Sedation in ICU: are we achieving goals?

The purpose of this study was to examine whether sedation goals, utilizing a validated sedation assessment scale, the Riker Sedation-Agitation Scale [SAS], and a standardized sedation protocol, were achieved in Intensive Care Unit [ICU] patients. This is a nested prospective cohort study. The study was conducted in a tertiary care medical-surgical ICU. All mechanically ventilated adult patients who were judged by their treating intensivists to require intravenous sedation for more than 24 hours, were included in the study. A goal-directed protocol using the SAS was initiated following an educational program to the medical and nursing staff. The following data was collected: patients' demographics, Acute Physiology and Chronic Health Evaluation [APACHE] II score, reason for admission, and outcome. For the first five ICU days, the bedside nurse documented ordered and average achieved SAS scores, every 4 hours. We compared the targeted versus achieved SAS scores using a paired Student's t-test. One hundred and five [105] patients were included in the study with mean age [ +/- SD] of 47 [ +/- 23] and APACHE II [ +/- SD] of 21 [ +/- 9]. Achieved sedation scores were consistently lower than the requested goals during daytime and nighttime shifts throughout the study period. This did not change even after 3 months of implementing the protocol. Achieved levels of SAS score were consistently lower than what was requested by physicians despite an educational program and the use of a standardized protocol. Differences between targeted and achieved SAS scores persisted throughout the whole study period even three months after protocol implementation. These data suggest the need for alternative, more sensitive and precise approaches, to titrate sedation to targeted levels

safety of percutaneous tracheostomy in patients with coagulopathy or thrombocytopenia

The safety and complications of percutaneous tracheostomy [PT] without bronchoscopic guidance in a group of ICU patients with thrombocytopenia platelet count of /= 1.5 or systemic heparinization], was studied. During the study period [May 2004-June 2005], 190 percutaneous tracheostomies were performed. Of these there were 11 [6%] patients with prolonged INR, 7 [4%] patients with thrombocytopenia and 14 [7%] patients on systemic heparin. There was no evidence of bleeding in patients with prolonged INR. A minor bleeding developed in only one patient with thrombocytopenia, and in two patients receiving systemic heparin. The PT was aborted for one patient with thrombocytopenia and slight increase of INR [1.3] due to major bleeding in spite of transfusion of both platelets and FFP. Our data suggest the incidence of bleeding is low in patients with coagulopathy and or thrombocytopenia-undergoing PT without bronchoscopic guidance