A randomized trial of daily awakening in critically ill patients managed with a sedation protocol: a pilot trial.

OBJECTIVE: Protocolized sedation (PS) and daily sedative interruption (DI) in critically ill patients have both been shown to shorten the durations of mechanical ventilation (MV) and intensive care unit (ICU) stay. Our objective was to determine the safety and feasibility of a randomized trial to determine whether adults managed with both PS + DI have a shorter duration of MV than patients managed with PS alone. DESIGN: Prospective randomized, concealed, unblinded, multicenter, pilot trial. SETTING: Three university-affiliated medical-surgical ICUs. PATIENTS: Sixty-five adults anticipated to require MV >48 hrs and receiving sedative/analgesic infusions. INTERVENTIONS: Patients were randomized to PS alone, or PS + DI. PS was implemented by bedside nurses; sedatives/analgesics were titrated to achieve Sedation Agitation Score (SAS) 3-4. The PS + DI group also had infusions interrupted daily until the patients awoke. MEASUREMENTS AND MAIN RESULTS: Diagnosis, age [mean +/- SD] (53 +/- 18.3 vs. 62.1 +/- 16.7 yrs) and Acute Physiology and Chronic Health Evaluation II (27.7 +/- 8.4 vs. 26.6 +/- 8.4) were similar in the PS and PS + DI groups, respectively. The median duration of MV in the PS and PS + DI groups was 8.0 vs. 10.5 days, and ICU stay was 10.0 vs. 13.0 days, respectively. The SAS was within target range (3-4) in 59% of 9,611 measurements, and within an acceptable range (2-5) in 86% of measurements. Self-assessed nursing and respiratory therapist workload was low in the majority of the cohort. Adverse events were similar in both groups. Patient recruitment was slower than projected (1.5 patients/mo). CONCLUSION: This pilot trial comparing PS vs. PS + DI confirmed the safety and acceptability of the sedation protocol and DI, and guided important modifications to the protocol, thus enhancing the feasibility of a future multicenter trial. This trial was not designed to detect small but significant differences in clinically important outcomes.

Canadian survey of the use of sedatives, analgesics, and neuromuscular blocking agents in critically ill patients.

OBJECTIVES: To characterize the perceived utilization of sedative, analgesic, and neuromuscular blocking agents, the use of sedation scales, algorithms, and daily sedative interruption in mechanically ventilated adults, and to define clinical factors that influence these practices. DESIGN: Cross-sectional mail survey. PARTICIPANTS: Canadian critical care practitioners. MEASUREMENTS AND MAIN RESULTS: A total of 273 of 448 eligible physicians (60%) responded. Respondents were well distributed with regard to age, years of practice, specialist certification, size of intensive care unit and hospital, and location of practice. Twenty-nine percent responded that a protocol/care pathway/guideline for the use of sedatives or analgesics is currently in use in their intensive care unit. Daily interruption of continuous infusions of sedatives or analgesics is practiced by 40% of intensivists. A sedation scoring system is used by 49% of respondents. Of these, 67% use the Ramsay scale, 10% use the Sedation-Agitation Scale, 9% use the Glasgow Coma Scale, and 8% use the Motor Activity Assessment Scale. Only 3.7% of intensivists use a delirium scoring system in their intensive care units. Only 22% of respondents currently have a protocol for the use of neuromuscular blocking agents in their intensive care unit, and 84% of respondents use peripheral nerve stimulation for monitoring. In patients receiving neuromuscular blocking agents for >24 hrs, 63.7% of respondents discontinue the neuromuscular blocking agent daily. Intensivists working in university-affiliated hospitals are more likely to employ a sedation protocol and scale (p < .0001), as are intensivists working in larger intensive care units (>or=15 beds, p < .01). Intensivists with anesthesiology training (and no formal critical care training) are more likely to use a protocol and sedation scale, and critical care-trained intensivists are more likely to use daily interruption. Younger physicians (<40 yrs) are more likely to practice daily interruption (p = .0092). CONCLUSIONS: There is significant variation in critical care sedation, analgesia, and neuromuscular blockade practice. Given the potential effect of practices regarding these medications on patient outcome, future research and educational efforts related to evidence-based protocols for the use of these agents in mechanically ventilated patients might be worthwhile.

Prospective evaluation of an internet-linked handheld computer critical care knowledge access system.

INTRODUCTION: Critical care physicians may benefit from immediate access to medical reference material. We evaluated the feasibility and potential benefits of a handheld computer based knowledge access system linking a central academic intensive care unit (ICU) to multiple community-based ICUs. METHODS: Four community hospital ICUs with 17 physicians participated in this prospective interventional study. Following training in the use of an internet-linked, updateable handheld computer knowledge access system, the physicians used the handheld devices in their clinical environment for a 12-month intervention period. Feasibility of the system was evaluated by tracking use of the handheld computer and by conducting surveys and focus group discussions. Before and after the intervention period, participants underwent simulated patient care scenarios designed to evaluate the information sources they accessed, as well as the speed and quality of their decision making. Participants generated admission orders during each scenario, which were scored by blinded evaluators. RESULTS: Ten physicians (59%) used the system regularly, predominantly for nonmedical applications (median 32.8/month, interquartile range [IQR] 28.3-126.8), with medical software accessed less often (median 9/month, IQR 3.7-13.7). Eight out of 13 physicians (62%) who completed the final scenarios chose to use the handheld computer for information access. The median time to access information on the handheld handheld computer was 19 s (IQR 15-40 s). This group exhibited a significant improvement in admission order score as compared with those who used other resources (P = 0.018). Benefits and barriers to use of this technology were identified. CONCLUSION: An updateable handheld computer system is feasible as a means of point-of-care access to medical reference material and may improve clinical decision making. However, during the study, acceptance of the system was variable. Improved training and new technology may overcome some of the barriers we identified.

Critical care procedure logging using handheld computers.

INTRODUCTION: We conducted this study to evaluate the feasibility of implementing an internet-linked handheld computer procedure logging system in a critical care training program. METHODS: Subspecialty trainees in the Interdepartmental Division of Critical Care at the University of Toronto received and were trained in the use of Palm handheld computers loaded with a customized program for logging critical care procedures. The procedures were entered into the handheld device using checkboxes and drop-down lists, and data were uploaded to a central database via the internet. To evaluate the feasibility of this system, we tracked the utilization of this data collection system. Benefits and disadvantages were assessed through surveys. RESULTS: All 11 trainees successfully uploaded data to the central database, but only six (55%) continued to upload data on a regular basis. The most common reason cited for not using the system pertained to initial technical problems with data uploading. From 1 July 2002 to 30 June 2003, a total of 914 procedures were logged. Significant variability was noted in the number of procedures logged by individual trainees (range 13-242). The database generated by regular users provided potentially useful information to the training program director regarding the scope and location of procedural training among the different rotations and hospitals. CONCLUSION: A handheld computer procedure logging system can be effectively used in a critical care training program. However, user acceptance was not uniform, and continued training and support are required to increase user acceptance. Such a procedure database may provide valuable information that may be used to optimize trainees' educational experience and to document clinical training experience for licensing and accreditation.