Top

Critical Care

Published in:

Open Access 01-04-2010 | Research

A systematic review of the impact of sedation practice in the ICU on resource use, costs and patient safety

Authors: Daniel L Jackson, Clare W Proudfoot, Kimberley F Cann, Tim Walsh

Published in: Critical Care | Issue 2/2010

Abstract

Introduction

Patients in intensive care units (ICUs) often receive sedation for prolonged periods. In order to better understand the impact of sub-optimal sedation practice on outcomes, we performed a systematic review, including observational studies and controlled trials which were conducted in sedated patients in the ICU and which compared the impact of changes in or different protocols for sedation management on economic and patient safety outcomes.

Methods

We searched Medline, Embase and CINAHL online literature databases from 1988 to 15^th May 2008 and hand searched conferences. English-language studies set in the ICU, in sedated adult humans on mechanical ventilation, which reported the impact of sedation practice on cost and resource use and patient safety outcomes, were included. All abstracts were reviewed twice by two independent reviewers, with all conflicts resolved by a third reviewer, to check that they met the review inclusion criteria. Full-text papers of all included studies were retrieved and again reviewed twice against inclusion criteria. Data were doubly extracted from studies. Study aims, design, population, and outcomes including duration of mechanical ventilation, length of stay in ICU and hospital, costs and rates of mortality and adverse events were extracted. Due to heterogeneity between study designs and outcomes reported, no quantitative data synthesis such as meta-analysis was possible.

Results

Included studies varied in design, patient population and aim, with the majority being before-after studies. Overall, studies showed that improvements in sedation practice, such as the introduction of guidelines and protocols, or daily interruption of sedation, were associated with improvements in outcomes including ICU and hospital length of stay, duration of mechanical ventilation, and costs. Mortality and the incidence of nosocomial infections were also reduced.

Conclusions

Systematic interventions to improve sedation practice and maintain patients at an optimal sedation level in the ICU may improve patient outcomes and optimize resource usage.

Available only for authorised users

SIGN. Methodology - search filters [Report][http://www.sign.ac.uk/methodology/filters.html]

Costa J, Cabre L, Molina R, Carrasco G: Cost of ICU sedation: comparison of empirical and controlled sedation methods. Clin Intensive Care 1994, 5: 17-21.PubMed

Burns SM, Earven S, Fisher C, Lewis R, Merrell P, Schubart JR, Truwit JD, Bleck TP, University of Virginia Long Term Mechanical Ventilation Team: Implementation of an institutional program to improve clinical and financial outcomes of mechanically ventilated patients: one-year outcomes and lessons learned[see comment]. Crit Care Med 2003, 31: 2752-2763. 10.1097/01.CCM.0000094217.07170.75CrossRefPubMed

Kress JP, Pohlman AS, Hall JB: Effects of sedative interruption in critically ill, mechanically ventilated patients receiving midazolam or propofol. JCOM 2001, 8: 33-39.

Kollef MH, Levy NT, Ahrens TS, Schaiff R, Prentice D, Sherman G: The use of continuous IV sedation is associated with prolongation of mechanical ventilation. Chest 1998, 114: 541-548. 10.1378/chest.114.2.541CrossRefPubMed

Girard TD, Kress JP, Fuchs BD, Thomason JW, Schweickert WD, Pun BT, Taichman DB, Dunn JG, Pohlman AS, Kinniry PA, Jackson JC, Canonico AE, Light RW, Shintani AK, Thompson JL, Gordon SM, Hall JB, Dittus RS, Bernard GR, Ely EW: Efficacy and safety of a paired sedation and ventilator weaning protocol for mechanically ventilated patients in intensive care (Awakening and Breathing Controlled trial): a randomised controlled trial[see comment]. Lancet 2008, 371: 126-134. 10.1016/S0140-6736(08)60105-1CrossRefPubMed

Weatherburn C, Endacott R, Tynan P, Bailey M: The impact of bispectral index monitoring on sedation administration in mechanically ventilated patients. Anaesth Intensive Care 2007, 35: 204-208.PubMed

Carson SS, Kress JP, Rodgers JE, Vinayak A, Campbell-Bright S, Levitt J, Bourdet S, Ivanova A, Henderson AG, Pohlman A, Chang L, Rich PB, Hall J: A randomized trial of intermittent lorazepam versus propofol with daily interruption in mechanically ventilated patients[see comment]. Crit Care Med 2006, 34: 1326-1332. 10.1097/01.CCM.0000215513.63207.7FCrossRefPubMed

Anon: Sedation monitoring service reduces costs, cuts duration of ventilation and ICU stay. Formulary 1999, 34: 710-711.

