Prospective Pilot Study: Tolerability of Outpatient Penile Plication Under Nursing-Administered Conscious Sedation vs Anesthesiologist-Administered Deep Sedation.

INTRODUCTION: Penile plication is commonly performed for Peyronie's disease under general or spinal anesthesia. Conscious sedation (CS) offers decreased anesthetic risks, cost-effectiveness, and the ability to perform the procedure in outpatient settings with shorter wait times. We sought to compare tolerability of penile plication under deep intravenous sedation (DIS) administered by anesthesiologists and nursing-administered CS (NACS). METHODS: Tolerability for penile plication was prospectively evaluated, excluding revision surgeries and those with hourglass or hinge deformities. DIS included midazolam and ketamine with infusion of propofol and remifentanil. NACS consisted of midazolam and fentanyl. Baseline characteristics, procedural information, and patient- and surgeon-reported pain assessments were collected. Patients were administered a standardized tolerability questionnaire on follow-up. RESULTS: Forty patients were enrolled (23 DIS; 17 NACS) with similar baseline characteristics. Median curvature of the DIS cohort was 55° (interquartile range = 43.75-76.25) and 45° (interquartile range = 45-60) in NACS. There was a 100% success rate with no procedure abortion or conversion to general anesthetic. On follow-up, all patients had functional curvature (<20°), and 100% of patients in the DIS and NACS cohorts reported that they would recommend CS to others. Over 93% of patients in both cohorts would choose CS over general anesthetic in the future, with no differences in perioperative and postoperative pain between groups. CONCLUSIONS: Penile plication with CS, whether administered by an anesthesiologist or nursing, is well tolerated with no differences in pain or complications. This indicates that outpatient penile plication with trained nursing staff administering CS can safely reduce costs, risks, and wait times.

Conhecimento e percepção de enfermeiros frente à sedação paliativa na oncologia / Knowledge and perception of nurses dealing with palliative sedation in oncology / Conocimiento y percepción de los enfermeros frente a la sedación paliativa en oncología

Objetivo: compreender o conhecimento e a percepção de enfermeiros quanto à sedação paliativa em oncologia. Método: estudo qualitativo, exploratório e descritivo, com delineamento transversal. Participaram do estudo 16 enfermeiros atuantes na oncologia de um hospital de referência localizado ao norte do Rio Grande do Sul. A coleta de dados ocorreu por meio de entrevista gravada com duração de aproximadamente 10 minutos, sendo aplicado um roteiro de perguntas fechadas com a finalidade de caracterizar os enfermeiros participantes da pesquisa, e perguntas abertas e específicas para contemplar o objetivo do estudo. O método utilizado para o diagnóstico e verificação dos dados da pesquisa foi a análise de conteúdo de Bardin. Os dados foram analisados e codificados por meio do software NVivo 10, que gerou categorias de similaridade e correlações. Resultados: surgiram cinco categorias intituladas "Conhecimento sobre sedação paliativa; Percepção sobre sedação paliativa na oncologia; Sentimentos em relação à sedação paliativa aos pacientes oncológicos; Vivência em relação à sedação paliativa em pacientes oncológicos e Participação do enfermeiro no procedimento de sedação paliativa". Conclusão: o enfermeiro atua de forma efetiva e fundamental na prestação do cuidado e na avaliação do paciente em sedação paliativa, mas ainda encontram-se diversos obstáculos relacionados à participação na tomada de decisões. Evidencia-se a importância de novas pesquisas sobre a temática, como também a implementação de protocolos que subsidiem na indicação da sedação paliativa.(AU)

Objective: to understand the knowledge and perception of nurses dealing with palliative sedation in oncology. Method: this is a qualitative, exploratory, and descriptive study, with a cross-sectional design. The study included 16 nurses working in oncology at a reference hospital located in the north of Rio Grande do Sul. Data were collected through recorded interviews lasting approximately 10 minutes, with a script of closed questions being applied to characterize the nurses participating in the research, and open and specific questions, to contemplate the objective of the study. The method used for the diagnosis and verification of research data was Bardin's content analysis. Data were analyzed and coded using the NVivo 10 software, which generated categories of similarity and correlations. Results: five categories emerged: (i) Knowledge about palliative sedation; (ii) Perception of palliative sedation in oncology; (iii) Feelings regarding palliative sedation in cancer patients; (iv) Experience with palliative sedation in cancer patients; and (v) Participation of the nurse in the palliative sedation procedure. Conclusion: nurses act effectively and fundamentally in providing care and evaluating patients undergoing palliative sedation, but there are still several obstacles related to their participation in decision-making. The importance of new research on the subject is evident, as well as the implementation of protocols that support the indication of palliative sedation.(AU)

