Impact Of Daily Sedation Breaks On Ventilation Time In ICU Patients: A Systematic Review

Discuss about the Sedation Practice in Intensive Care Evaluation.

Nursing care in the I.C.U. (Intensive Care Unit) is multi-faceted and challenging, with the care of the mechanically ventilated patient at the center of their practice. The care of the ventilated patient requires a good knowledge of mechanical ventilation and invasive monitoring. Sedation is an important element of caring for ventilated patients. Sedation relieves anxiety and discomfort caused by procedures such as intubation. Adequate sedation supports a calm and comfortable experience for the patient. Multiple complications exist from over/under sedation. Daily sedation breaks have proven to be beneficial to the patient with respect to long term psychological outcomes (Nassar et al, 2015). The longer a patient is ventilated and sedated, the longer the stay in ICU, the higher the risk of developing delirium. In 2011, Ely from Vanderbilt University Hospital Tennessee suggested that 80% of ventilated patients experience delirium. Most patients who require analgesia and sedation infusions are ventilated at the same time (Pandharipande, 2007). The relationship between the two is paramount in ensuring patient comfort and safety and helps in the reduction of ventilation time. Use of analgesia and sedation can prevent pain and anxiety, allows for invasive procedures, reduces stress and oxygen consumption, and improves patient synchrony with the ventilator. (Curley, 2015, 380) Sedation preference depends on the hospital, patient history and the Clinician’s choice. Thiscan lead to a wide discrepancy in patient sedation. Sedation also helps to reduce environmental pollution of the critical care environment, which is usually filled with a high level of background noise with people and the alarms of the machines. Sedation in the ICU can reduce the following: stress endogenous catecholamine activity, increased oxygen consumption, tachycardia, hypercoagulability, hyper metabolism, and immunosuppression and anxiety that include sympathetic response. (Curley 2015, 382)

The time taken from the start of ventilation to the start of weaning depends largely on the sedatives used and on the duration of sedation. Some hospitals give their patients daily sedation breaks while some leave the patients on a continuous break or some give fewer breaks or no breaks. Among these patients there was a notable difference in the start of weaning from ventilation and extubating. (Kress et al 2003, 1459). Daily sedation interruptions and regular administration of sedatives are effective in reducing ventilation time although it is not clear which method is more favorable.

To encourage best practice with sedation management this research proposal will aim to review if daily sedation breaks can reduce ventilation time in ICU patients. Primarily this research centers on achieving scientific facts based on careful observation, objective sampling, data analysis and factual conclusion. (Kress, 2003). It will be a quantitative systematic review.

Patients in intensive care units require life-support techniques including mechanical ventilation. ICU patients experience anxiety, pain, and deprivation of sleep resulting from illness (Holm and Dreyer 2017, p.83). As a result, proper pain control and adequate sedation are key procedures required in the management of ICU patients. Specifically, sedation facilitates intubation, ventilation, and tolerance of tubes (Vincent 2017, p.11). The management of these patients requires continuous infusion of sedative drugs so the stability of blood vessels is maintained (Page and McAuley 2015, p.141). On the contrary, administration of too many sedative drugs can both increase the time taken on mechanical ventilation as well as enhance the side effects such as pneumonia (Balter et al and Conti et al 2016, p.206). To avoid the build-up of sedative drugs into body and side effects, dose adjustment methods are used. One of the principal methods is sedation interruption.

Importance of Sedation in ICUs

The use of DSI as a method of reducing mechanical ventilation and the time taken in ICU has fundamental conflicts. Devlin and Roberts (2011, p. 571), Hughes, McGrane and Panharipande (2012, p. 41), Kress et al. (2000, p.1474), Pinder and Christensen (2008, p.68), and Kallet et al. (2018, p.7) indicate that sedation interruption not only allows the body time to clear sedative drugs but also makes the patient relatively more awake and ready hence earlier liberation from the ICU. In addition, the study shows that lack of sedation breaks results in poor long-term outcomes such as psychological stress. Similarly, Barr et al. (2013, p.301) indicates that protocol sedation reduces the duration of mechanical ventilation.  On the other hand, Shebabi et al (2012, p. 725) argues that DSI does not alter time taken in mechanical ventilation. Instead, sedation reduces response to environmental factors, depression, and stress. As a result, it is important to have an updated systematic review on the effects of DSI on time taken in mechanical ventilation. The principal objective of this systematic review will be ton compare the total duration of mechanical ventilation for ICU patients who were managed with DSI against those with no DSI. The primary research question will be to find out if sedation breaks reduce the time for mechanical ventilation.

