ICU protocol for analgesia, sedation, and delirium improves outcomes
MedWire News: An educational initiative incorporating systemic management protocols with nonpharmacologic measures and individualized titration of therapies for sedation, analgesia, and delirium can improve patient outcomes, researchers say.
Teaching intensive care unit (ICU) staff to use a protocol in which the clinical features of pain, agitation, and delirium are monitored and used to refine treatment reduced medication use, rates of iatrogenic coma and subsyndromal delirium, and also decreased death rates.
Sedatives and analgesics use in the ICU in doses that alter consciousness contribute to delirium and mortality, say Yoanna Skrobik (Hôpital Maisonneuve-Rosemont, Montreal, Canada) and colleagues.
They examined the effect of a pilot scheme run by a multidisciplinary team that taught and implemented individualized nonpharmacologic strategies and titration of analgesics, sedatives, and antipsychotics based on sedation, analgesia, and delirium scores at a single tertiary care adult ICU between April and November 2005.
Prior to the protocol, daily symptom assessments were performed routinely but pharmacologic interventions prescribed by physicians were not routinely titrated, opiate and sedative perfusions were usually prescribed at a fixed rate without systematic adjustments, and there were no systematic nonpharmacologic interventions.
Compared with 610 patients treated in a pre-pilot period from August 2003 to February 2004, 604 patients treated after its instigation benefited from better analgesia, receiving significantly lower mean doses of opiates (22.3 vs 103.5 morphine equivalents/day).
Despite comparable sedation, patients treated during the protocol period also had shorter duration of mechanical ventilation. They also had significantly lower medication-induced coma rates (8.7% vs 20.5%), ICU and hospital length of stay, and dependency at discharge than those treated beforehand.
Subsyndromal delirium was significantly reduced by the protocol although delirium was similar. The risk for death at 30 days was significantly lower in patients after the protocol was initiated compared with beforehand (22.9% vs 29.4%).
Reporting in the journal Anaesthesia and Analgesia, the researchers conclude: "These data suggest that individualization of care with therapeutic intent improves outcomes."
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By Anita Wilkinson