Analgesic, sedative, antipsychotic, and neuromuscular blocker use in Canadian intensive care units: a prospective, multicentre, observational study

  • Lisa D. Burry
  • David R. Williamson
  • Marc M. Perreault
  • Louise Rose
  • Deborah J. Cook
  • Niall D. Ferguson
  • Stephanie C. Lapinsky
  • Sangheeta Mehta
Reports of Original Investigations

Abstract

Purpose

Our aim was to describe analgo-sedation and antipsychotic and neuromuscular blocking drug (NMBD) use in critically ill patients, management strategies, and variables associated with these practice patterns.

Methods

This prospective observational study in 51 intensive care units (ICUs) included all patients who underwent invasive mechanical ventilation (MV) over a two-week period during 2008-2009.

Results

We included 712 patients representing 3,620 patient-days. Median MV duration was 3.0 days (interquartile range 2-6). During MV, 92% of patients received analgo-sedation, 32% an adjunct agent (e.g., acetaminophen), 18% NMBDs, and 10% antipsychotics. Opioids were used more frequently than benzodiazepines or propofol (84.8% vs 62.2% vs 10.1% patients, respectively, P < 0.0001). Independent predictors of opioid and benzodiazepine use were a longer MV duration, assessment scales, physical restraints, and university-affiliated hospital. Although more than 50% of ICUs reported that assessment tools, protocols, and daily sedation interruption (DSI) were available for use, application was modest: sedation scale 53.0%, pain scale 19.1%, delirium scale 5.2%, protocol 25.0%, DSI 42.1%. Accidental device removal occurred in 4.6% of patients, with 75.8% of events during DSI. Daily sedation interruption was associated with protocol use, physical restraints, university-affiliated hospital, and short-duration MV. Variables associated with protocol use included assessment scales, longer MV duration, lack of physical restraints, and admission to a community hospital.

Conclusion

Nearly all MV patients received analgo-sedation. Opioids were used more often than sedatives despite infrequent use of pain scales. Few patients received antipsychotic therapy, but physical restraint was common. Protocol use was poor compared to DSI. Duration of MV predicted the use of either.

Utilisation des analgésiques, sédatifs, antipsychotiques et bloqueurs neuromusculaires dans les unités de soins intensifs canadiennes: étude observationnelle prospective, multicentrique

Résumé

Objectif

Notre objectif était de décrire l’utilisation des médicaments antalgiques-sédatifs et bloqueurs neuromusculaires (NMBD) chez des patients dans un état critique, les stratégies de prise en charge et les variables associées aux pratiques habituelles.

Méthodes

Cette étude observationnelle prospective menée dans 51 unités de soins intensifs (USI) a inclus tous les patients ayant bénéficié d’une ventilation mécanique (VM) invasive sur une période de deux semaines au cours des années 2008-2009.

Résultats

Nous avons inclus 712 patients représentant 3 620 jours-patients. La durée médiane de VM a été de 3,0 jours (intervalle interquartile: 2-6). Au cours de la VM, 92 % des patients ont reçu une analgésie-sédation, 32 % ont reçu un médicament d’appoint (par exemple: acétaminophène), 18 % des NMBD, et 10 % des antipsychotiques. Les morphiniques ont été utilisés plus souvent que les benzodiazépines ou le propofol (respectivement, 84,8 % contre 62,2 % et 10,1 % des patients, P < 0,0001). Les facteurs prédictifs indépendants de l’utilisation des morphiniques et des benzodiazépines étaient une plus longue durée de VM, les échelles d’évaluation, la contention physique et l’affiliation universitaire de l’hôpital. Bien que plus de 50 % des USI aient indiqué la disponibilité d’outils d’évaluation, de protocoles et d’interruptions quotidiennes de la sédation (DSI), leur utilisation pratique a été modeste: échelle de sédation 53,0 %, échelle de douleur 19,1 %, échelle d’évaluation du délire 5,2%, protocole 25,0 %, DSI 42,1 %. Un retrait accidentel du dispositif est survenu chez 4,6 % des patients, 75,8 % de ces événements survenant au cours d’une DSI. L’interruption quotidienne de la sédation était associée à l’utilisation d’un protocole, une contention physique, l’affiliation universitaire de l’hôpital et la courte durée de la VM. Les variables associées à l’utilisation d’un protocole incluaient les échelles d’évaluation, une plus longue durée de VM, l’absence de contrainte physique et l’hospitalisation dans un hôpital général.

Conclusion

Presque tous les patients sous VM ont reçu une analgésie-sédation. Les morphiniques ont été utilisés plus souvent que les sédatifs en dépit de l’utilisation rare des échelles de douleur. Peu de patients ont reçu un traitement antipsychotique, mais les dispositifs de contention étaient courants. L’utilisation d’un protocole a été faible par rapport à la DSI. La durée de la VM a prédit l’utilisation des deux.