We will search EMBASE, MEDLINE, and CINAHL online databases from 2008 to May 2018 with keywords sedation, Intensive Care Unit, critical care, sedation break, sedation protocol, reduced ventilation, and ventilation time. On the other hand, conference proceedings from 2015 to 2018 will be hand-searched. The studies included for systematic review will include English language studies conducted in the ICU. The studies must have been carried out in sedated adult humans and must report the effect of sedation on ventilation time. The online databases will be selected for systematic review given the nature of the study. Since the study is medical in nature, the databases considered for systematic review needed to be medical. In addition, the databases will provide both randomized controlled trials and observational studies. Randomized controlled trials will be retrieved for studies whose objectives were generation of hypothesis. On the other hand, observational studies will provide critical information about studies conducted on the effect of sedation breaks on ventilation time.

The studies to be included for this systematic review must have been conducted in a population of adult patients. In addition, the patients must have been sedated and were on mechanical ventilation within the ICU. Further, the studies must have reported the effects of sedation such as duration of mechanical ventilation and length of stay in the hospital. Moreover, the studies to be included for review must be those that report the incidence rates of optimal sedation. Finally, all the studies must have been reported in English language. On the other hand, the review will exclude studies conducted on patients sedated for less than 24 hours.

The inclusion and exclusion criteria will be vital in ensuring that the samples selected for review are representative of the general population. For instance, studies conducted in patients sedated for less than 24 hours will be excluded because they will not provide a significant period of stay in the ICU that can be used to study the effects of sedation breaks on ventilation time. In addition, studies on infants and toddlers will be considered since these populations may suffer from other conditions that may have confounding effects on ventilation time. For these reasons it will be crucial to select sample that reflect the generation population in terms of age and clinical setups. In this systematic review, the studies that will be considered for review will be those conducted in patients aged between 18 and 85 years. However, the studies considered for review will not need to be skewed towards a particular gender since mechanical ventilation intervention is applicable for both genders. Finally, the year of publication will be restricted for the last 10 years to ensure that mechanical ventilation interventions are consistent for all studies. It is likely that the intervention mechanisms have significantly changed over the last ten years and therefore including studies conducted earlier that this would have different results.

Sedation Strategies in ICU

Data to be collected from all the included studies will include study aims and objectives, study design, and the length of stay in mechanical ventilation. Data will be double extracted for all studied included in the systematic review. More importantly, data will be extracted and stored in SQL-based databases. Study aims will be vital in providing the cause factor, in this case sedation breaks. Data will only be extracted from studies that were aimed at determining the effect of sedation breaks on ventilation time, in this case the outcome.

To ensure that the rigor of research is realized, the systematic review will consider three fundamental mechanisms. Firstly, the full-text paper of all studies included for systematic review will be double reviewed to ascertain that they meet the inclusion criteria. In addition, the abstracts of all studies will be reviewed by two independent reviewers. In the event that, conflicts will arise from the review results, the conflicts will be resolved by a third review through board discussions. Finally, data will be double extracted from all studies included for review. Ensuring rigor will be a critical part of this systematic review. Particularly, rigor of the research minimizes bias and ensures reproducibility and applicability of results. It will be important the results of this systematic review are transferable to other similar medical setups. As a consequence, it will be important that data extraction and review of abstracts are double checked.

Data collection will involve computation of geometric means and risk ratios for ICU mortality. Computation of geometric means will be used in calculation of lengths of stay in mechanical ventilation. The geometric mean of ventilation time will then be expressed as mean  standard deviation. The computed means of ventilation time will then be compared for patients with sedation breaks and patients with no sedation breaks. On the other hand, relative risks will be calculated to determine the effect of sedation on ventilation time. In particular, relative risk of population without sedation breaks compared with those with sedation breaks will be computed. The relative risks will be interpreted to ascertain if sedation breaks reduce ventilation time. More specifically, RR>1 will be interpreted to mean that ventilation time is longer in the population without sedation break while RR<1 will mean ventilation time is longer in population with sedation breaks. Relative risks will be used since they provide accurate determination of cause and effect relationship between two factors. Given the heterogeneity of the studies that will be considered for this systematic review, statistical analysis such as meta-analysis will not be carried out.

Ethical consideration in systematic review will play a vital role in ensuring that the research the results of review are ethical and of high quality. The studies included for review will be checked to meet a number of ethical issues. Firstly, the studies reviewed will review for finical support. In particular, the sponsors of the researchers will be considered to ensure the level of bias is minimized. In addition, the studies will be reviewed fro justification to ensure that calculation of sample size was done at the research stage. The review will also take into consideration any possible sources of conflict of interest. Finally, the systematic review will take into consideration publication bias. The highlighted ethical considerations will aim at ensuring validity and reliability of the results of systematic review.