10.

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

11.

Brattebo G, Hofoss D, Flaatten H, Muri AK, Gjerde S, Plsek PE: Effect of a scoring system and protocol for sedation on duration of patients' need for ventilator support in a surgical intensive care unit. QUAL SAF HEALTH CARE 2004, 13: 203-205. 10.1136/qhc.13.3.203PubMedCentralCrossRefPubMed

12.

Brook AD, Ahrens TS, Schaiff R, Prentice D, Sherman G, Shannon W, Kollef MH: Effect of a nursing-implemented sedation protocol on the duration of mechanical ventilation[see comment]. Crit Care Med 1999, 27: 2609-2615. 10.1097/00003246-199912000-00001CrossRefPubMed

13.

Chanques G, Jaber S, Barbotte E, Violet S, Sebbane M, Perrigault PF, Mann C, Lefrant JY, Eledjam JJ: Impact of systematic evaluation of pain and agitation in an intensive care unit[see comment]. Crit Care Med 2006, 34: 1691-1699. 10.1097/01.CCM.0000218416.62457.56CrossRefPubMed

14.

De Jonghe B, Bastuji-Garin S, Fangio P, Lacherade JC, Jabot J, Appere-De-Vecchi C, Rocha N, Outin H: Sedation algorithm in critically ill patients without acute brain injury. Crit Care Med 2005, 33: 120-127. 10.1097/01.CCM.0000150268.04228.68CrossRefPubMed

15.

Devlin JW, Holbrook AM, Fuller HD: The effect of ICU sedation guidelines and pharmacist interventions on clinical outcomes and drug cost. Ann Pharmacother 1997, 31: 689-695.PubMed

16.

Jakob SM, Lubszky S, Friolet R, Rothen HU, Kolarova A, Takala J: Sedation and weaning from mechanical ventilation: effects of process optimization outside a clinical trial. J Crit Care 2007, 22: 219-228. 10.1016/j.jcrc.2007.01.001CrossRefPubMed

17.

MacLaren R, Plamondon JM, Ramsay KB, Rocker GM, Patrick WD, Hall RI: A prospective evaluation of empiric versus protocol-based sedation and analgesia. Pharmacotherapy 2000, 20: 662-672. 10.1592/phco.20.7.662.35172CrossRefPubMed

18.

Marshall J, Finn CA, Theodore AC: Impact of a clinical pharmacist-enforced intensive care unit sedation protocol on duration of mechanical ventilation and hospital stay[see comment]. Crit Care Med 2008, 36: 427-433. 10.1097/01.CCM.0000300275.63811.B3CrossRefPubMed

19.

Mascia MF, Koch M, Medicis JJ: Pharmacoeconomic impact of rational use guidelines on the provision of analgesia, sedation, and neuromuscular blockade in critical care[see comment]. Crit Care Med 2000, 28: 2300-2306. 10.1097/00003246-200007000-00019CrossRefPubMed

20.

Quenot JP, Ladoire S, Devoucoux F, Doise JM, Cailliod R, Cunin N, Aube H, Blettery B, Charles PE: Effect of a nurse-implemented sedation protocol on the incidence of ventilator-associated pneumonia[see comment]. Crit Care Med 2007, 35: 2031-2036. 10.1097/01.ccm.0000282733.83089.4dCrossRefPubMed

21.

Tierney M, Snell CC, Cardinal P, Baxter A: Comparison of duration of mechanical ventilation and cost associated with midazolam and lorazepam infusions in critically ill patients. Can J Hosp Pharm 1996, 49: 211-215.

22.