References

  1. 1.
    Barr J, Fraser GL, Puntillo K, 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: 263-306.PubMedCrossRefGoogle Scholar
  2. 2.
    Arroliga A, Frutos-Vivar F, Hall J, et al. Use of sedatives and neuromuscular blockers in a cohort of patients receiving mechanical ventilation. Chest 2005; 128: 496-506.PubMedCrossRefGoogle Scholar
  3. 3.
    Mehta S, McCullagh I, Burry L. Current sedation practices: lessons learned from international surveys. Crit Care Clin 2009; 25: 471-88.PubMedCrossRefGoogle Scholar
  4. 4.
    Brook AD, Ahrens TS, Schaiff R, et al. Effect of a nursing-implemented sedation protocol on the duration of mechanical ventilation. Crit Care Med 1999; 27: 2609-15.PubMedCrossRefGoogle Scholar
  5. 5.
    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: 1471-7.PubMedCrossRefGoogle Scholar
  6. 6.
    Pandharipande PP, Pun BT, Herr DL, 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: 2644-53.PubMedCrossRefGoogle Scholar
  7. 7.
    Pandharipande P, Shintani A, Peterson J, et al. Lorazepam is an independent risk factor for transitioning to delirium in intensive care unit patients. Anesthesiology 2006; 104: 21-6.PubMedCrossRefGoogle Scholar
  8. 8.
    Riker RR, Shehabi Y, Bokesch PM, et al. Dexmedetomidine vs midazolam for sedation of critically ill patients: a randomized trial. JAMA 2009; 301: 489-99.PubMedCrossRefGoogle Scholar
  9. 9.
    Carson SS, Kress JP, Rodgers JE, et al. A randomized trial of intermittent lorazepam versus propofol with daily interruption in mechanically ventilated patients. Crit Care Med 2006; 34: 1326-32.PubMedCrossRefGoogle Scholar
  10. 10.
    Breen D, Karabinis A, Malbrain M, et al. Decreased duration of mechanical ventilation when comparing analgesia-based sedation using remifentanil with standard hypnotic-based sedation for up to 10 days in intensive care unit patients: a randomised trial [ISRCTN47583497]. Crit Care 2005; 9: R200-10.PubMedCentralPubMedCrossRefGoogle Scholar
  11. 11.
    Martin J, Heymann A, Basell K, et al. Evidence and consensus-based German guidelines for the management of analgesia, sedation and delirium in intensive care—short version. Ger Med Sci 2010; DOI: 10.3205/000091.Google Scholar
  12. 12.
    Mattia C, Savoia G, Paoletti F, et al. SIAARTI recommendations for analgo-sedation in intensive care unit. Minerva Anestesiol 2006; 72: 769-805.PubMedGoogle Scholar
  13. 13.
    Mehta S, Burry L, Fischer S, et al. Canadian survey of the use of sedatives, analgesics, and neuromuscular blocking agents in critically ill patients. Crit Care Med 2006; 34: 374-80.PubMedCrossRefGoogle Scholar
  14. 14.
    Woien H, Stubhaug A, Bjork IT. Analgesia and sedation of mechanically ventilated patients – a national survey of clinical practice. Acta Anaesthesiol Scand 2012; 56: 23-9.PubMedCrossRefGoogle Scholar
  15. 15.
    Varney Gill K, Voils SA, Chenault GA, Brophy GM. Perceived versus actual sedation practices in adult intensive care unit patients receiving mechanical ventilation. Ann Pharmacother 2012; 46: 1331-9.CrossRefGoogle Scholar
  16. 16.
    Payen JF, Chanques G, Mantz J, et al. Current practices in sedation and analgesia for mechanically ventilated critically ill patients: a prospective multicenter patient-based study. Anesthesiology 2007; 106: 687-95.PubMedCrossRefGoogle Scholar
  17. 17.
    Bertolini G, Melotti R, Romano P, et al. Use of sedative and analgesic drugs in the first week of ICU stay. A pharmaco-epidemiological perspective. Minerva Anestesiol 2001; 67: 97-105.PubMedGoogle Scholar
  18. 18.
    Martin J, Franck M, Fischer M, Spies C. Sedation and analgesia in German intensive care units: how is it done in reality? Results of a patient-based survey of analgesia and sedation. Intensive Care Med 2006; 32: 1137-42.PubMedCrossRefGoogle Scholar
  19. 19.
    Weinert CR, Calvin AD. Epidemiology of sedation and sedation adequacy for mechanically ventilated patients in a medical and surgical intensive care unit. Crit Care Med 2007; 35: 393-401.PubMedCrossRefGoogle Scholar
  20. 20.
    Riker RR, Picard JT, Fraser GL. Prospective evaluation of the Sedation-Agitation Scale for adult critically ill patients. Crit Care Med 1999; 27: 1325-9.PubMedCrossRefGoogle Scholar
  21. 21.
    Harrell FE Jr, Lee KL, Califf RM, Pryor DB, Rosati RA. Regression modelling strategies for improved prognostic prediction. Stat Med 1984; 3: 143-52.PubMedCrossRefGoogle Scholar
  22. 22.
    Wunch H, Kahn JM, Kramer AA, Rubenfeld GD. Use of intravenous infusion sedation among mechanically ventilated patients in the United States. Crit Care Med 2009; 37: 3031-9.CrossRefGoogle Scholar
  23. 23.
    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. Crit Care Med 2008; 36: 427-33.PubMedCrossRefGoogle Scholar
  24. 24.
    Ramsay MA, Savege TM, Simpson BR, Goodwin R. Controlled sedation with alphaxalone-alphadolone. BMJ 1974; 2: 656-9.PubMedCentralPubMedCrossRefGoogle Scholar
  25. 25.
    Sessler CN, Gosnell MS, Grap MJ, et al. The Richmond Agitation-Sedation Scale: validity and reliability in adult intensive care unit patients. Am J Respir Crit Care Med 2002; 166: 1338-44.PubMedCrossRefGoogle Scholar
  26. 26.
    Jensen MP, Karoly P, O’Riordan EF, Bland F, Burns RS Jr. The subjective experience of acute pain. An assessment of the utility of 10 indices. Clin J Pain 1989; 5: 153-9.PubMedCrossRefGoogle Scholar
  27. 27.
    Ely EW, Margolin R, Francis J, et al. Evaluation of delirium in critically ill patients: validation of the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU). Crit Care Med 2001; 29: 1370-9.PubMedCrossRefGoogle Scholar
  28. 28.
    Bergeron N, Dubois MJ, Dumont M, Dial S, Skrobik Y. Intensive Care Delirium Screening Checklist: evaluation of a new screening tool. Intensive Care Med 2001; 27: 859-64.PubMedCrossRefGoogle Scholar
  29. 29.
    Neelon VJ, Champagne MT, Carlson JR, Funk SG. The NEECHAM Confusion Scale: construction, validation, and clinical testing. Nurs Res 1996; 45: 324-30.PubMedCrossRefGoogle Scholar
  30. 30.
    Shehabi Y, Botha JA, Boyle MS, et al. Sedation and delirium in the intensive care unit: an Australian and New Zealand perspective. Anaesth Intensive Care 2008; 36: 570-8.PubMedGoogle Scholar
  31. 31.
    Ely EW, Shintani A, Truman B, et al. Delirium as a predictor of mortality in mechanically ventilated patients in the intensive care unit. JAMA 2004; 291: 1753-62.PubMedCrossRefGoogle Scholar
  32. 32.
    Ray WA, Chung CP, Murray KT, Hall K, Stein CM. Atypical antipsychotic drugs and the risk of sudden cardiac death. N Engl J Med 2009; 360: 225-35.PubMedCentralPubMedCrossRefGoogle Scholar
  33. 33.
    Payen JF, Bosson JL, Chanques G, Mantz J, Labarere J; DOLOREA Investigators. Pain assessment is associated with decreased duration of mechanical ventilation in the intensive care unit: a post hoc analysis of the DOLOREA study. Anesthesiology 2009; 111: 1308-16.PubMedCrossRefGoogle Scholar
  34. 34.
    Woien H, Vaeroy H, Aamodt G, Bjork IT. Improving the systematic approach to pain and sedation management in the ICU by using assessment tools. J Clin Nurs 2012; DOI: 10.1111/j.1365-2702.2012.04309.x.PubMedGoogle Scholar
  35. 35.
    Mehta S, Burry L, Cook D, et al.; SLEAP Investigators; Canadian Critical Care Trials Group. Daily sedation interruption in mechanically ventilated critically ill patients cared for with a sedation protocol: a randomized controlled trial. JAMA 2012; 308: 1985-92.PubMedCrossRefGoogle Scholar