Conflicting Evidence on the Use of Daily Sedation Breaks

Conclusion

All this can be prevented by carefully taking a legally accepted patient representative through the research, answer all the questions that arise and ensuring the consent form is duly filled for the right patient. During the research it is also important to ensure patient comfort to ascertain high integrity. Care of the ICU patient is costly. Reducing the duration of ventilation will probably reduce costs of the problems that are associated with increased ventilation time such as pneumonia and infection. Daily interruption of the sedation is a cost saving intervention as well as all the other mental and physical benefits to the patient, it also allows Clinicians and nurses to target the minimal sedation necessary to keep the patient comfortable.

References

Balter, M.B., Manheimer, D.I., Mellinger, G. and Uhlenhuth, E.H. A cross-national comparison of anti-anxiety/sedative drug use. Current Medical Research and Opinion, 8, 1984:5-20.

Barr, J.  Fraser, G. L., Puntillo, K., Ely, E. W., Gélinas, C., Dasta, J. F., & Coursin,D.B. “Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit”. Critical care medicine  41(1), 2013: 263-306.

Conti, G., Ranieri, V.M., Costa, R., Garratt, C., Wighton, A., Spinazzola, G., Urbino, R., Mascia, L., Ferrone, G., Pohjanjousi, P. and Ferreyra, G. Effects of dexmedetomidine and propofol on patient-ventilator interaction in difficult-to-wean, mechanically ventilated patients: a prospective, open-label, randomised, multicentre study. Critical Care, 20(1),2016:206.

Curley, M.A., Wypij, D., Watson, R.S., Grant, M.J.C., Asaro, L.A., Cheifetz, I.M., Dodson, B.L., Franck, L.S., Gedeit, R.G., Angus, D.C. and Matthay, M.A. Protocolized sedation vs usual care in pediatric patients mechanically ventilated for acute respiratory failure: a randomized clinical trial. Jama, 313(4), 2015: 379-389.

Devlin, J. W. and R. J. Roberts "Pharmacology of Commonly Used Analgesics and Sedatives in the ICU: Benzodiazepines, Propofol, and Opioids." Anesthesiology Clinics 29 (4), 2013: 567-585.

Holm, A. and Dreyer, P. Intensive care unit patients' experience of being conscious during endotracheal intubation and mechanical ventilation. Nursing in critical care, 22(2), 2017:81-88.

Hughes, C. G., et al. "Daily sedation interruption versus targeted light sedation strategies in ICU patients." Critical Care Med 41(9 Suppl 1), 2013: S39-45.

Kallet, R. H., et al. "Spontaneous Breathing Trials and Conservative Sedation Practices Reduce Mechanical Ventilation Duration in Subjects with ARDS." Respiratory

Care 63(1), 2018: 1-10.

Kress, J.P., Gehlbach, B., Lacy, M., Pliskin, N., Pohlman, A.S. and Hall, J.B. The long-term psychological effects of daily sedative interruption on critically ill patients. American journal of respiratory and critical care medicine, 168(12), 2003:1457-1461.

Kress, J.P., Pohlman, A.S., O'Connor, M.F. and Hall, J.B. Daily interruption of sedative infusions in critically ill patients undergoing mechanical ventilation. New England Journal of Medicine, 342(20), 2000:1471-1477.

Nassar Jr AP, Zampieri FG, Ranzani OT, Park M. Protocolized sedation effect on post-ICU posttraumatic stress disorder prevalence: A systematic review and network meta-analysis. Journal of Critical Care, 30(6), 2015:1278–1282. [PubMed]

Page, V.J. and McAuley, D.F. Sedation/drugs used in intensive care sedation. Current Opinion in Anesthesiology, 28(2), 2015:139-144.

Pandharipande, P.P., Pun, B.T., Herr, D.L., Maze, M., Girard, T.D., Miller, R.R., Shintani, A.K., Thompson, J.L., Jackson, J.C., Deppen, S.A. and Stiles, R.A. Effect of sedation with dexmedetomidine vs lorazepam on acute brain dysfunction in mechanically ventilated patients: the MENDS randomized controlled trial. Jama, 298(22), 2007:2644-2653.

Pinder, S. and M. Christensen. "Sedation breaks: are they good for the critically ill patient? A review." Nursing in Critical Care 13 (2), 2008: 64-70.

Shehabi, Y. Bellomo, R., Reade, M. C., Bailey, M., Bass, F., Howe, B., & Weisbrodt, L. “Sedation Practice in Intensive Care Evaluation (SPICE) Study Investigators; ANZICS Clinical Trials Group. Early intensive care sedation predicts long-term mortality in ventilated critically ill patients”. American Journal of Respiratory Critical Care Medicine 186(8), 2012: 724-31.

Vincent, J.L. Optimizing sedation in the ICU: the eCASH concept. Signa Vitae, 13(3), 2017: pp.10-13.