Jenny B Hobbs MD Chief of Medicine Rounds June 2, 2009

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Transcription:

Jenny B Hobbs MD Chief of Medicine Rounds June 2, 2009

Daily interruption of sedation has been shown to decrease duration of mechanical ventilation (MV) Sedation interruption protocols have been widely implemented The effectiveness of sedative interruption outside of research settings remains unclear HMC patients can be quite delirious for days to weeks following MV

After implementation of our sedation protocol, what proportion of eligible patients actually receive an interruption of sedation? When sedative interruption is performed, is it done according to protocol? What are the reasons that sedative interruption is not performed in every eligible patient?

Emphasis on bolus dosing rather than gtt - lorazepam up to 4mg IV q15min, morphine up to 10mg IV q10min Sedation interruption only for those on gtts If pt sedated (Ramsay score >3): Stop sedative & analgesic gtts qam until Ramsay 1-3, or pain/vent problems After interruption, bolus & resume gtt at 50% prior rate If pt at goal (Ramsay 1-3): Reduce gtt rate by 50% Discontinue gtt if rate is already low

Must have new MD order to hold sedation interruption each day Acceptable conditions for holding sedation interruption: Hemodynamically unstable on pressors Significant desats NOT assoc w/turns on FiO2 >80%, PEEP >15 Unstable ICP (freq spikes >15min or consistent ICP>25)

Retrospective chart review Setting: all HMC ICU s Inclusion: On MV for >24h during Nov 06 or May 07 On continuous sedative and/or analgesic gtt at 9AM on Day 2, 4, and/or 8 of MV Exclusion: bolus sedation only Full implementation of sedation interruption: stopping gtts entirely for any length of time, and restarting at 50% or less of prior dose

CLINICAL CHARACTERISTICS Total eligible patients 115 Male (%) 65 Age (mean [SD]) 45 (16) Type of service: (%) Medicine 27 Surgery 45 Neurology/Neurosurgery 28

DAY 2 DAY 4 DAY 8 Number eligible 95 56 32 Sedative interruption: (N, [% of total]) Ordered 60 (63) 39 (70) 26 (81) Attempted 63 (66) 36 (65) 18 (56) Fully implemented 26 (27) 11 (20) 6 (19) Duration of sedative interruption, minutes (median [IQR]) 60 (25-110) 60 (30-143) 50 (42-60)

DAY 2 DAY 4 DAY 8 Number eligible 95 56 32 Sedative interruption: (N, [% of total]) Ordered 60 (63) 39 (70) 26 (81) Attempted 63 (66) 36 (65) 18 (56) Fully implemented 26 (27) 11 (20) 6 (19) Duration of sedative interruption, minutes (median [IQR]) 60 (25-110) 60 (30-143) 50 (42-60)

DAY 2 DAY 4 DAY 8 Number eligible 95 56 32 Sedative interruption: (N, [% of total]) Ordered 60 (63) 39 (70) 26 (81) Attempted 63 (66) 36 (65) 18 (56) Fully implemented 26 (27) 11 (20) 6 (19) Duration of sedative interruption, minutes (median [IQR]) 60 (25-110) 60 (30-143) 50 (42-60)

DAY 2 DAY 4 DAY 8 Number eligible 95 56 32 Sedative interruption: (N, [% of total]) Ordered 60 (63) 39 (70) 26 (81) Attempted 63 (66) 36 (65) 18 (56) Fully implemented 26 (27) 11 (20) 6 (19) Duration of sedative interruption, minutes (median [IQR]) 60 (25-110) 60 (30-143) 50 (42-60)

Day 2 (N=37) Day 4 (N=25) Day 8 (N=12) Total Sedation not stopped 14 5 2 21 Analgesia not stopped 2 2 3 7 Sedation restarted at >50% prior rate 30 19 7 56 Analgesia restarted at >50% prior rate 7 8 8 23 Data not recorded 5 2 1 8

Small sample size Single institution study Lack of detailed information available about patients level of agitation during and after sedative interruption Inconsistent documentation

Significant variability in practice, even within a single institution with a well-defined protocol. Full implementation occurred in less than 25% of eligible patients Improved documentation necessary to better understand reasons for incomplete implementation Efforts should be made to improve knowledge and practices of staff Larger study population needed to evaluate outcomes and differences in practice between medical services/nursing floors

Terri Hough (Research mentor) Veena Karir (Coauthor) Scott Weigle Internal Medicine Residency program Arch Shaw Foundation NIH K grant

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