Objetivo: comprender el conocimiento y la percepción de los enfermeros sobre la sedación paliativa en oncología. Método: estudio cualitativo, exploratorio y descriptivo, con diseño transversal. El estudio abarcó 16 enfermeros que trabajaban en oncología en un hospital de referencia localizado en el norte de Rio Grande do Sul. La colecta de datos ocurrió por medio de entrevista grabada con duración aproximada de 10 minutos, siendo aplicado un guión de preguntas cerradas con la finalidad de caracterizar los enfermeros participantes de la investigación, y preguntas abiertas y específicas para contemplar el objetivo del estudio. El método utilizado para el diagnóstico y verificación de los datos de la investigación fue el análisis de contenido de Bardin. Los datos fueron analizados y codificados utilizando el software NVivo 10, que generó categorías de similitud y correlaciones. Resultados: surgieron cinco categorías tituladas "Conocimientos sobre sedación paliativa; Percepción de la sedación paliativa en oncología; Sentimientos con respecto a la sedación paliativa para pacientes con cáncer; Experiencia con sedación paliativa en pacientes oncológicos y participación de Enfermeros en el procedimiento de sedación paliativa". Conclusión: el enfermero actúa de forma eficaz y fundamental en la prestación del cuidado y en la evaluación del paciente en sedación paliativa, pero aún existen varios obstáculos relacionados con la participación en la toma de decisiones. Es evidente la importancia de seguir investigando sobre el tema, así como la implementación de protocolos que sustenten la indicación de la sedación paliativa.(AU)

Airway Management for Deep Sedation: Current Practice, Limitations, and Needs as Identified by Clinical Observation and Survey Results.

Using deep sedation, adjunct airway devices such as oral or nasal airways are frequently required to maintain airway patency. Traditional oral airways (TOAs, made of rigid plastic) or nasal airways (made of pliable materials) can be associated with adverse effects, contributing to a trend of anesthesia providers placing nasal airways orally. A clinical observational study and an electronic provider survey were conducted to examine this emerging practice. The observation study objective was to investigate reported postoperative sore throat occurrence associated with use of either a nontraditional airway (nasal airway used orally) or TOA in deep sedation procedures (N = 243). Patients receiving nontraditional airways reported significantly less postoperative sore throat than those receiving TOAs (17% vs 40%, respectively; P < .001). These results prompted a broader exploration into airway practices of anesthesia providers via an electronic survey. Most respondents (n = 293) reported adverse effects, including gagging/coughing on insertion, oral cavity injury, and bleeding with TOAs. More than half (52.8%) reported using nasal airways orally. These results suggest a clinical void in current airway management options for deep sedation. Providers indicated the need for airway devices that provide a patent airway while mitigating adverse effects associated with commonly used airways.

Procedimientos de sedoanalgesia pediátricos: formación y práctica profesional de los enfermeros en los servicios de urgencias españoles / Procedures for pediatric sedation and analgesia: professional training and practice of nurses in Spanish emergency departments

No disponible

Relación entre factores del paciente, del profesional de enfermería y de la institución con el logro de un objetivo de sedoanalgesia en una UCI de adultos de Medellín, Colombia / Relationship between factors of the patient, the nursing professional and the institution with the achievement of a sedoanalgesia goal in an adult ICU in Medellín, Colombia

Objetivo: Analizar la relación existente entre los factores del paciente, del profesional de enfermería y de la institución con el logro de un objetivo de sedoanalgesia en una UCI de adultos de Medellín, Colombia. Metodología: Estudio cuantitativo, descriptivo, transversal, correlacional, realizado con 79 pacientes adultos de una UCI de una Institución de Medellín (ANT), durante 6 meses entre el 2019 y el 2020. Se revisaron historias clínicas de los pacientes para analizar las variables independientes: estado nutricional, función renal, nivel de adherencia al protocolo de sedoanalgesia institucional por parte de los profesionales de enfermería, carga laboral; y la variable dependiente: logro del objetivo de sedoanalgesia, y, si se encontró asociación estadística entre las variables a través de la aplicación del Coeficiente de correlación de Spearman. Resultados: el 86% de los pacientes obtuvieron un riesgo nutricional alto según la NUTRIC. El 53,4% del total de pacientes masculinos y el 19,4% del género femenino tuvo un nivel de creatinina superior al normal. El 56,9% de los pacientes tuvo un IFG inferior al normal. En el 94% de los pacientes se encontró un nivel de adherencia al protocolo alto por parte de enfermería. El 96% de los pacientes tuvo un grado IV según la clasificación de la TISS-28. El 57% de los pacientes alcanzaron el objetivo de sedoanalgesia. Se encontró asociación positiva débil (0,263) estadísticamente significativa (p=0,019) entre la variable NUTRIC con el logro del objetivo de sedoanalgesia Conclusiones: Existe relación entre el estado nutricional y el logro de un objetivo de sedoanalgesia. (AU)

