Front-Loaded Trauma ICU Sedation Regimen Improved Outcomes

An approach to sedating intubated patients in the intensive care unit, designed to minimize continuous analgesic and sedative infusions, was associated with better outcomes than was the sedation interruption regimen previously used, according to a retrospective study of almost 1,500 patients.

The new approach resulted in a nearly 80% reduction in the overall use of sedatives and narcotics, as well as fewer infections and days spent on a ventilator – with no increase in patient discomfort, falls, or unintended extubations, Brenton J. LaRiccia, RPA, lead physician assistant in the Kessler Family Burn Trauma Intensive Care Unit (BTICU) at Strong Memorial Hospital, Rochester, N.Y., reported at the annual meeting of the American Association for the Surgery of Trauma.

Courtesy Kessler Trauma Center

Protocols that address the worse outcomes associated with oversedation of mechanically ventilated patients include sedation interruption (SI) regimens. While the interruption regimens have been shown to reduce sedation use in medical ICUs, their regimens in trauma ICUs have been unclear, said Mr. LaRiccia, who is also in the division of acute care surgery at the University of Rochester (N.Y.).

In 2011, a protocol designed to minimize the use of continuous infusions was implemented at the BTICU at Strong Memorial Hospital, which he described as "aggressive upfront bolus dosing" of analgesic and sedative medications during the first hour of admission, continuous infusions if the bolus dosing was not effective, followed by "nursing-driven regimented weaning of all medications," both intermittently dosed and continuous medications.

The study compared outcomes associated with this approach among 749 patients admitted to the trauma ICU in 2011 with outcomes among 743 patients in 2009, when the SI protocol was still used. The patients (average age 55-57 years) were all ventilated and had similar APACHE II scores; burn patients and those who required hourly neurologic checks were not included.

Compared with the SI regimen, the new regimen was associated with significantly fewer sedation days (a total of 344 vs. 1,784 days) and significantly fewer days on a ventilator (an average of 6.2 vs. 8.4 days ). In addition, about one-fourth of those on the new protocol never required a continuous infusion of a sedative or analgesic, which "was in stark contrast to our prior sedation interruption–based practice where almost all intubated patients were placed on continuous infusions on arrival to the BTICU," Mr. LaRiccia said. (Among those on the SI protocol, 11% never required continuous sedatives and 13% never required continuous narcotics, compared with 25% and 27%, respectively, of those on the new protocol, statistically significant differences).

Mortality (18%-19%) and the average ICU length of stay (almost 10 days), as well as pain scores and the total number of falls and self-extubation rates, were similar between the two groups. Limitations of the study include the retrospective analysis, the single ICU setting, and the relatively small sample size and lack of long-term data, and more studies are needed to confirm these results, he pointed out.

The results indicate that an analgesia-based protocol implemented on ICU admission, which "focuses on front loading analgesia with upfront use of intermittent pain medications and sedation medications, instead of continuous infusions with sedation, greatly decreases ICU sedation use," and is well-tolerated by patients, reduces ICU infection rates and ventilator days without significant complications, Mr. LaRiccia concluded.

"By moving beyond the sedation interruption mindset, we change our goal from being ‘When can this sedation be stopped?’ to ‘Does this sedation even need to be started?’ – thereby truly optimizing patient care," he added, emphasizing that a multidisciplinary effort is needed to ensure that the protocol is implemented properly.

He and his coinvestigators reported having no relevant financial conflicts.

An approach to sedating intubated patients in the intensive care unit, designed to minimize continuous analgesic and sedative infusions, was associated with better outcomes than was the sedation interruption regimen previously used, according to a retrospective study of almost 1,500 patients.

The new approach resulted in a nearly 80% reduction in the overall use of sedatives and narcotics, as well as fewer infections and days spent on a ventilator – with no increase in patient discomfort, falls, or unintended extubations, Brenton J. LaRiccia, RPA, lead physician assistant in the Kessler Family Burn Trauma Intensive Care Unit (BTICU) at Strong Memorial Hospital, Rochester, N.Y., reported at the annual meeting of the American Association for the Surgery of Trauma.

Courtesy Kessler Trauma Center

Protocols that address the worse outcomes associated with oversedation of mechanically ventilated patients include sedation interruption (SI) regimens. While the interruption regimens have been shown to reduce sedation use in medical ICUs, their regimens in trauma ICUs have been unclear, said Mr. LaRiccia, who is also in the division of acute care surgery at the University of Rochester (N.Y.).

In 2011, a protocol designed to minimize the use of continuous infusions was implemented at the BTICU at Strong Memorial Hospital, which he described as "aggressive upfront bolus dosing" of analgesic and sedative medications during the first hour of admission, continuous infusions if the bolus dosing was not effective, followed by "nursing-driven regimented weaning of all medications," both intermittently dosed and continuous medications.

The study compared outcomes associated with this approach among 749 patients admitted to the trauma ICU in 2011 with outcomes among 743 patients in 2009, when the SI protocol was still used. The patients (average age 55-57 years) were all ventilated and had similar APACHE II scores; burn patients and those who required hourly neurologic checks were not included.

