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Anaesthesia ; 77:19, 2022.
Article in English | EMBASE | ID: covidwho-2032358

ABSTRACT

Sedation is integral to facilitating interventions on the intensive care unit (ICU), which would otherwise be intolerable;however, in excess it may prolong intubation and lead to brain dysfunction such as delirium [1]. This is a frequently under-diagnosed problem in the ICU, shown to result in worsened neurological outcomes [2]. The Critical Care Pain Observation Tool (CPOT), Richmond Agitation- Sedation Score (RASS), Confusion Assessment Method for the ICU (CAMICU) are validated to assess for pain, over-sedation and delirium, respectively. We explored how effectively these were used in a hospital in the Northeast of England to address over-sedation and delirium. Methods Adults intubated and ventilated on critical care were identified, and the most recent 24 h of bedside observation charts examined for completion of 4-h RASS, 4-h CPOT and 12-h CAM-ICU assessments. For those over-sedated during this time, we assessed whether sedation was appropriately titrated or held. Patients on neuromuscular blocking agents, with acute brain injury or with specific indication for deep sedation were excluded. Results Fifty-five patient-days were audited, during which sedation was utilised in 71% (n = 39). Overall, pain and RASS were monitored well, assessed at 88% and 91% of 4-h opportunities, respectively;however, CAM-ICU was recorded at only 15% of opportunities. Where documented, RASS scores were within target (-2 to 1) 45% of the time. Where out of range, this was almost exclusively due to oversedation (RASS ≤ -3). Eighty-five per cent (n = 33) of patients were over-sedated on at least one occasion in the last 24 h. Of these, 39% (n = 13) had their sedation neither titrated nor held during this time. Notably, this was the case for 55% (n = 11) of the 20 patients intubated for COVID-19, in contrast to only 15% (n = 2) of the 13 patients intubated for other reasons. Discussion Over-sedation in ICU remains prevalent despite adequate RASS surveillance. This is particularly true among COVID-19 patients. Further, infrequent CAM-ICU use may result in delirium being missed, carrying risk of adverse neurological outcomes and mortality [2]. We have implemented protocolled PAD pathways within each bed space, to empower nurses to titrate sedation and improve awareness of CAM-ICU. Additionally, we have disseminated education on the harms of over-sedation and unrecognised delirium, and we are evaluating re-audit data to ascertain if there has been a resulting improvement in PAD management for sedated patients.

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