Objective: To analyze the relationship between the factors of the patient, the nursing professional and the institution with the achievement of a sedoanalgesia objective in an ICU for adults in Medellín, Colombia. Methodology: Quantitative, descriptive, cross-sectional, correlational study, carried out with 79 adult patients from an ICU of an Institution of Medellín (ANT), during 6 months between 2019 and 2020. Medical records of the patients were reviewed to analyze the independent variables : nutritional status, kidney function, level of adherence to the institutional sedoanalgesia protocol by nursing professionals, workload; and the dependent variable: achievement of the sedoanalgesia objective, and, if a statistical association was found between the variables through the application of the Spearman correlation coefficient. Results: 86% of the patients obtained a high nutritional risk according to NUTRIC. 53.4% of the total male patients and 19.4% of the female gender had a creatinine level higher than normal. 56.9% of the patients had a lower than normal GFR. In 94% of the patients, a high level of adherence to the protocol was found by the nursing staff. 96% of the patients had a grade IV according to the TISS-28 classification. 57% of the patients reached the goal of sedoanalgesia. We found a weak positive association (0.263) statistically significant (p = 0.019) between the NUTRIC variable with the achievement of the sedoanalgesia goal. Conclusions: There is a relationship between the nutritional status and the achievement of a sedoanalgesia goal. (AU)

Nurses' Attitudes and Practices Related to Sedation: A National Survey.

BACKGROUND: Nurses are fundamental to the implementation of sedation protocols for patients receiving mechanical ventilation. A 2005 survey showed that nurses' attitudes toward sedation affected their sedation practices. Since then, updated guidelines on managing pain, agitation, and delirium have been published. OBJECTIVE: To explore nurses' self-reported attitudes and practices related to sedation and determine whether they have changed in the past decade. METHODS: Members of the American Association of Critical-Care Nurses were invited to complete the Nurse Sedation Practices Scale, which measures nurses' self-reported sedation practices and factors that affect them. Item and subscale responses were analyzed, and differences in item responses by respondent characteristics were determined. RESULTS: Respondents (N = 177) were mostly staff nurses (68%) with a bachelor's degree in nursing (63%). Nurses' attitudes toward the effectiveness of sedation in relieving patients' distress during mechanical ventilation correlated positively with their intention to administer sedatives (r s = 0.65). Sixty-six percent of nurses agreed that sedation was necessary for patients' comfort, and 34% agreed that limiting patients' recall was a desired outcome of sedation. Respondents with more experience or CCRN certification had a less positive evaluation of the effectiveness of sedation in minimizing distress. CONCLUSIONS: Nurses' attitudes toward sedating patients receiving mechanical ventilation have shifted in the past decade, with fewer nurses now believing that all patients should be sedated. However, more than half of nurses still agree that sedation is needed for patients' comfort, highlighting the need to consider nurses' attitudes when seeking to optimize sedation practices during mechanical ventilation.

The early diagnosis and management of mixed delirium in a patient placed on ECMO and with difficult sedation: A case report.

Delirium represents a serious problem that impacts the physical and cognitive prognosis of patients admitted to intensive care units and requires prompt diagnosis and management. This article describes the case and progress of a patient placed on Extracorporeal Membrane Oxygenation with difficult sedation criteria and an early diagnosis of mixed delirium. During the case report, we reflect on the pharmacological and non-pharmacological strategies employed to cope with delirium paying special attention to the non-use of physical restraint measures in order to preserve vital support devices (endotracheal tube or Extracorporeal Membrane Oxygenation cannula). The multimodal and multidisciplinary approach, focused on nursing interventions, strict Pain/Agitation/Delirium monitoring and pharmacological measures, as well as the implementation of measures according to the eCASH (early Comfort using Analgesia, minimal Sedatives and maximal Human Care) concept, were effective, resulting in a relatively short admission considering the severity of the patient's condition and the associated complications. Early independent ambulation was achieved prior to transfer to a hospitalisation unit.

