Judith Jacobi, PharmD, FCCM, BCPS; Gilles L. Fraser, PharmD, FCCM; Douglas B. Coursin, MD; Richard R. Riker, MD; Dorrie Fontaine, RN, DNSc, FAAN; Eric T. Wittbrodt, PharmD; Donald B. Chalfin, MD, MS, FCCM; Michael F. Masica, MD, MPH; H. Scott Bjerke, MD; William M. Coplin, MD; David W. Crippen, MD, FCCM; Barry D. Fuchs, MD; Ruth M. Kelleher, RN; Paul E. Marik, MDBCh, FCCM; Stanley A. Nasraway, Jr, MD, FCCM; Michael J. Murray, MD, PhD, FCCM; William T. Peruzzi, MD, FCCM; Philip D. Lumb, MB, BS, FCCM. Developed through the Task Force of the American College of Critical Care Medicine (ACCM) of the Society of Critical Care Medicine (SCCM), in collaboration with the American Society of Health-System Pharmacists (ASHP), and in alliance with the American College of Chest Physicians; and approved by the Board of Regents of ACCM and the Council of SCCM and the ASHP Board of Directors

/pdf/clinical-practice-guidelines-for-the-sustained-use-of-550x8gqibj.pdf

Clinical practice guidelines for the sustained use of sedatives and analgesics in the critically ill adult.

ContextGoal-directed delivery of sedative and analgesic medications is recommended
as standard care in intensive care units (ICUs) because of the impact these
medications have on ventilator weaning and ICU length of stay, but few of
the available sedation scales have been appropriately tested for reliability
and validity.ObjectiveTo test the reliability and validity of the Richmond Agitation-Sedation
Scale (RASS).DesignProspective cohort study.SettingAdult medical and coronary ICUs of a university-based medical center.ParticipantsThirty-eight medical ICU patients enrolled for reliability testing (46%
receiving mechanical ventilation) from July 21, 1999, to September 7, 1999,
and an independent cohort of 275 patients receiving mechanical ventilation
were enrolled for validity testing from February 1, 2000, to May 3, 2001.Main Outcome MeasuresInterrater reliability of the RASS, Glasgow Coma Scale (GCS), and Ramsay
Scale (RS); validity of the RASS correlated with reference standard ratings,
assessments of content of consciousness, GCS scores, doses of sedatives and
analgesics, and bispectral electroencephalography.ResultsIn 290-paired observations by nurses, results of both the RASS and RS
demonstrated excellent interrater reliability (weighted κ, 0.91 and
0.94, respectively), which were both superior to the GCS (weighted κ,
0.64; P<.001 for both comparisons). Criterion
validity was tested in 411-paired observations in the first 96 patients of
the validation cohort, in whom the RASS showed significant differences between
levels of consciousness (P<.001 for all) and correctly
identified fluctuations within patients over time (P<.001).
In addition, 5 methods were used to test the construct validity of the RASS,
including correlation with an attention screening examination (r = 0.78, P<.001), GCS scores (r = 0.91, P<.001), quantity of different
psychoactive medication dosages 8 hours prior to assessment (eg, lorazepam: r = − 0.31, P<.001),
successful extubation (P = .07), and bispectral electroencephalography
(r = 0.63, P<.001). Face
validity was demonstrated via a survey of 26 critical care nurses, which the
results showed that 92% agreed or strongly agreed with the RASS scoring scheme,
and 81% agreed or strongly agreed that the instrument provided a consensus
for goal-directed delivery of medications.ConclusionsThe RASS demonstrated excellent interrater reliability and criterion,
construct, and face validity. This is the first sedation scale to be validated
for its ability to detect changes in sedation status over consecutive days
of ICU care, against constructs of level of consciousness and delirium, and
correlated with the administered dose of sedative and analgesic medications.

https://jamanetwork.com/journals/jama/articlepdf/196696/JCE20052.pdf

Monitoring sedation status over time in ICU patients: reliability and validity of the Richmond Agitation-Sedation Scale (RASS).

