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Published in: Systematic Reviews 1/2016

Open Access 01-12-2016 | Protocol

Comparison of sedation strategies for critically ill patients: a protocol for a systematic review incorporating network meta-analyses

Authors: Brian Hutton, Lisa D. Burry, Salmaan Kanji, Sangeeta Mehta, Melanie Guenette, Claudio M. Martin, Dean A. Fergusson, Neill K. Adhikari, Ingrid Egerod, David Williamson, Sharon Straus, David Moher, E. Wesley Ely, Louise Rose

Published in: Systematic Reviews | Issue 1/2016

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Abstract

Background

Sedatives and analgesics are administered to provide sedation and manage agitation and pain in most critically ill mechanically ventilated patients. Various sedation administration strategies including protocolized sedation and daily sedation interruption are used to mitigate drug pharmacokinetic limitations and minimize oversedation, thereby shortening the duration of mechanical ventilation. At present, it is unclear which strategy is most effective, as few have been directly compared. Our review will use network meta-analysis (NMA) to compare and rank sedation strategies to determine their efficacy and safety for mechanically ventilated patients.

Methods

We will search the following from 1980 to March 2016: Ovid MEDLINE, CINAHL, Embase, PsycINFO, and Web of Science. We will also search the Cochrane Library, gray literature, and the International Clinical Trials Registry Platform. We will use a validated randomized control trial search filter to identify studies evaluating any strategy to optimize sedation in mechanically ventilated adult patients. Authors will independently extract data from eligible studies in duplicate and complete the Cochrane Risk of Bias tool. Our outcomes of interest include duration of mechanical ventilation, time to first extubation, ICU and hospital length of stay, re-intubation, tracheostomy, mortality, total sedative and opioid exposure, health-related quality of life, and adverse events. To inform our NMA, we will first conduct conventional pair-wise meta-analyses using random-effects models. Where appropriate, we will perform Bayesian NMA using WinBUGS software.

Discussion

There are multiple strategies to optimize sedation for mechanically ventilated patients. Current ICU guidelines recommend protocolized sedation or daily sedation interruption. Our systematic review incorporating NMA will provide a unified analysis of all sedation strategies to determine the relative efficacy and safety of interventions that may not have been compared directly. We will provide knowledge users, decision makers, and professional societies with ranking of multiple sedation strategies to inform future sedation guidelines.