Percepções reais e ilusórias de pacientes após coma induzido: subsídios da literatura na perspectiva da elaboração de instrumento de avaliação / Real and illusory perceptions of patient after induced coma: aid from literature at the perspective of elaborate a device of evaluation

O coma pode ser definido como uma diminuição da capacidade neural do indivíduo, podendo ser fisiológico ou induzido. O coma induzido é obtido através da administração intencional de sedativos frente a necessidade de prevenção de distúrbios neurais ou até mesmo para conforto do paciente. A escolha e a manutenção da sedação são direcionadas por diretrizes nacionais e internacionais de sociedades de especialistas em cuidados críticos e medicina intensiva, porém ainda não há precisão e consenso sobre qual é a melhor forma de realizar a sedação, fármaco de escolha, ou tempo ideal de sedação, devendo tais decisões serem tomadas de forma integral e individualizada para cada paciente. Frente a esse contexto o presente estudo teve o objetivo de construir questionário estruturado para avaliação de percepções reais e ilusórias de pacientes após o coma induzido. Foi desenvolvido em duas fases, sendo a primeira referente a revisão integrativa de 15 estudos primários localizados nas bases de dados Medline, Web of Science, Lilacs, Cinahl e Scopus. Na segunda fase foi elaborada a versão protótipo de um questionário para avaliação das percepções reais e ilusórias de pacientes após o coma induzido. A revisão integrativa permitiu identificar que as principais memórias relatadas após o coma induzido são sede, frio e dor. Há estudos em que os pacientes afirmaram não distinguir se estavam acordados ou sonhando, se era real ou irreal. Identificaram-se relatos de memórias satisfatórias relacionadas ao cuidado recebido e ao uso de diários de cabeceira. Tendo como referência a síntese das evidências identificadas, propusemos a versão protótipo do "Questionário de avaliação das percepções do paciente após o coma induzido" composto de 15 itens, sendo oito questões fechadas e sete questões mistas distribuídas em duas seções, uma relativa a temática das percepções e a segunda sobre a caracterização do paciente. O instrumento ora apresentado deverá ter suas propriedades psicométricas validadas para adoção na prática clínica

The coma can be define such as a decrease of neural capacity of individual, could be physiological or induced. The induced coma occurs by means of the intentional management of sedatives faced the necessary on prevent neural disorders or even the comfort to patient. The choice and maintenance about sedation are target by national and international guidelines of specialists in critical cares and intensive medicine, however there is not a precision and consensus about how is the best way to realize the sedation, the medicine of choice, or the ideal time of sedation, this decisions should be taken in full and individual way as each patient. On this context, the objective of this research was set up a structured questionnaire for evaluation the real and illusory perceptions of patients after the induced coma. It was developed in two phases, in the first refer to a integrative review of fifteen primary studies location in the databases of Medline, Web of Science, Lilacs, Cinahl, Scopus. In the second phase, it was elaborated the prototype version of one questionnaire for evaluation the real and illusory perceptions of patients after the induced coma. The integrative review possibilited identify that main memories related after the induced coma are thirst, cold and pain. There are studies wherein the patients said they don't discern if they were waked up or dreaming, if it was real or unreal. It was identified reports of satisfactory memories related about care that they received and the use of head of table diaries. The synthesis of evidences that it was identified, enabled we propose a prototype version of "Questionnaire of evaluation of the perceptions of patient after the induced coma", that is compound with fifteen questions, being eight objective questions and seven mixed questions, one on the subject of perceptions and the second about the characterization of the patient. The instrument presents should have yours psychometric properties authenticate for the introduction in clinical pratice

Relatos de vida y fotografía de pacientes sedados en UCI: ¿estrategia de humanización posible? / Relatos de vida e fotografia de pacientes sedados em UTI: estratégia de humanização possível? / Life stories and photographs of sedated patients in the ICU: a possible humanization strategy?

Objetivos: (1) Identificar la influencia del contexto del paciente sedado a través de las historias de vida y fotografía en la percepción del cuidar del personal de enfermería y (2) evaluar la intervención que se propone como una estrategia de humanización para cuidar al paciente sedado. Método: Investigación cualitativa de intervención con 43 profesionales del equipo de enfermería de una Unidad de Cuidados Intensivos. La colecta de datos consistió en una entrevista previa, la intervención (fijación de los cuadros de los pacientes sedados en la cabecera y orientación para que los profesionales los leyesen; la intervención duró 10 días) y entrevista posterior a la intervención. Tres cuadros fueron fijados, que contenían las fotos y las historias de vida de los pacientes planteadas por sus familias. Resultados: En la pre-intervención, los discursos mostraron que la interacción verbal aporta una mayor seguridad durante el cuidado, hay razones para la preferencia del cuidado de los pacientes inconscientes, como el reto de la complejidad y la recompensa de la recuperación, como la no disponibilidad para cumplir con las solicitudes frecuentesdel paciente, la atención se valora independientemente del nivel de conciencia, el conocimiento sobre los aspectos de la vida del paciente mejora el compromiso y existe la preocupación de no juzgar al paciente y rescatar lo mejor del otro. En la post-intervención se encontró que el contexto del paciente rescató elementos importantes para el cuidado como la emoción, promoviendo sensibilidad, el despertar de la empatía con la contextualización, la implicación y el compromiso con el cuidado, por otra parte era evidente el conflicto entre el cambio actitud y salir a la defensiva. Conclusión: La intervención propuesta ha sido validada como una estrategia para humanizar la atención de los pacientes sedados (AU)