Copyright information

© Canadian Anesthesiologists' Society 2014

Authors and Affiliations

  • Lisa D. Burry
    • 1
  • David R. Williamson
    • 2
  • Marc M. Perreault
    • 3
  • Louise Rose
    • 4
  • Deborah J. Cook
    • 5
  • Niall D. Ferguson
    • 6
  • Stephanie C. Lapinsky
    • 7
  • Sangheeta Mehta
    • 8
  1. 1.Department of Pharmacy, Mount Sinai HospitalUniversity of TorontoTorontoCanada
  2. 2.Faculty of Pharmacy, Hôpital du Sacré-CoeurUniversité de MontréalMontrealCanada
  3. 3.McGill University Health Center, and Faculty of PharmacyUniversité de MontréalMontrealCanada
  4. 4.Lawrence S. Bloomberg Faculty of NursingUniversity of TorontoTorontoCanada
  5. 5.Departments of Medicine, Clinical Epidemiology & Biostatistics, St Joseph’s HealthcareMcMaster UniversityHamiltonCanada
  6. 6.Interdepartmental Division of Critical Care Medicine, and Division of Respirology, Department of Medicine, University Health Network & Mount Sinai HospitalUniversity of TorontoTorontoCanada
  7. 7.University of TorontoTorontoCanada
  8. 8.Department of Medicine, Mount Sinai HospitalUniversity of TorontoTorontoCanada

Personalised recommendations