Systematic review registration

Appendix
Available only for authorised users
Literature
1.
Arroliga A, Frutos-Vivar F, Hall J, Esteban A, Apezteguia C, Soto L, et al. Use of sedatives and neuromuscular blockers in a cohort of patients receiving mechanical ventilation. Chest. 2005;128(2):496–506.CrossRefPubMed
2.
Burry LD, Williamson DR, Perreault MM, Rose L, Cook DJ, Ferguson ND, et al. Analgesic, sedative, antipsychotic, and neuromuscular blocker use in Canadian intensive care units: a prospective, multicentre, observational study. Can J Anesth. 2014;61(7):619–30.CrossRefPubMed
3.
Mehta S, Burry L, Fischer S, Martinez-Motta JC, Hallett D, Bowman D, et al. Canadian survey of the use of sedatives, analgesics, and neuromuscular blocking agents in critically ill patients. Crit Care Med. 2006;34(2):374–80.CrossRefPubMed
4.
Mehta S, McCullagh I, Burry L. Current sedation practices: lessons learned from international surveys. Anesthesiol Clin. 2011;29(4):607–24.CrossRefPubMed
5.
Arabi Y, Haddad S, Hawes R, Moore T, Pillay M, Naidu B, et al. Changing sedation practices in the intensive care unit—protocol implementation, multifaceted multidisciplinary approach and teamwork. Middle East J Anesthesiol. 2007;19(2):429–47.PubMed
6.
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(3):203–5.CrossRefPubMedPubMedCentral
7.
Brook AD, Ahrens TS, Schaiff R, Prentice D, Sherman G, Shannon W, et al. Effect of a nursing-implemented sedation protocol on the duration of mechanical ventilation. Crit Care Med. 1999;27(12):2609–15.CrossRefPubMed
8.
Burns SM, Earven S, Fisher C, Lewis R, Merrell P, Schubart JR, et al. Implementation of an institutional program to improve clinical and financial outcomes of mechanically ventilated patients: one-year outcomes and lessons learned. Crit Care Med. 2003;31(12):2752–63.CrossRefPubMed
9.
Carson SS, Kress JP, Rodgers JE, Vinayak A, Campbell-Bright S, Levitt J, et al. A randomized trial of intermittent lorazepam versus propofol with daily interruption in mechanically ventilated patients. Crit Care Med. 2006;34(5):1326–32.CrossRefPubMed
10.
Girard TD, Kress JP, Fuchs BD, Thomason JWW, Schweickert WD, Pun BT, et al. 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. Lancet. 2008;371(9607):126–34.CrossRefPubMed
11.
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(3):219–28.CrossRefPubMed
12.
Kollef MH, Levy NT, Ahrens TS, Schaiff R, Prentice D, Sherman G. The use of continuous i.v. sedation is associated with prolongation of mechanical ventilation. Chest. 1998;114(2):541–8.CrossRefPubMed
13.
Kress JP, Pohlman AS, O’Connor MF, Hall JB. Daily interruption of sedative infusions in critically ill patients undergoing mechanical ventilation. N Engl J Med. 2000;342(20):1471–7.CrossRefPubMed
14.
Strøm T, Martinussen T, Toft P. A protocol of no sedation for critically ill patients receiving mechanical ventilation: a randomised trial. Lancet. 2010;375(9713):475–80.CrossRefPubMed
15.
Kress JP, Gehlbach B, Lacy M, Pliskin N, Pohlman AS, Hall JB. The long-term psychological effects of daily sedative interruption on critically ill patients. Am J Respir Crit Care Med. 2003;168(12):1457–61.CrossRefPubMed
16.
Pandharipande PP, Pun BT, Herr DL, Maze M, Girard TD, Miller RR, et al. Effect of sedation with dexmedetomidine vs lorazepam on acute brain dysfunction in mechanically ventilated patients: the MENDS randomized controlled trial. JAMA. 2007;298(22):2644–53.CrossRefPubMed
17.
Barr J, Fraser GL, Puntillo K, Ely EW, Gelinas C, Dasta JF, et al. Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit. Crit Care Med. 2013;41(1):263–306.CrossRefPubMed
18.
Cipriani A, Higgins JP, Geddes JR, Salanti G. Conceptual and technical challenges in network meta-analysis. Ann Intern Med. 2013;159(2):130–7.CrossRefPubMed
19.
Ioannidis JP. Integration of evidence from multiple meta-analyses: a primer on umbrella reviews, treatment networks and multiple treatments meta-analyses. CMAJ. 2009;181(8):488–93.CrossRefPubMedPubMedCentral
20.
Lu G, Ades AE. Combination of direct and indirect evidence in mixed treatment comparisons. Stat Med. 2004;23(20):3105–24.CrossRefPubMed
21.
Shamseer L, Moher D, Clarke M, Ghersi D, Liberati A, Petticrew M, et al. Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015: elaboration and explanation. BMJ. 2015;349:g7647.CrossRefPubMed
22.
McGowan J, Sampson M, Salzwedel DM, Cogo E, Foerster V, Lefebvre C. PRESS peer review of electronic search strategies: 2015 guideline statement. J Clin Epidemiol. 2016;75:40–6.CrossRefPubMed
23.
Sampson M, McGowan J, Cogo E, Grimshaw J, Moher D, Lefebvre C. An evidence-based practice guideline for the peer review of electronic search strategies. J Clin Epidemiol. 2009;62(9):944–52.CrossRefPubMed
24.
25.
Catala-Lopez F, Tobias A, Cameron C, Moher D, Hutton B. Network meta-analysis for comparing treatment effects of multiple interventions: an introduction. Rheumatol Int. 2014;34(11):1489–96.CrossRefPubMed
26.
Moher D, Liberati A, Tetzlaff J, Altman DG, Group P. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med. 2009;6(7), e1000097.CrossRefPubMedPubMedCentral
27.
28.
Donegan S, Williamson P, D’Alessandro U, Tudur Smith C. Assessing key assumptions of network meta-analysis: a review of methods. Res Synth Methods. 2013;4(4):291–323.CrossRefPubMed
29.
30.
Lunn DJ, Thomas A, Best N, Spiegelhalter D. WinBUGS—a Bayesian modelling framework: concepts, structure, and extensibility. Stat Comput. 2000;10(4):325–37.CrossRef
31.
Lu G, Ades A. Assessing evidence inconsistency in mixed treatment comparisons. J Am Stat Assoc. 2006;101(474):447–59.CrossRef
