midazolam) Study Group: Delirium duration and mortality in lightly sedated, mechanically ventilated intensive care patients. Crit Care Med. 2010, 38: 2311-2318.CrossRefPubMed
Metadata
Title
Early sedation and clinical outcomes of mechanically ventilated patients: a prospective multicenter cohort study
Authors
Lilian Maria Sobreira Tanaka
Luciano Cesar Pontes Azevedo
Marcelo Park
Guilherme Schettino
Antonio Paulo Nassar Jr
Alvaro Réa-Neto
Luana Tannous
Vicente Ces de Souza-Dantas
André Torelly
Thiago Lisboa
Claudio Piras
Frederico Bruzzi Carvalho
Marcelo de Oliveira Maia
Fabio Poianas Giannini
Flavia Ribeiro Machado
Felipe Dal-Pizzol
Alexandre Guilherme Ribeiro de Carvalho
Ronaldo Batista dos Santos
Paulo Fernando Guimarães Morando Marzocchi Tierno
Marcio Soares
Jorge Ibrain Figueira Salluh
for the ERICC study investigators
Publication date
01-08-2014
Publisher
BioMed Central
Published in
Critical Care / Issue 4/2014
Electronic ISSN: 1364-8535
DOI
https://doi.org/10.1186/cc13995

Other articles of this Issue 4/2014

Critical Care 4/2014 Go to the issue

Research

Comparison of clinical outcome variables in patients with and without etomidate-facilitated anesthesia induction ahead of major cardiac surgery: a retrospective analysis

Commentary

There’s life in the old dog yet: vitamin C as a therapeutic option in endothelial dysfunction

Research

Purified cell wall from the probiotic bacterium Lactobacillus gasseriactivates systemic inflammation and, at higher doses, produces lethality in a rat model

Research

A new device for continuous assessment of gut perfusion: proof of concept on a porcine model of septic shock

Commentary

The role of nuclear cardiac imaging in redefining neurogenic stunned myocardium in subarachnoid hemorrhage: a deeper look into the heart

Book report

European respiratory monographs: community-acquired pneumonia