Effect of daily sedation interruption and the patient’s outcome who are under mechanical ventilation: A mini systematic review

Continuous administration of sedatives to the intensive care unit may increase the duration of mechanical ventilation, extend the patient's stay in the intensive care unit, and, subsequently, to the hospital. The objective was to improve the outcome of intubated patients in terms of the total duration of mechanical ventilation, the stay of these patients in the intensive care unit (ICU), and their mortality. This systematic review was conducted using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The literature search was conducted in October 2020. Articles were searched in the PubMed and Cochrane Library online databases. Data were extracted from all included research studies and analyzed thematically. The search duration was between 2008 and 2018. The studies do not document statistically significant differences with the parameters under study (total duration of mechanical ventilation, the total length of stay in the intensive care unit (ICU), and mortality), for a better outcome of intubated patients. The application of the daily sedation interruption (DSI) did not appear to affect the duration of Mechanical Ventilation, the length of stay in the ICU, and mortality in intubated patients. Keywords: Daily sedation interruption, intubated patients

Impact of Each Component of a Ventilator Bundle on Preventing Ventilator-Associated Pneumonia and Lower Respiratory Infection

Background: Ventilator-associated lower respiratory infections (LRIs) and pneumonia (VAP) are important healthcare-associated infections and are among the leading causes of death worldwide. Prevention of these infections are often based on care bundles. We investigated the incidence of VAP+LRI and the preventive efficacy of each component of our ventilator bundle. Methods: Our ventilator bundle includes 6 components that are daily checked by an infection control practitioner. These 6 evidence-based practices were implemented in 3 ICUs from a general tertiary-care private hospital in Belo Horizonte City (Brazil): (1) daily oral care with chlorhexidine; (2) elevate the head of the bed to between 30 and 45; (3) avoid scheduled ventilator circuit change; (4) monitor cuff pressure; (5) use subglottic secretion drainage; and (6) daily sedation interruption and daily assessment of readiness to extubate. VAP and ventilator-LRI definitions were obtained from the CDC NHSN. The impact of adherence rate to items in the ventilator bundle (%) on the incidence rate of VAP+LRI was assessed using linear regression and scatterplot analyses. Results: Between January 2018 and April 2019, 1,888 ventilator days were observed in the 3 ICUs, with 42 VAP and LRI events, an overall incidence rate of 22.2 cases per 1,000 ventilator days. After September 2018, the infection control service started a campaign to increase the ventilator bundle compliance (Fig. 1). Adherence rates to all 6 bundle components increased between January–August 2018 and September 2018–April 2019 from 25% to 55% for daily oral care, from 34% to 79% for elevating the head of the bed, 28% to 86% for avoiding scheduled ventilator circuit change, from 32% to 83% for cuff pressure monitoring, from 32% to 83% for subglottic secretion drainage, and from 33% to 85% for daily sedation interruption. PAV and LRI incidence decreased from 41 to 16 in ICU A, from 22 to 14 in ICU B and from 24 to 18 in ICU C. The impact of each bundle component was identified by linear regression, calculating the percentage of PAV+LRI incidence rate that is explained by bundle item adherence (r2) and correlation coefficient (r): daily sedation interruption (r2 = 48%; r = 0.69; P = .004) (Fig. 2), cuff pressure monitorization (r2 = 0.3721; r = 0.61; P = .016), subglottic secretion drainage (r2 = 36%; r = 0.60; P = .017), avoidance of scheduled ventilator circuit change (r2 = 34%; r = 0.58; P = .023), daily oral care (r2 = 25%; r = 0.50; P = .050), and elevate the head of the bed (r2 = 25%; r = 0.48; P = .067). Conclusions: The impact of each bundle component on preventing PAV+LRI was identified by the study. An educational intervention performed by the infection control service increased the adherence to the ventilator bundle, and the PAV and LRI incidence decreased.Funding: NoneDisclosures: None

P96 Preliminary results on the study to identify the relation between midazolam concentrations and level of sedation in critically mechanically ventilated children