Background:Delirium has recently been shown as a predictor of death, increased cost, and longer duration of stay in ventilated patients. Sedative and analgesic medications relieve anxiety and pain but may contribute to patients’ transitioning into delirium.Methods:In this cohort study, the authors d

Lorazepam is an independent risk factor for transitioning to delirium in intensive care unit patients.

Delirium, an acute and fluctuating disturbance of consciousness and cognition, is a common manifestation of acute brain dysfunction in critically ill patients, occurring in up to 80% of the sickest intensive care unit (ICU) populations. Critically ill patients are subject to numerous risk factors for delirium. Some of these, such as exposure to sedative and analgesic medications, may be modified to reduce risk. Although dysfunction of other organ systems continues to receive more clinical attention, delirium is now recognized to be a significant contributor to morbidity and mortality in the ICU, and it is recommended that all ICU patients be monitored using a validated delirium assessment instrument. Patients with delirium have longer hospital stays and lower 6-month survival than do patients without delirium, and preliminary research suggests that delirium may be associated with cognitive impairment that persists months to years after discharge. Little evidence exists regarding the prevention and treatment of delirium in the ICU, but multicomponent interventions reduce the incidence of delirium in non-ICU studies. Strategies for the prevention and treatment of ICU delirium are the subjects of multiple ongoing investigations.

/pdf/delirium-in-the-intensive-care-unit-5bylz8s74u.pdf

Delirium in the intensive care unit

Background
Delirium or acute brain dysfunction is extremely prevalent in medical intensive care unit (ICU) patients, but limited data exist regarding its prevalence and risk factors among surgical (SICU) and trauma ICU (TICU) patients. The purpose of this study was to determine the prevalence and risk factors for delirium in surgical and trauma ICU patients.

Prevalence and risk factors for development of delirium in surgical and trauma intensive care unit patients

ContextSedation has become an integral part of critical care practice in minimizing
patient discomfort; however, sedatives have adverse effects and the potential
to prolong mechanical ventilation, which may increase health care costs.ObjectiveTo determine which form of sedation is associated with optimal sedation,
the shortest time to extubation, and length of intensive care unit (ICU) stay.Data SourcesA key word search of MEDLINE, EMBASE, and the Cochrane Collaboration
databases and hand searches of 6 anesthesiology journals from 1980 to June
1998. Experts and industry representatives were contacted, personal files
were searched, and reference lists of relevant primary and review articles
were reviewed.Study SelectionStudies included were randomized controlled trials enrolling adult patients
receiving mechanical ventilation and requiring short-term or long-term sedation.
At least 2 sedative agents had to be compared and the quality of sedation,
time to extubation, or length of ICU stay analyzed.Data ExtractionData on population, intervention, outcome, and methodological quality
were extracted in duplicate by 2 of 3 investigators using 8 validity criteria.Data SynthesisOf 49 identified randomized controlled trials, 32 met our selection
criteria; 20 studied short-term sedation and 14, long-term sedation. Of these,
20 compared propofol with midazolam. Most trials were not double-blind and
did not report or standardize important cointerventions. Propofol provides
at least as effective sedation as midazolam and results in a faster time to
extubation, with an increased risk of hypotension and higher cost. Insufficient
data exist to determine effect on length of stay in the ICU. Isoflurane demonstrated
some advantages over midazolam, and ketamine had a more favorable hemodynamic
profile than fentanyl in patients with head injuries.ConclusionConsidering the widespread use of sedation for critically ill patients,
more large, high-quality, randomized controlled trials of the effectiveness
of different agents for short-term and long-term sedation are warranted.

https://jamanetwork.com/journals/jama/articlepdf/192488/JCE80003.pdf

Roxanne A. Seiferling

Papers

Sedation in the intensive care unit: a systematic review.