32.
Salanti G, Ades AE, Ioannidis JP. Graphical methods and numerical summaries for presenting results from multiple-treatment meta-analysis: an overview and tutorial. J Clin Epidemiol. 2011;64(2):163–71.CrossRefPubMed
33.
Dias S, Sutton AJ, Welton NJ, Ades AE. Evidence synthesis for decision making 3: heterogeneity—subgroups, meta-regression, bias, and bias-adjustment. Med Decis Making. 2013;33(5):618–40.CrossRefPubMedPubMedCentral
34.
Dias S, Welton NJ, Sutton AJ, Caldwell DM, Lu G, Ades AE. NICE DSU technical support document 4: inconsistency in networks of evidence based on randomised controlled trials. 2011. Available from: http://​www.​nicedsu.​org.​uk.
35.
Dias S, Welton NJ, Sutton AJ, Ades AE. NICE DSU technical support document 2: a generalised linear modelling framework for pairwise and network meta-analysis of randomised controlled trials. 2011. Available from: http://​www.​nicedsu.​org.​uk.
36.
Spiegelhalter DJ, Best NG, Carlin BP, Van Der Linde A. Bayesian measures of model complexity and fit. J R Stat Soc Ser B (Statistical Methodology). 2002;64(4):583–639.CrossRef
37.
Hutton B, Salanti G, Caldwell DM, Chaimani A, Schmid CH, Cameron C, et al. The PRISMA extension statement for reporting of systematic reviews incorporating network meta-analyses of health care interventions: checklist and explanations. Ann Intern Med. 2015;162(11):777–84.CrossRefPubMed
38.
Adam C, Rosser D, Manji M. Impact of introducing a sedation management guideline in intensive care. Anaesthesia. 2006;61(3):260–3.CrossRefPubMed
39.
Aitken LM, Bucknall T, Kent B, Mitchell M, Burmeister E, Keogh SJ. Protocol-directed sedation versus non-protocol-directed sedation to reduce duration of mechanical ventilation in mechanically ventilated intensive care patients. Cochrane Database Syst Rev. 2015;1.
40.
Anifantaki S, Prinianakis G, Vitsaksaki E, Katsouli V, Mari S, Symianakis A, et al. Daily interruption of sedative infusions in an adult medical-surgical intensive care unit: randomized controlled trial. J Adv Nurs. 2009;65(5):1054–60.CrossRefPubMed
41.
Arias-Rivera S, Sanchez-Sanchez Mdel M, Santos-Diaz R, Gallardo-Murillo J, Sanchez-Izquierdo R, Frutos-Vivar F, et al. Effect of a nursing-implemented sedation protocol on weaning outcome. Crit Care Med. 2008;36(7):2054–60.CrossRefPubMed
42.
Augustes R, Ho KM. Meta-analysis of randomised controlled trials on daily sedation interruption for critically ill adult patients. Anaesth Intensive Care. 2011;39(3):401–9.PubMed
43.
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(7350):1386–9.CrossRefPubMedPubMedCentral
44.
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(5):1444–50.CrossRefPubMed
45.
Burry L, Rose L, McCullagh IJ, Fergusson DA, Ferguson ND, Mehta S. Daily sedation interruption versus no daily sedation interruption for critically ill adult patients requiring invasive mechanical ventilation. Cochrane Database Syst Rev. 2014;7:CD009176.
46.
De Jonghe B, Bastuji-Garin S, Fangio P, Lacherade JC, Jabot J, Appere-De-Vecchi C, et al. Sedation algorithm in critically ill patients without acute brain injury. Crit Care Med. 2005;33(1):120–7.CrossRefPubMed
47.
de Wit M, Gennings C, Jenvey WI, Epstein SK. Randomized trial comparing daily interruption of sedation and nursing-implemented sedation algorithm in medical intensive care unit patients. Crit Care. 2008;12(3):R70.CrossRefPubMedPubMedCentral
48.
Elliott R, McKinley S, Aitken LM, Hendrikz J. The effect of an algorithm-based sedation guideline on the duration of mechanical ventilation in an Australian intensive care unit. Intensive Care Med. 2006;32(10):1506–14.CrossRefPubMed
49.
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(6):662–72.CrossRefPubMed
50.
Mehta S, Burry L, Cook D, Fergusson D, Steinberg M, Granton J, et al. Daily sedation interruption in mechanically ventilated critically ill patients cared for with a sedation protocol: a randomized controlled trial. JAMA. 2012;308(19):1985–92.CrossRefPubMed
51.
Minhas MA, Velasquez AG, Kaul A, Salinas PD, Celi LA. Effect of protocolized sedation on clinical outcomes in mechanically ventilated intensive care unit patients: a systematic review and meta-analysis of randomized controlled trials. Mayo Clin Proc. 2015;90(5):613–23.CrossRefPubMed
52.
Quenot JP, Ladoire S, Devoucoux F, Doise JM, Cailliod R, Cunin N. Effect of a nurse-implemented sedation protocol on the incidence of ventilator-associated pneumonia [see comment]. Crit Care Med. 2007;35(9):2031–6.CrossRefPubMed
53.
Robinson BR, Mueller EW, Henson K, Branson RD, Barsoum S, Tsuei BJ. An analgesia-delirium-sedation protocol for critically ill trauma patients reduces ventilator days and hospital length of stay. J Trauma. 2008;65(3):517–26.CrossRefPubMed
54.
Skrobik Y, Ahern S, Leblanc M, Marquis F, Awissi DK, Kavanagh BP. Protocolized intensive care unit management of analgesia, sedation, and delirium improves analgesia and subsyndromal delirium rates. Anesth Analg. 2010;111(2):451–63.CrossRefPubMed
Metadata
Title
Comparison of sedation strategies for critically ill patients: a protocol for a systematic review incorporating network meta-analyses
Authors
Brian Hutton
Lisa D. Burry
Salmaan Kanji
Sangeeta Mehta
Melanie Guenette
Claudio M. Martin
Dean A. Fergusson
Neill K. Adhikari
Ingrid Egerod
David Williamson
Sharon Straus
David Moher
E. Wesley Ely
Louise Rose
Publication date
01-12-2016
Publisher
BioMed Central
Published in
Systematic Reviews / Issue 1/2016
Electronic ISSN: 2046-4053
DOI
https://doi.org/10.1186/s13643-016-0338-x

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