Compared with the SI regimen, the new regimen was associated with significantly fewer sedation days (a total of 344 vs. 1,784 days) and significantly fewer days on a ventilator (an average of 6.2 vs. 8.4 days ). In addition, about one-fourth of those on the new protocol never required a continuous infusion of a sedative or analgesic, which "was in stark contrast to our prior sedation interruption–based practice where almost all intubated patients were placed on continuous infusions on arrival to the BTICU," Mr. LaRiccia said. (Among those on the SI protocol, 11% never required continuous sedatives and 13% never required continuous narcotics, compared with 25% and 27%, respectively, of those on the new protocol, statistically significant differences).

Mortality (18%-19%) and the average ICU length of stay (almost 10 days), as well as pain scores and the total number of falls and self-extubation rates, were similar between the two groups. Limitations of the study include the retrospective analysis, the single ICU setting, and the relatively small sample size and lack of long-term data, and more studies are needed to confirm these results, he pointed out.

The results indicate that an analgesia-based protocol implemented on ICU admission, which "focuses on front loading analgesia with upfront use of intermittent pain medications and sedation medications, instead of continuous infusions with sedation, greatly decreases ICU sedation use," and is well-tolerated by patients, reduces ICU infection rates and ventilator days without significant complications, Mr. LaRiccia concluded.

"By moving beyond the sedation interruption mindset, we change our goal from being ‘When can this sedation be stopped?’ to ‘Does this sedation even need to be started?’ – thereby truly optimizing patient care," he added, emphasizing that a multidisciplinary effort is needed to ensure that the protocol is implemented properly.

He and his coinvestigators reported having no relevant financial conflicts.

An approach to sedating intubated patients in the intensive care unit, designed to minimize continuous analgesic and sedative infusions, was associated with better outcomes than was the sedation interruption regimen previously used, according to a retrospective study of almost 1,500 patients.

The new approach resulted in a nearly 80% reduction in the overall use of sedatives and narcotics, as well as fewer infections and days spent on a ventilator – with no increase in patient discomfort, falls, or unintended extubations, Brenton J. LaRiccia, RPA, lead physician assistant in the Kessler Family Burn Trauma Intensive Care Unit (BTICU) at Strong Memorial Hospital, Rochester, N.Y., reported at the annual meeting of the American Association for the Surgery of Trauma.

Courtesy Kessler Trauma Center

Protocols that address the worse outcomes associated with oversedation of mechanically ventilated patients include sedation interruption (SI) regimens. While the interruption regimens have been shown to reduce sedation use in medical ICUs, their regimens in trauma ICUs have been unclear, said Mr. LaRiccia, who is also in the division of acute care surgery at the University of Rochester (N.Y.).

In 2011, a protocol designed to minimize the use of continuous infusions was implemented at the BTICU at Strong Memorial Hospital, which he described as "aggressive upfront bolus dosing" of analgesic and sedative medications during the first hour of admission, continuous infusions if the bolus dosing was not effective, followed by "nursing-driven regimented weaning of all medications," both intermittently dosed and continuous medications.

The study compared outcomes associated with this approach among 749 patients admitted to the trauma ICU in 2011 with outcomes among 743 patients in 2009, when the SI protocol was still used. The patients (average age 55-57 years) were all ventilated and had similar APACHE II scores; burn patients and those who required hourly neurologic checks were not included.

Compared with the SI regimen, the new regimen was associated with significantly fewer sedation days (a total of 344 vs. 1,784 days) and significantly fewer days on a ventilator (an average of 6.2 vs. 8.4 days ). In addition, about one-fourth of those on the new protocol never required a continuous infusion of a sedative or analgesic, which "was in stark contrast to our prior sedation interruption–based practice where almost all intubated patients were placed on continuous infusions on arrival to the BTICU," Mr. LaRiccia said. (Among those on the SI protocol, 11% never required continuous sedatives and 13% never required continuous narcotics, compared with 25% and 27%, respectively, of those on the new protocol, statistically significant differences).

Mortality (18%-19%) and the average ICU length of stay (almost 10 days), as well as pain scores and the total number of falls and self-extubation rates, were similar between the two groups. Limitations of the study include the retrospective analysis, the single ICU setting, and the relatively small sample size and lack of long-term data, and more studies are needed to confirm these results, he pointed out.

The results indicate that an analgesia-based protocol implemented on ICU admission, which "focuses on front loading analgesia with upfront use of intermittent pain medications and sedation medications, instead of continuous infusions with sedation, greatly decreases ICU sedation use," and is well-tolerated by patients, reduces ICU infection rates and ventilator days without significant complications, Mr. LaRiccia concluded.

"By moving beyond the sedation interruption mindset, we change our goal from being ‘When can this sedation be stopped?’ to ‘Does this sedation even need to be started?’ – thereby truly optimizing patient care," he added, emphasizing that a multidisciplinary effort is needed to ensure that the protocol is implemented properly.

He and his coinvestigators reported having no relevant financial conflicts.