Objetivos: (1) Identificar a influência da contextualização do paciente sedado por meio de relatos de vida e fotografia na percepção do cuidar da equipe de enfermagem e (2) avaliar a intervenção proposta como uma estratégia de humanização para o cuidado ao paciente sedado. Método: Pesquisa qualitativa e de intervenção com 43 profissionais da equipe de enfermagem de uma Unidade de Terapia Intensiva. A coleta de dados consistiu de uma entrevista prévia, intervenção (fixação de quadros de pacientes sedados à beira do leito e orientação para que os profissionais os lessem; a intervenção teve duração de 10 dias) e entrevista pós-intervenção. Três quadros foram fixados e estes continham fotografia e relatos de vida dos pacientes levantados por meio de seus familiares. Resultados: Na pré-intervenção, os discursos mostraram que a interação verbal traz mais segurança durante o cuidado, há razões para preferência do cuidar de pacientes inconscientes, como o desafio da complexidade e a recompensa da recuperação, como a indisponibilidade para atender solicitações frequentes do paciente, o cuidado é valorizado independentemente do nível de consciência, conhecimento sobre aspectos da vida do paciente melhora o envolvimento e há uma preocupação de não julgar o paciente e resgatar o melhor do outro. Na pós-intervenção constatou-se que a contextualização do paciente resgatou elementos importantes para o cuidar, como a emoção promovendo sensibilização, o despertar da empatia com a contextualização, o envolvimento e o compromisso com o cuidado, além disso foi aparente um conflito entre mudar de atitude e sair da defensiva. Conclusão: A intervenção proposta foi validada como estratégia para humanização no cuidado de pacientes sedados (AU)

Aims: (1) To identify the influence of the contextualization of sedated patient, by means of life reports and photographs, from the perception of care of the nursing team and (2) to evaluate the proposed intervention as a strategy for humanization in the care for sedated patients. Method: Qualitative intervention study, with 43 professionals of the nursing team of an Intensive Care Unit. Data collection consisted of a prior interview, the intervention (fixing of pictures and life reports of sedated patients to the bedside and orientation for the professionals to read them, with the intervention lasting 10 days) and a post-intervention interview. Three frames were fixed and these contained a photograph and life reports of the patients collected through their family members. Results: In the pre-intervention, the discourses showed that verbal interaction provides more security during the care, there are reasons for preferring to care for unconscious patients, such as the challenge of the complexity and the reward with recovery, as well as the unavailability to attend to frequent requests of the conscious patient. The care was valorized independent of the level of consciousness, knowledge about aspects of the patient’s life increased involvement and there was a concern not to judge the patient and to rescue the best of the other. In the post-intervention, it was observed that the contextualization of the patient rescued important elements for the care, such as emotion promoting sensitization, the awakening of empathy with the contextualization, and the involvement and commitment to the care. In addition, a conflict between change of attitude and being defensive was apparent. Conclusion: The proposed intervention was validated as a strategy for humanization in the care for sedated patients (AU)

[Pharmacological Treatment in End-of-Life Sedation]. / Manejo farmacológico de la sedación paliativa en la agonía.

Objective: To control the physical symptoms in end-of-life pharmacological management involves major intervention. The aim of this article is to review the relevant issues in the management of clinical nursing situation and drugs commonly used in palliative sedation in agony. Methodology: Nursing management in Palliative Sedation recommended by scientific literature search in Scopus, CINAHL, Medline-PubMed and Google Scholar, with key words "palliative sedation", "pharmacology", "nursing care" and "palliative care" are selected. Results: The goal of palliative sedation (PS) is to reduce the level of consciousness as the only way to relieve intense suffering in terminally ill patients, such as refractory delirium or dyspnea, massive bleeding, convulsive status, crackles premortem or refractory psychological suffering. The route of choice in PS is subcutaneous injection (sc). First line drugs in sedation are midazolam and levomepromazina. Opioids should be kept at equi-analgesic doses, morphine chloride being the most widely used. The fundamental role of nursing in SP is monitoring the level of sedation based on the Ramsay scale (or similar) and recognition of the indicative signs of discomfort for administration rescue sedative or analgesic medication and/or screening treatable intercurrent process (distended bladder, constipation, obstruction way, final dose effect, etc.).