Kress JP, Pohlman AS, O'Connor MF, Hall JB: Daily interruption of sedative infusions in critically ill patients undergoing mechanical ventilation[see comment]. N Engl J Med 2000, 342: 1471-1477. 10.1056/NEJM200005183422002CrossRefPubMed

23.

Bair N, Bobek MB, Hoffman-Hogg L, Mion LC, Slomka J, Arroliga AC: Introduction of sedative, analgesic, and neuromuscular blocking agent guidelines in a medical intensive care unit: physician and nurse adherence[see comment]. Crit Care Med 2000, 28: 707-713. 10.1097/00003246-200003000-00018CrossRefPubMed

24.

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[see comment]. JAMA 2007, 298: 2644-2653. 10.1001/jama.298.22.2644CrossRefPubMed

25.

American Thoracic Society: Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. Am J Respir Crit Care Med 2005, 171: 388-416. 10.1164/rccm.200405-644STCrossRef

26.

Girard TD, Pandharipande PP, Ely EW: Delirium in the intensive care unit. Crit Care 2008, 12 Suppl 3: S3.CrossRefPubMed

27.

Dellinger RP, Levy MM, Carlet JM, Bion J, Parker MM, Jaeschke R, Reinhart K, Angus DC, Brun-Buisson C, Beale R, Calandra T, Dhainaut JF, Gerlach H, Harvey M, Marini JJ, Marshall J, Ranieri M, Ramsay G, Sevransky J, Thompson BT, Townsend S, Vender JS, Zimmerman JL, Vincent JL: Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock: 2008. Crit Care Med 2008, 36: 296-327. 10.1097/01.CCM.0000298158.12101.41CrossRefPubMed

28.

Brattebo G, Hofoss D, Flaatten H, Muri AK, Gjerde S, Plsek PE: Effect of a scoring system and protocol for sedation on duration of patients' need for ventilator support in a surgical intensive care unit. BMJ 2002, 324: 1386-1389. 10.1136/bmj.324.7350.1386PubMedCentralCrossRefPubMed

29.

Schweickert WD, Gehlbach BK, Pohlman AS, Hall JB, Kress JP: Daily interruption of sedative infusions and complications of critical illness in mechanically ventilated patients[see comment]. Crit Care Med 2004, 32: 1272-1276. 10.1097/01.CCM.0000127263.54807.79CrossRefPubMed

30.

Pandharipande PP, Herr DL, Maze M, Thompson JL, Ely EW: Efficacy of long-term sedation and delirium duration with dexmedetomidine in critically ill patients [Abstract]. Anesthesiology 2007, 107: A1214.

31.

Pandharipande PP, Frizzell J, Pun BT, Maze M, Ely EW: Randomized controlled trial comparing dexmedetomidine with lorazepam to reduce delirium in the ICU [Abstract]. Anesthesiology 2006, 105: A210.

Title: A systematic review of the impact of sedation practice in the ICU on resource use, costs and patient safety
Authors: Daniel L Jackson
Clare W Proudfoot
Kimberley F Cann
Tim Walsh
Publication date: 01-04-2010
Publisher: BioMed Central
Published in: Critical Care / Issue 2/2010
Electronic ISSN: 1364-8535
DOI: https://doi.org/10.1186/cc8956

Keynote webinar | Spotlight on sleep in brain health

Springer Medicine

A systematic review of the impact of sedation practice in the ICU on resource use, costs and patient safety

Abstract

Introduction

Methods

Results

Conclusions

Keynote webinar | Spotlight on sleep in brain health

Springer Medicine

Abstract

Introduction

Methods

Results

Conclusions

Please log in to get access to this content

Other articles of this Issue 2/2010

Leptin in sepsis: a well-suited biomarker in critically ill patients?

Cardiac arrest - has the time of MRI come?

Mild therapeutic hypothermia alters neuron specific enolase as an outcome predictor after resuscitation: 97 prospective hypothermia patients compared to 133 historical non-hypothermia patients

Prognostic value of cell-free plasma DNA in patients with cardiac arrest outside the hospital: an observational cohort study

Adequate thromboprophylaxis in critically ill patients

Bedside adherence to clinical practice guidelines for enteral nutrition in critically ill patients receiving mechanical ventilation: a prospective, multi-centre, observational study