Características e impacto de la sedación, la analgesia y el bloqueo neuromuscular en los pacientes críticos que recibieron ventilación mecánica prolongada

doi:10.1016/j.medin.2009.04.001

Medicina Intensiva

Volume 33, Issue 7, October 2009, Pages 311-320

https://doi.org/10.1016/j.medin.2009.04.001 Get rights and content

Resumen

Objetivo

Describir el uso de sedantes, analgésicos y bloqueantes neuromusculares (BNM) en los pacientes con ventilación mecánica (VM) prolongada y evaluar los factores asociados a su empleo y asociación con la mortalidad a los 28 días.

Diseño

Estudio multicéntrico, prospectivo y observacional de cohorte.

Ámbito

Trece unidades de cuidados intensivos (UCI) en Chile.

Pacientes

Pacientes con VM superior a 48 h. Excluimos los pacientes con enfermedad neurológica, cirrosis hepática, insuficiencia renal crónica, sospecha de adicción a drogas y limitación precoz del esfuerzo terapéutico.

Intervención

Ninguna

Variables de interés principales

Proporción de uso y dosis de sedantes, analgésicos y BNM. Nivel de sedación observado (SAS [sedation-agitation scale ‘escala de sedación-agitación’]). Variables asociadas al nivel de la SAS, y el uso de sedantes, analgésicos y BNM. Regresión logística multivariada de variables asociadas a la mortalidad a los 28 días.

Resultados

Participaron 155 pacientes (60±18 años, el 57% eran varones, SOFA 7 [6–10], APACHE II 18 [15–22], el 63% con sepsis y el 47% con lesión pulmonar aguda/síndrome de distrés respiratorio agudo. Los fármacos empleados fueron midazolam (85%; 4 mg/h [1,9–6,8]) y fentanilo (81%; 76 μg/h [39–140]). Un 30% de los pacientes usó BNM al menos un día. El 55% de la SAS fue 1-2. Existe una asociación entre el uso de BNM y la mortalidad a los 28 días, pero ésta no fue consistente en todos los modelos de uso de BNM evaluados.

Conclusiones

En el grupo estudiado fue frecuente el uso de sedantes y la presencia de sedación profunda, el midazolam y el fentanilo fueron los fármacos más usados. El uso de BNM podría asociarse de forma independiente a una mayor mortalidad.

Abstract

Aim

To describe use of sedatives, analgesics, and neuromuscular blockers (NMB) in patients undergoing long-term mechanical ventilation and to assess factors associated with their use and their association with mortality at 28 days.

Design

Prospective observational multicenter cohort study.

Setting

Thirteen intensive care units (ICU) in Chile.

Patients

Patients undergoing mechanical ventilation for more than 48 h. We excluded patients with neurological disorders, cirrhosis of the liver, chronic renal failure, suspected drug addiction, and early no resuscitation orders.

Intervention

None.

Main measurements

Proportion of use and dosage of sedatives, analgesics, and NMB. Level of sedation observed (SAS). Variables associated with the Sedation Agitation Scale (SAS), use of sedatives, analgesics, and NMB. Multivariate logistic regression of variables associated to mortality at 28 days.

Results

A total of 155 patients participated (60±18 years, 57% male, SOFA 7 [6–10], APACHE II 18 [15–22], 63% with sepsis, and 47% with acute lung injury/adult respiratory distress syndrome. The drugs most frequently used were midazolam (85%, 4 [1.9–6.8] mg/hr) and fentanyl (81%, 76 [39–140] μg/hr). NMB were administered at least 1 day in 30% of patients. SAS score was 1 or 2 in 55% of patients. There was an association between NMB use and mortality at 28 days, but it was not consistent in all the models of NMB evaluated.

Conclusions

Sedatives were frequently employed and deep sedation was common. Midazolam and fentanyl were the most frequently administered drugs. The use of NMB might be independently associated to greater mortality.

Section snippets

Introducción

El uso de sedantes y analgésicos es con frecuencia necesario en los pacientes críticos, para propiciar el confort durante la ventilación mecánica (VM) o para reducir el consumo de oxígeno en los pacientes con estados de shock1, 2. Su empleo se ha asociado a una prolongación del tiempo en la VM, al aumento de complicaciones y al incremento de los costos asociados3, 4, 5, 6. Algunos fármacos en particular se han relacionado a riesgos específicos. Las benzodiacepinas se asocian a una mayor