Sedation versus no sedation: Are there differences in relatives' satisfaction with the Intensive Care Unit? A survey study based on data from a randomised controlled trial.

BACKGROUND: Currently there is a trend towards less or no use of sedation of mechanically ventilated patients. Still, little is known about how different sedation strategies affect relatives' satisfaction with the Intensive Care Unit (ICU). AIM: To explore if there was a difference in relatives' personal reactions and the degree of satisfaction with information, communication, surroundings, care and treatment in the ICU between relatives of patients who receive no sedation compared with relatives of patients receiving sedation during mechanical ventilation in the ICU. METHOD: A survey study using a questionnaire with 39 questions was distributed to relatives of mechanically ventilated patients, who had been randomised to either sedation with daily wake up or no sedation. RESULTS: Forty-nine questionnaires were sent out and 36 relatives answered. The response rate was 73%. We found no differences in relatives' personal reactions or in the degree of satisfaction with information, communication, care and treatment in the ICU between relatives of patients in the two groups. Relatives of patients treated with no sedation felt more bothered by disturbances in the surroundings compared with relatives of patients who were sedated (p=0.03). CONCLUSION: Treating the patient during mechanical ventilation with no sedation does not affect relatives' satisfaction adversely.

Implementation of a Nurse-Driven Sedation Protocol in a PICU Decreases Daily Doses of Midazolam.

OBJECTIVES: To evaluate the impact of a nurse-driven sedation protocol on the length of mechanical ventilation, total daily doses of sedatives, and complications of sedation. DESIGN: A single-center prospective before and after study was conducted from October 2010 to December 2013. SETTING: Twelve-bed surgical and medical PICU of the university-affiliated hospital in Nantes, France. PATIENTS: A total of 235 patients, between 28 days and 18 years old, requiring mechanical ventilation for at least 24 hours were included in the study; data from 194 patients were analyzed. INTERVENTIONS: During the first study phase, no protocol was used. During the second phase, patients were sedated according to a nurse-driven protocol. MEASUREMENTS AND MAIN RESULTS: In the whole population, the length of mechanical ventilation did not differ between protocol and control groups (protocol, 4 [3-8] vs control, 5 [3-7.5]; p = 0.44). Analyzing age subgroups, the length of mechanical ventilation was significantly shorter in the protocol group than in the control group in children older than 12 months (4 [3-8] vs 5 [2.75-11.25] d; p = 0.04). Daily dose of midazolam decreased during the protocol phase compared with the control phase (1 [0.56-1.8] and 1.2 [0.85-2.4] mg/kg/d, respectively; p = 0.02). No differences were shown regarding other daily dose of drugs. In the control group, 68% of children had more than 20% of COMFORT-behavior scale assessment under the target (oversedation) versus 59% in the protocol group (p = 0.139). CONCLUSIONS: Implementation of a nurse-driven sedation protocol in a PICU is feasible and safe, allowed a decrease in daily dose of benzodiazepines, and decreased the duration of mechanical ventilation in older patients.

Variation in diurnal sedation in mechanically ventilated patients who are managed with a sedation protocol alone or a sedation protocol and daily interruption.

BACKGROUND: Mechanically ventilated patients may receive more sedation during the night than during the day, potentially delaying extubation. We compared nighttime and daytime benzodiazepine and opioid administration in adult patients enrolled in a multicenter sedation trial comparing protocolized sedation alone or protocolized sedation combined with daily sedation interruption; and we evaluated whether nighttime and daytime doses were associated with liberation from mechanical ventilation. METHODS: This is a secondary analysis of a randomized trial which was conducted in 16 North American medical-surgical ICUs. In all 423 patients, nurses applied a validated sedation scale hourly to titrate benzodiazepine and opioid infusions to achieve a light level of sedation. Using fentanyl equivalents and midazolam equivalents, we compared dosages administered during night (19:00 to 07:00) and day (07:00 to 19:00) shifts. Using multivariable logistic regression we evaluated the association between nighttime and daytime opioid and sedative doses, and spontaneous breathing trial (SBT) conduct, SBT success, and extubation. RESULTS: Nighttime benzodiazepine and opioid doses were significantly higher than daytime doses (mean difference midazolam equivalents 23.3 mg, 95 % CI 12.9, 33.8, p < 0.0001; mean difference fentanyl equivalents 356 mcg, 95 % CI 130, 582, p = 0.0021). Mean Sedation Agitation Scale score was similar between night and day, and was at target (3.2 vs 3.3, 95 % CI -0.05, 0.02, p = 0.35). Self-reported nurse workload was similar during the night and day. Patients were more often restrained during day shifts (76.3 % vs 73.7 %, p < 0.0001), and there were more unintentional device removals during the day compared with night (15.9 % vs 9.1 %, p < 0.0001). Increases in nighttime drug doses were independently associated with failure to meet SBT screening criteria, SBT failure, and the decision not to extubate the patient despite successful SBT. CONCLUSION: Patients received higher doses of opioids and benzodiazepines at night. Higher nighttime doses were associated with SBT failure and delayed extubation. TRIAL REGISTRATION: ClinicalTrials.gov NCT00675363 . Registered 7 May 2008.