IntroductionWhile evidence on the pharmacokinetics of midazolam in children in increasing, there is only limited information on the pharmacokinetic-pharmacodynamic relation of midazolam in critically ill children. In this study, we explored the relation between midazolam concentrations and level of sedation using data from a multi-institutional clinical trial1 comparing Daily Sedation Interruption (DSI) with protocolised sedation versus protocolised sedation alone (i.e DSI + PS vs. PS) in critically-ill, mechanically ventilated paediatric ICU (P-ICU) patients.MethodsPharmacokinetic information on midazolam use along with COMFORT and NISS scores from 113 mechanically ventilated P-ICU patients (median age 3 months, range: 0 to 17 years) admitted between 2010 and 2014 were used from the original study.1 Midazolam plasma concentrations at the time of each COMFORT score were calculated using a pharmacokinetic model published on the same dataset.2 Sedation scores were categorised into under-, adequate- and over-sedated categories according to the study protocol.3ResultsIn total, 6662 COMFORT scores were elicited (3112 and 3550 records for DSI+PS and PS arms, respectively). Patients were observed to be adequately sedated in 4232 (64%) scores, and under- and over-sedated in 720 scores (10%) and 1710 (26%) scores, respectively. For all three sedation categories, median midazolam concentrations were significantly lower in the DSI+PS arm compared to PS (P < 0.001). Generalized multivariate linear mixed-effects modelling identified previously reported over-sedation scores (P < 0.001) in combination with high log-transformed midazolam concentrations (P < 0.001) as predictors of over-sedation in patients. Prior under-sedation, but not individual predicted midazolam concentration, predicted current under-sedation (P < 0.001).ConclusionThese preliminary results suggest a role of previous sedation scores in subsequent sedation scores. Further exploration of these data using Markov modelling seems required to identity the relation between midazolam concentrations and level of sedation in mechanically ventilated P-ICU patients.ReferencesVet NJ, de Wildt SN, Verlaat CW, et al. A randomized controlled trial of daily sedation interruption in critically ill children. Intensive care medicine 2016;42(2):233–44. doi: 10.1007/s00134-015-4136-z [published Online First: 2015/11/26]Vet NJ, Brussee JM, de Hoog M, et al. Inflammation and organ failure severely affect midazolam clearance in critically ill children. American journal of respiratory and critical care medicine 2016;194(1):58–66. doi: 10.1164/rccm.201510-2114OC [published Online First: 2016/01/23]Vet NJ, de Wildt SN, Verlaat CW, et al. Daily interruption of sedation in critically ill children: study protocol for a randomized controlled trial. Trials 2014;15:55. doi: 10.1186/1745-6215-15-55 [published Online First: 2014/02/15]Disclosure(s)Conflict of interest statement: The original trial was supported by project grants from the Netherlands Organization for Health Research and Development, ZonMw Priority Medicines for Children (grant numbers 113202002 and 92003549) and Erasmus MC Cost-Effectiveness Research.

Evaluation of a Multidisciplinary Pain, Agitation, and Delirium Guideline in Mechanically Ventilated Critically Ill Adults

Background: A multidisciplinary team updated an institution-specific pain, agitation, and delirium (PAD) guideline based on the recommendations from the Society of Critical Care Medicine (SCCM) PAD guidelines. This institution-specific guideline emphasized protocolized sedation with increased as needed boluses, and nonbenzodiazepine infusions, daily sedation interruption, and pairing of spontaneous awakening (SAT) and breathing trials (SBT). Objective: The purpose of this study was to evaluate the impact of implementation of a PAD guideline on clinical outcomes and medication utilization in an academic medical center intensive care unit (ICU). It was hypothesized that implementation of an updated guideline would improve clinical outcomes and decrease usage of benzodiazepine infusions. Methods: Pre-post retrospective chart review of 2417 (1147 pre, 1270 post) critically ill, mechanically ventilated adults in a medical/surgical ICU over a 2-year period (1 year pre and post guideline implementation). Results: After guideline implementation, average ventilation days was reduced (3.98 vs 3.43 days, P = .0021), as well as ICU and hospital length of stay (LOS) (4.79 vs 4.34 days, P = .048 and 13.96 vs 12.97 days, P = .045, respectively). Hospital mortality (19 vs 19%, P = .96) and acute physiology and chronic health evaluation (APACHE) IV scores (77.28 vs 78.75, P = .27) were similar. After guideline implementation, the percentage of patients receiving midazolam infusions decreased (422/1147 [37%] vs 363/1270 patients [29%], P = .0001). The percentage of patients receiving continuous infusion propofol (679/1147 [59%] vs 896/1270 [70%], P = .0001) and dexmedetomidine (78/1147 [7%] vs 147/1270 [12%], P = .0001) increased. Conclusions: Implementing a multidisciplinary PAD guideline utilizing protocolized sedation and daily sedation interruption decreased ventilation days and ICU and hospital LOS while decreasing midazolam drip usage.

Daily Interruption of Sedative Infusions in Critically Ill Patients Undergoing Mechanical Ventilation

This chapter provides a summary of a landmark study in critical care medicine. Does the daily interruption of continuous sedative infusions in critically ill patients receiving mechanical ventilation decrease the duration of mechanical ventilation and the duration of stay in the intensive care unit (ICU)? This chapter describes the study designed to answer that question including funding, study location, patient population, study design, study intervention, follow-up, endpoints, results, and criticism and limitations. The chapter briefly reviews other relevant context and studies, discusses implications, and concludes with a relevant clinical case. This was the first randomized-controlled trial to demonstrate that daily sedation interruption for mechanically ventilated medical ICU patients is safe and may reduce the duration of mechanical ventilation and length of stay in the ICU.