Pacientes y métodos

Se realizó un estudio de cohorte en el que se incluyeron los pacientes mayores de 18 años que requirieron VM superior a 48 h, ingresados entre el 15 de abril y el 20 de junio de 2006 en 13 UCI pertenecientes a 12 hospitales de Chile (apéndice II). De éstas, 7 forman parte del Sistema Público de Atención de Salud, 3 pertenecen a universidades, 2 a las Fuerzas Armadas y una a una clínica privada. Estas unidades son cerradas y se dedican al tratamiento de los pacientes medicoquirúrgicos no

Resultados

Evaluamos 432 pacientes con VM superior a 48 h, de los cuales 155 (35,9%) cumplieron criterios de selección. Los motivos más frecuentes de exclusión fueron enfermedad neurológica (114 [26,4%]), daño hepático crónico (38 [8,8%]) e insuficiencia renal crónica (30 [6,9%]). Tres pacientes (1,9%) tuvieron pérdida de seguimiento (traslado a otro hospital) y se los excluyó del análisis. Los pacientes incluidos tenían APACHE II 18 (15–22) y SOFA 7 (6–10). Hubo una elevada incidencia de sepsis e IPA/SDRA

Discusión

Los principales hallazgos de este estudio son la observación de un elevado uso de sedantes, con presencia de niveles profundos de sedación y un elevado empleo de BNM. El análisis del impacto de la sedación, la analgesia y los BNM en la mortalidad a los 28 días indica un dato interesante: presencia de asociación entre el empleo de BNM y la mortalidad en 2 de los modelos de empleo de BNM analizados.

En el grupo estudiado, el 100% de los pacientes emplearon sedantes y un 97% opiáceos. Esto es

Bibliografía (40)

M.H. Kollef et al.
The use of continuous i.v. sedation is associated with prolongation of mechanical ventilation
Chest
(1998)
A. Arroliga et al.
Use of sedatives and neuromuscular blockers in a cohort of patients receiving mechanical ventilation
Chest
(2005)
W.D. Schweickert et al.
ICU-acquired weakness
Chest
(2007)
H.M. Soliman et al.
Sedative and analgesic practice in the intensive care unit: The results of a European survey
Br J Anaesth
(2001)
O. Peñuelas et al.
Validez de los criterios diagnósticos del síndrome de distrés respiratorio agudo
Med Intensiva
(2006)
C.M. Romero et al.
Extended prone position ventilation in severe acute respiratory distress syndrome: A pilot feasibility study
J Crit Care
(2009)
H. Burchardi
Aims of sedation/analgesia
Minerva Anestesiol
(2004)
J.P. Kress et al.
Sedation in the mechanically ventilated patient
Crit Care Med
(2006)
W.D. Schweickert et al.
Daily interruption of sedative infusions and complications of critical illness in mechanically ventilated patients
Crit Care Med
(2004)
D.J. Cook et al.
Incidence of and risk factors for ventilator-associated pneumonia in critically ill patients
Ann Intern Med
(1998)

P. Pandharipande et al.

Lorazepam is an independent risk factor for transitioning to delirium in intensive care unit patients

Anesthesiology

(2006)

P. Pandharipande et al.

Prevalence and risk factors for development of delirium in surgical and trauma intensive care unit patients

J Trauma

(2008)

J. Garnacho-Montero et al.

Critical illness polyneuropathy: Risk factors and clinical consequences. A cohort study in septic patients

Intensive Care Med

(2001)

G. Brattebo et al.

Effect of a scoring system and protocol for sedation on duration of patients’ need for ventilator support in a surgical intensive care unit

BMJ

(2002)

S.M. Burns et al.

Implementation of an institutional program to improve clinical and financial outcomes of mechanically ventilated patients: One-year outcomes and lessons learned

Crit Care Med

(2003)

B.W. Holcomb et al.

New ways to reduce unnecessary variation and improve outcomes in the intensive care unit

Curr Opin Crit Care

(2001)

M.F. Mascia et al.

Pharmacoeconomic impact of rational use guidelines on the provision of analgesia, sedation, and neuromuscular blockade in critical care

Crit Care Med

(2000)

A.D. Brook et al.

Effect of a nursing-implemented sedation protocol on the duration of mechanical ventilation

Crit Care Med

(1999)

J.P. Kress et al.