La limitación terapéutica en la Unidad de Cuidados Intensivos / Therapeutic limitation of intenseve care unit

La limitación terapéutica es una práctica relativamente frecuente dentro de las Unidades de Cuidados Intensivos. Existen distintos tipos de limitación terapéutica, y se puede clasificar al paciente en función de las medidas susceptibles de retirarse o no iniciarse. Entre dichas medidas, cabe destacar la retirada de la ventilación mecánica junto con la analgesia y la sedación aplicadas al final de la vida del paciente (AU)

The therapeutic limitation is a relatively common in Intensive Care Units practice. There are different types of therapeutic limitation, and the patient can be classified according to measures likely to withdraw or not start. Among such measures include removal of stand mechanical ventilation with the analgesia and sedation applied to the end of life of the patient (AU)

Evaluación de la sedación mediante la escala Richmond Agitation Sedation Scale en pacientes con ventilación mecánica de larga duración / Evaluation of sedation using the Richmond Agitation Sedation Scale in patients with prolonged mechanical ventilation

Introducción. Monitorizar la sedación es necesario para evitar la infra o sobresedación. Objetivos. Evaluar los niveles de sedación más prevalentes en la UCI de acuerdo a las categorías de la escala RASS y valorar si el tratamiento es individualizado. Métodos. Estudio prospectivo de cohortes en pacientes conectados a ventilación mecánica ≥ 96 horas por un periodo de 7 meses. Registro de los valores RASS, junto con el tratamiento sedoanalgésico, modos de ventilación mecánica y signos vitales. Resultados. Se analizaron 1021 valores RASS de 220 días de ventilación mecánica, categorizados en los siguientes rangos: 404 (39.6 %) sedación profunda, 474 (46.4 %) sedación consciente y 54 (5.3 %) agitación. Hubo 89 (8.7 %) valores faltantes. Los pacientes que recibieron sedoanalgesia continua estuvieron más tiempo en sedación profunda que consciente (87.1 % frente a 32.3 %, p < 0.001) y se realizaron más cambios de tratamiento en la sedación consciente que en la profunda, tanto en cuanto a sedoanalgesia en perfusión (42.5 % frente a 22.3 %, p < 0.001) como según modo ventilatorio (12.6 % frente a 2.9 %, p < 0.001). Para valores RASS en el rango de la sedación consciente había un incremento del uso de opiáceos en bolo (6.4 %). Conclusiones. La sedación profunda es predominante en pacientes con sedoanalgesia, con pocos cambios en el modo ventilatorio, ya que prevalece la modalidad controlada y no hay cambios en la perfusión de sedoanalgesia (AU)

Introduction. Sedation is monitored to avoid both under- and oversedation. Objectives. Determine the most prevalent sedation levels in the ICU according to RASS categories and whether treatment is individualized on the basis of these scores. Methods. Prospective cohort study of patients connected to mechanical ventilation ≥ 96 hours in the intensive care unit between January 1 and August 31. Daily assessments were recorded in the intensive care unit, together with sedoanalgesic treatment, ventilation modes, or vital signs. Results. We analyzed 1021 RASS scores collected over a total of 220 MV days, categorized in the following ranges: 404 (39.6 %) deep sedation, 474 (46.4 %) conscious sedation, and 54 (5.3 %) agitation; 89 (8.7 %) were missing scores. Patients receiving continuous sedoanalgesia were more likely to be in the deep sedation than conscious sedation range (87.1 % vs. 32.3 %, p < 0.001). Analysis of patients under continuous sedation and in ventilation mode found more changes in the conscious sedation range than in deep sedation (42.5 % vs. 22.3 % and 12.6 % vs. 2.9 %, respectively; p < 0.001 in both cases). In conscious sedation range there was increased use of opiates in bolus (6.4 %). Conclusions. Deep sedation was clearly prevalent in patients with mechanical ventilation under continuous sedation, with few changes in ventilation mode, because it is prevalent control ventilation mode and no changes in sedonalagesic perfusion in that range (AU)

Moderate and deep nurse-administered propofol sedation is safe.

