Impact of a Nurse-Implemented Sedation and Analgesia Algorithm on Complications of Critical Illness in a Surgical Intensive Care Unit

Research Article

Austin Crit Care J. 2019; 6(1): 1028.

Impact of a Nurse-Implemented Sedation and Analgesia Algorithm on Complications of Critical Illness in a Surgical Intensive Care Unit

Pottier V*, Bornemann Y, Fauroux J, Desmeulles I, Verrier P, Orabona M, Samba D, Viquesnel G, Ethuin F and Hanouz JL

Department of Anesthesia and Surgical Intensive Care, Caen University Hospital, France

*Corresponding author: Véronique Pottier, M.D.Département d’Anesthésie-Réanimation (niveau 6), CHU de Caen, avenue Côte de Nacre, 14033 Caen Cedex, France

Received: October 09, 2019; Accepted: November 11, 2019; Published: November 18, 2019


Objective: To examine the effects of a nurse-applied sedation and analgesia algorithm on sedative doses, duration of mechanical ventilation (MV), patient comfort, morbidity and mortality.

Design: Before-and-after prospective, observational study.

Setting: 26-bed Surgical ICU in Caen University Hospital.

Patients: Mechanically ventilated patients with sedation predicted to last 48 hours and without brain injury, between November 2014 and April 2017.

Intervention: Setting up an algorithm considered as recommended common practice.

Measurements and Main Results: A total of 1156 mechanically ventilated patients were admitted during the study period. Among the 145 eligible patients, 100 were included during a « Before » period and 45 during an « After » period. The duration of MV after inclusion was significantly shorter in the « After » period (11 vs 8 days, p = 0.042), as the duration of target RASS (-2 to 0) was significantly longer (0 vs 1 day, p = 0.038), the duration of RASS › - 2 was significantly shorter (7 vs 3 days, p ‹ 0.001), and the dose of sedatives was significantly decreased (1330 vs 315 mg, p ‹ 0.001 for hypnotics and 1803 vs 900 μg, p ‹ 0.001 for opioids, respectively) along with the sedation cost (25 vs 12 euros, p = 0.004). The patients experienced less ventilator-acquired pneumonia (VAP) and delirium during the « After » period (55% vs 24%, p = 0.004, and 41% vs 27%, p = 0.015, respectively).

Conclusions: The nurses’ implementation of a sedation-analgesia algorithm was associated with a trend towards a reduction in duration of MV and ICU length of stay. Moreover, the prevalence of VAP and delirium was reduced. This type of algorithm is necessary to reduce the morbidity and mortality associated with MV.

Keywords: Sedation; Analgesia; Algorithm; Intensive care unit; Ventilatoracquired pneumonia; Delirium


In intensive care units (ICU), the main objectives of sedation and analgesia are to ensure the safety of critically ill patients during therapeutic and diagnostic procedures, as well as their physical and psychological comfort. Furthermore, sedation and analgesia are an important part of treatment during the acute phase of life-threatening illness, such as acute respiratory distress syndrome, severe neurologic aggression, and shock [1].

To limit the risks associated with sedation and analgesia, [2,3]. Standardized and repeated evaluation of efficacy and adequacy is mandatory at every stage of the patient’s clinical evolution [4]. This recommendation is widely accepted by physicians and based on validated clinical scales such as the Richmond Agitation-Sedation Scale (RASS) [5,6] scale and the Behavior Pain Scale (BPS) [7] quantifying consciousness, pain, and comfort in patients with mechanical ventilation (MV).

Thus, implementation of a dynamic sedation and analgesia algorithm has been shown to improve drug administration, patient comfort, awakening and cooperation. Because of their permanent presence next to patients, the transfer of the management of sedationanalgesia to nurses should result in a fine adaptation of the dosages without significant mismatch or disruption. This practice was initiated by Kollef et al in 1998, [8] followed by Kress et al in 2000 [9]. and adopted in US4 and French1 guidelines. Indeed, these studies showed a decreased duration of MV and length of stay in the ICU. However, the studies were carried out in medical or polyvalent ICUs [10,11]. Which are not representative of a surgical ICU. This is of importance, since it has been shown that patients may differ substantially between medical and surgical ICUs [12].

Consequently, the aim of the present study was to examine effects of the implementation of a nurse-controlled sedation and analgesia algorithm on sedative drug consumption reduction, major clinical outcomes, and patient comfort in a surgical ICU.

Materials and Methods

We conducted a prospective, « Before-After » interventional study in the 26-bed surgical ICU of Caen University Hospital between November 2014 and April 2017. The study was approved by the local Ethical Committee (CPP Nord Ouest III, CHU de Caen, Caen, France) under the number A14-D65-VOL.23, on December 06, 2014. The committee considered it as part of routine practice, and patient approval was not required. However, written information was systematically given to each included patient or to their next of kin. The study is recorded in ClinicalTrials with the number NCT03186521.

Inclusion criteria`

All patients aged 18 years or older, admitted to the ICU, and anticipated to require more than 48 hours of sedation and analgesia were eligible and assessed for enrollment.

Non-inclusion criteria

Patients were not eligible if they were under guardianship or ‹ 18 years; pregnant; under palliative care; experiencing brain injury; presenting with an initial Glasgow Coma score ‹ 14; receiving neuromuscular blocking agents at the time of enrollment; under therapeutic sedation (Acute Respiratory Distress Syndrome, acute severe asthma, intracranial hypertension, etc.); or admitted following resuscitated cardiac arrest.

Exclusion criteria

Patients were excluded from the study if they were extubated or dead within 48 hours after inclusion.

Study protocol

Patients admitted to the surgical intensive care unit with orotracheal intubation and mechanical ventilation were recorded by one of the two principal investigators (VP and YB).

« Before » Period: Sedation and analgesia was exclusively managed by the attending physician, guided by the Richmond Agitation-Sedation Scale (RASS) [5,6] and Behavior Pain Scale (BPS) [7] and recorded every 4 hours by nurses. The dosage and choice of the hypnotic drug (Propofol® or Midazolam®) was at the discretion of the physician, and the only opioid used was Sufentanil®.

Between the two periods, principal investigators conducted several informational meetings with the paramedical teams and the medical staff.

« After » Period: Following medical prescription, the patient’s sedation and analgesia was managed by the ICU nurses according to the protocol displayed in each bedroom (see Appendix 1).

A flow chart of the study design is depicted in Figure 1. During the study period, 1156 intubated and mechanically ventilated patients were admitted to the surgical ICU of Caen University Hospital. Among the 1014 non-eligible patients 507 (50%) were sedated less than 48 hours and 304 (30%) had an initial Glasgow coma score ‹ 14.