Daily interruption of sedative infusions in critically ill patients undergoing mechanical ventilation

N Engl J Med

(2000)

B. De Jonghe et al.

Sedation algorithm in critically ill patients without acute brain injury

Crit Care Med

(2005)

Cited by (7)

Sedation and analgesia practices in neonatal intensive care units (EUROPAIN): Results from a prospective cohort study
2015, The Lancet Respiratory Medicine
Citation Excerpt :
In adults, according to a review of 20 surveys,20 reported from 1999 to 2009, only two surveys were prospective—one was a national survey21 designed to study sedation and analgesia in ventilated adults and another was an international survey22 designed to study mechanical ventilation but not analgesia and sedation. From 2010 to 2015, we found 15 surveys, including only two national prospective studies, one from Canada23 and another from Chile,24 of sedation and analgesia practices in ICUs for adults. One study25 in the USA was a retrospective assessment of a single-centre cohort and the other 12 studies (appendix) used declarative questionnaires mainly about the use of written local procedures, sedation, analgesia, sedation scales, and the routes of drug administration.
Neonates who are in pain or are stressed during care in the intensive care unit (ICU) are often given sedation or analgesia. We investigated the current use of sedation or analgesia in neonatal ICUs (NICUs) in European countries.
EUROPAIN (EUROpean Pain Audit In Neonates) was a prospective cohort study of the management of sedation and analgesia in patients in NICUs. All neonates admitted to NICUs during 1 month were included in this study. Data on demographics, methods of respiration, use of continuous or intermittent sedation, analgesia, or neuromuscular blockers, pain assessments, and drug withdrawal syndromes were gathered during the first 28 days of admission to NICUs. Multivariable linear regression models and propensity scores were used to assess the association between duration of tracheal ventilation (TV) and exposure to opioids, sedatives-hypnotics, or general anaesthetics in neonates (O-SH-GA). This study is registered with ClinicalTrials.gov, number NCT01694745.
From Oct 1, 2012, to June 30, 2013, 6680 neonates were enrolled in 243 NICUs in 18 European countries. Mean gestational age of these neonates was 35·0 weeks (SD 4·6) and birthweight was 2384 g (1007). 2142 (32%) neonates were given TV, 1496 (22%) non-invasive ventilation (NIV), and 3042 (46%) were kept on spontaneous ventilation (SV). 1746 (82%), 266 (18%), and 282 (9%) neonates in the TV, NIV, and SV groups, respectively, were given sedation or analgesia as a continuous infusion, intermittent doses, or both (p<0·0001). In the participating NICUs, the median use of sedation or analgesia was 89·3% (70·0–100) for neonates in the TV group. Opioids were given to 1764 (26%) of 6680 neonates and to 1589 (74%) of 2142 neonates in the TV group. Midazolam was given to 576 (9%) of 6680 neonates and 536 (25%) neonates of 2142 neonates in the TV group. 542 (25%) neonates in the TV group were given neuromuscular blockers, which were administered as continuous infusions to 146 (7%) of these neonates. Pain assessments were recorded in 1250 (58%) of 2138, 672 (45%) of 1493, and 916 (30%) of 3017 neonates in the TV, NIV, and SV groups, respectively (p<0·0001). In the univariate analysis, neonates given O-SH-GA in the TV group needed a longer duration of TV than did those who were not given O-SH-GA (mean 136·2 h [SD 173·1] vs 39·8 h [94·7] h; p<0·0001). Multivariable and propensity score analyses confirmed this association (p<0·0001).
Wide variations in sedation and analgesia practices occur between NICUs and countries. Widespread use of O-SH-GA in intubated neonates might prolong their need for mechanical ventilation, but further research is needed to investigate the therapeutic and adverse effects of O-SH-GA in neonates, and to develop new and safe approaches for sedation and analgesia.
European Community's Seventh Framework Programme.
Intensive Medicine in spanish
2010, Medicina Intensiva
Safety practices in mechanical ventilation in patients in Intensive Care Units of the city of Medellín, Colombia, in the year 2018
2020, Acta Colombiana de Cuidado Intensivo
Determinar el cumplimiento de estrategias de seguridad en pacientes adultos con ventilación mecánica en Unidades de Cuidados Intensivos (UCI) de Medellín, Colombia, en el año 2018.
Estudio observacional, descriptivo, transversal y multicéntrico, de una cohorte de punto, con fuente secundaria de información obtenida por los registros e historia clínica de pacientes adultos en UCI, aplicando un formulario electrónico en Excel. Se realizaron análisis univariado y bivariado.
El cumplimiento más alto de las medidas de seguridad fue del 91,8% y el más bajo, del 64,3%. Los parámetros para prevenir la neumonía asociada a la ventilación se cumplían en la mayoría de los casos. El 82,43% de los casos cumplían con el lavado de manos; 67 pacientes tenían la presión del neumotaponador adecuada, y a 6 se les realizó succión subglótica. El 44,59% tenía RASS de sedación entre −1 y 2, y en el 58,1% se cumplía el despertar diario. La inclinación de la cabecera era adecuada en el 77,1%. Se realizó profilaxis e higiene oral en más del 85% de los pacientes. El 91,89% tenía presión meseta adecuada previniendo lesión pulmonar. El PEEP promedio fue de 7,54 cmH₂O, establecido en el 47,3% según la tabla del estudio ARMA y en el 2,7% según la curva P/V. El volumen corriente era inadecuado en 48 pacientes (64,86%) y el protocolo de sedoanalgesia se cumplió en 70 individuos (94,6%).
Si bien los criterios establecidos se cumplen en su mayoría, aún hay una gran oportunidad de mejora en la seguridad del paciente que recibe ventilación mecánica en la UCI en la ciudad de Medellín.
To determine the compliance to patient safety measures in adult patients receiving mechanical ventilation in different Intensive Care Units (ICU) in Medellín, Colombia, during 2018.
Observational, descriptive, cross-sectional and multicentre study. Information was collected from registers and medical files of adult patients in the ICU who were receiving mechanical ventilation. Data was entered in Excel sheets, and univariate and bivariate analyses were performed.
The highest compliance to the standards was 91.8% and the lowest was 64.3%. Ventilation associated Pneumoniae prevention measures were fulfilled in the majority of cases. Hand washing was performed in 82.43% of the cases. Adequate endotracheal tube cuff pressure was observed in 67 patients, and 6 received sub-glottic suction. Less than half (44.59%) of patients were sedated between −1 and 2 on the RASS scale, and 58.1% were awakened daily. The bed head elevation was adequate in 77.1%. Oral hygiene and prophylaxis was carried out on more than 85% of the patients. The large majority (91.89%) had a suitable plateau pressure to prevent lung injury. The average PEEP was 7.54 cmH₂O, established according to ARMA in 47.3% and to Pressure-Volume curves in 2.7%. Tidal volume was inadequate in 48 (64.86%) patients. The sedation and analgesia protocol was accomplished in 70 (94.6%) patients.
Despite de fact that the established criteria are mostly fulfilled, there is still a great opportunity to improve the safety of the patients who receive mechanical ventilation in the ICU in the city of Medellín.
Analgesia, sedation, neuromuscular blockade and delirium management practices in Chilean intensive care units
2021, Revista Medica de Chile
Agitation during prolonged mechanical ventilation and influence on weaning outcomes
2016, Noninvasive Mechanical Ventilation and Difficult Weaning in Critical Care: Key Topics and Practical Approaches
The implementation of an analgesia-based sedation protocol reduced deep sedation and proved to be safe and feasible in patients on mechanical ventilation
2013, Revista Brasileira de Terapia Intensiva