INTRODUCTION: Non-anaesthesiologist-administered propofol sedation (NAPS/NAAP) is increasingly used in many countries. Most regimens aim for light or moderate sedation. Little evidence on safety of deep NAPS sedation is available. The aim of this study was to explore the safety of intermittent deep sedation with NAPS in patients undergoing gastroenterologic endoscopic procedures. METHODS: This was a retrospective case-control study. All patients sedated with NAPS for colonoscopies, sigmoidoscopies and oesophagogastroduodenoscopies from May 2007 through December 2012 were included. Cases were defined as patients developing an adverse event (oxygen saturation < 92%, a drop in mean arterial pressure of > 30% or a drop in systolic blood pressure of > 50 mmHg). The remaining patients served as controls. RESULTS: A total of 6,840 consecutive patients undergoing 7,364 procedures were included. The mean propofol dose was 331.6 mg (standard deviation = 179.4 mg). The overall rate of hypoxia was 3.2%, and the rate of hypotension was 3.1%. Assisted ventilation was needed in 0.5%. Age (p < 0.001), American Society of Anesthesiologists (ASA) class 3 (p = 0.017) and total propofol dose (p = 0.001) were associated with a higher rate of adverse events. CONCLUSION: Safety during intermittent deep sedation with NAPS was good. Age, ASA class 3 and total propofol dose were correlated with a higher rate of adverse events. Patients aged 60 years or more needed more handling during adverse events. FUNDING: Arvid Nilsson's Foundation provided funding for this study. The founders did not have any influence on the design or the presentation of the study. TRIAL REGISTRATION: not relevant.

Predictive value of the bispectral index for burst suppression on diagnostic electroencephalogram during drug-induced coma.

STUDY PURPOSE: To determine correlation and predictive value between data obtained with the bispectral index (BIS) and diagnostic electroencephalogram (EEG) in determining degree of burst suppression during drug-induced coma. This study seeks to answer the question: "To what degree can EEG suppression and burst count as measured by diagnostic EEG during drug-induced coma be predicted from data obtained from the BIS such as BIS value, suppression ratio (SR), and burst count?" BACKGROUND/SIGNIFICANCE: During drug-induced coma, cortical EEG is the gold standard for real-time monitoring and drug titration. Diagnostic EEG is, from setup through data analysis, labor intensive, costly, and difficult to maintain uniform clinician competency. BIS monitoring is less expensive, less labor-intensive, and easier to interpret data and establish/maintain competency. Validating BIS data versus diagnostic EEG facilitates effective brain monitoring during drug-induced coma at lower cost with similar outcomes. METHOD: This is a prospective, observational cohort study. Four consecutive patients receiving drug-induced coma/EEG monitoring were enrolled. BIS was initiated after informed consent. Variables recorded per minute included presence or absence of EEG burst suppression, burst count, BIS value over time, burst count, and SR. Pearson's product-moment and Spearman rank coefficient for BIS value and SR versus burst count were performed. Regression analysis was utilized to plot BIS values versus bursts/minute on EEG as well as SR versus burst count on EEG. EEG/BIS data were collected from digital data files and transcribed onto data sheets for corresponding time indices. RESULTS: Four patients yielded 1,972 data sets over 33 hours of EEG/BIS monitoring. Regression coefficient of 0.6673 shows robust predictive value between EEG burst count and BIS SR. Spearman rank coefficient of -0.8727 indicates strong inverse correlation between EEG burst count and BIS SR. Pearson's correlation coefficient between EEG versus BIS burst count was .8256 indicating strong positive correlation. Spearman's rank coefficient of 0.8810 and Pearson's correlation coefficient of .6819 showed strong correlation between BIS value versus EEG burst count. Number of patients (4) limits available statistics and ability to generalize results. Graphs and statistics show strong correlation/predictive value for BIS parameters to EEG suppression. CONCLUSIONS: This study is the first to measure correlation and predictive value between BIS monitoring and diagnostic EEG for degree of EEG suppression and burst count in the adult population. Available statistic tests and graphing of variables from BIS and diagnostic EEG show strong correlation and predictive value between both monitoring technologies during drug-induced coma. These support using BIS value, SR, and burst count to predict degree of EEG suppression in real time for titrating metabolic suppression therapy.