Variation in diurnal sedation in mechanically ventilated patients who are managed with a sedation protocol alone or a sedation protocol and daily interruption

被引:9
作者
Mehta, Sangeeta [1 ,2 ,3 ,26 ]
Meade, Maureen [4 ,5 ]
Burry, Lisa [3 ,6 ]
Mallick, Ranjeeta [7 ,8 ]
Katsios, Christina [9 ]
Fergusson, Dean [7 ,8 ]
Dodek, Peter [10 ,11 ,12 ]
Burns, Karen [9 ,13 ,14 ]
Herridge, Margaret [15 ,16 ,17 ]
Devlin, John W. [18 ]
Tanios, Maged [19 ]
Fowler, Robert [20 ]
Jacka, Michael [21 ]
Skrobik, Yoanna [22 ]
Olafson, Kendiss [23 ]
Cook, Deborah [24 ,25 ]
机构
[1] Mt Sinai Hosp, Dept Med, Toronto, ON M5G 1X5, Canada
[2] Mt Sinai Hosp, Interdepartmental Div Crit Care Med, Toronto, ON M5G 1X5, Canada
[3] Univ Toronto, Toronto, ON, Canada
[4] McMaster Univ, Dept Med, Hamilton, ON, Canada
[5] McMaster Univ, Dept Clin Epidemiol & Biostat, Hamilton, ON, Canada
[6] Mt Sinai Hosp, Dept Pharm & Med, Toronto, ON, Canada
[7] Univ Ottawa, Clin Epidemiol Program, Ottawa Hosp Res Inst, Ottawa, ON, Canada
[8] Univ Ottawa, Fac Med, Ottawa, ON, Canada
[9] Univ Toronto, Interdepartmental Div Crit Care Med, Toronto, ON, Canada
[10] St Pauls Hosp, Div Crit Care Med, Vancouver, BC, Canada
[11] St Pauls Hosp, Ctr Hlth Evaluat & Outcome Sci, Vancouver, BC, Canada
[12] Univ British Columbia, Vancouver, BC V5Z 1M9, Canada
[13] St Michaels Hosp, Dept Crit Care, Toronto, ON, Canada
[14] Li Ka Shing Inst, Toronto, ON, Canada
[15] Univ Hlth Network, Dept Med, Toronto, ON, Canada
[16] Univ Hlth Network, Interdepartmental Div Crit Care Med, Toronto, ON, Canada
[17] Univ Toronto, Toronto, ON, Canada
[18] Northeastern Univ, Sch Pharm, Boston, MA 02115 USA
[19] Long Beach Mem Med Ctr, Dept Med, Long Beach, CA 90806 USA
[20] Sunnybrook Hlth Sci Ctr, Dept Med & Crit Care Med, Toronto, ON, Canada
[21] Univ Alberta Hosp, Dept Anesthesiol, Edmonton, AB, Canada
[22] Hop Royal Victoria, Dept Med, Montreal, PQ, Canada
[23] Univ Manitoba, Dept Med, Sect Crit Care, Winnipeg, MB, Canada
[24] McMaster Univ, St Josephs Healthcare, Dept Med, Hamilton, ON, Canada
[25] McMaster Univ, St Josephs Healthcare, Dept Clin Epidemiol & Biostat, Hamilton, ON, Canada
[26] Mt Sinai Hosp, Suite 18-216,600 Univ Ave, Toronto, ON M5G 1X5, Canada
来源
CRITICAL CARE | 2016年 / 20卷
基金
加拿大健康研究院;
关键词
Sedation; Opioids; Mechanical ventilation; Protocols; Weaning; Diurnal rhythm; Intensive care unit; CRITICALLY-ILL PATIENTS; RANDOMIZED CONTROLLED-TRIAL; INTENSIVE-CARE-UNIT; LONG-TERM MORTALITY; DELIRIUM;
D O I
10.1186/s13054-016-1405-3
中图分类号
R4 [临床医学];
学科分类号
1002 ; 100602 ;
摘要
Background: Mechanically ventilated patients may receive more sedation during the night than during the day, potentially delaying extubation. We compared nighttime and daytime benzodiazepine and opioid administration in adult patients enrolled in a multicenter sedation trial comparing protocolized sedation alone or protocolized sedation combined with daily sedation interruption; and we evaluated whether nighttime and daytime doses were associated with liberation from mechanical ventilation. Methods: This is a secondary analysis of a randomized trial which was conducted in 16 North American medical-surgical ICUs. In all 423 patients, nurses applied a validated sedation scale hourly to titrate benzodiazepine and opioid infusions to achieve a light level of sedation. Using fentanyl equivalents and midazolam equivalents, we compared dosages administered during night (19: 00 to 07: 00) and day (07: 00 to 19: 00) shifts. Using multivariable logistic regression we evaluated the association between nighttime and daytime opioid and sedative doses, and spontaneous breathing trial (SBT) conduct, SBT success, and extubation. Results: Nighttime benzodiazepine and opioid doses were significantly higher than daytime doses (mean difference midazolam equivalents 23.3 mg, 95 % CI 12.9, 33.8, p < 0.0001; mean difference fentanyl equivalents 356 mcg, 95 % CI 130, 582, p = 0.0021). Mean Sedation Agitation Scale score was similar between night and day, and was at target (3.2 vs 3.3, 95 % CI -0.05, 0.02, p = 0.35). Self-reported nurse workload was similar during the night and day. Patients were more often restrained during day shifts (76.3 % vs 73.7 %, p < 0.0001), and there were more unintentional device removals during the day compared with night (15.9 % vs 9.1 %, p < 0.0001). Increases in nighttime drug doses were independently associated with failure to meet SBT screening criteria, SBT failure, and the decision not to extubate the patient despite successful SBT. Conclusion: Patients received higher doses of opioids and benzodiazepines at night. Higher nighttime doses were associated with SBT failure and delayed extubation.
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页数:7
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