View all citing articles on Scopus

View full text

Resumen

Objetivo

Diseño

Ámbito

Pacientes

Intervención

Variables de interés principales

Resultados

Conclusiones

Abstract

Aim

Design

Setting

Patients

Intervention

Main measurements

Results

Conclusions

Section snippets

Introducción

Pacientes y métodos

Resultados

Discusión

Chest

Chest

Chest

Br J Anaesth

Med Intensiva

J Crit Care

Aims of sedation/analgesia

Minerva Anestesiol

Sedation in the mechanically ventilated patient

Crit Care Med

Daily interruption of sedative infusions and complications of critical illness in mechanically ventilated patients

Crit Care Med

Incidence of and risk factors for ventilator-associated pneumonia in critically ill patients

Ann Intern Med

Lorazepam is an independent risk factor for transitioning to delirium in intensive care unit patients

Anesthesiology

Prevalence and risk factors for development of delirium in surgical and trauma intensive care unit patients

J Trauma

Critical illness polyneuropathy: Risk factors and clinical consequences. A cohort study in septic patients

Intensive Care Med

Effect of a scoring system and protocol for sedation on duration of patients’ need for ventilator support in a surgical intensive care unit

BMJ

Implementation of an institutional program to improve clinical and financial outcomes of mechanically ventilated patients: One-year outcomes and lessons learned

Crit Care Med

New ways to reduce unnecessary variation and improve outcomes in the intensive care unit

Curr Opin Crit Care

Pharmacoeconomic impact of rational use guidelines on the provision of analgesia, sedation, and neuromuscular blockade in critical care

Crit Care Med

Effect of a nursing-implemented sedation protocol on the duration of mechanical ventilation

Crit Care Med

Daily interruption of sedative infusions in critically ill patients undergoing mechanical ventilation

N Engl J Med

Sedation algorithm in critically ill patients without acute brain injury

Crit Care Med