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

  

    
Complications of Critical Illness
    
BEFORE Period
      
(n = 100)a
    
AFTER Period
      
(n = 45)b
    
p Value
  
  

    
Respiratory Failure
    
67 (67%)
    
22 (54%)
    
0.093
  
  

    
VAP
    
55 (55%)
    
11 (24%)
    
0.004
  
  

    
Replacement of Endotracheal tube
    
23 (23%)
    
17 (38%)
    
0.654
  
  

    
Time limit of reintubation (days) 
    
3 [0.5; 7.5]
    
4 [1.5; 10]
    
0.476
  
  

    
NIV
    
37 (37%)
    
18 (40%)
    
0.751 
  
  

    
Tracheotomy
    
4 (4 %)
    
2 (4 %)
    
1.000
  
  

    
Gastro-intestinal Injury
    
39 (39%)
    
17 (38%)
    
1.000
  
  

    
Neurological Injury 
    
51 (51%)
    
24 (53%)
    
0.093 
  
  

    
Delirium (CAM-ICU +) 
    
41 (41%)
    
12 (27%)
    
0.015
  
  

    
Duration of delirium (days) 
    
5 ± 4
    
7 ± 8
    
0.548
  
  

    
Self-extubations, tear off devices, etc. 
    
9 (9%)
    
6 (13%)
    
0.558
  
  

    
Resort to cerebral imaging for wake-up delay 
    
4 (4%)
    
2 (4%)
    
1.000
  
  

    
Cerebral Scan 
    
0
    
2 (4%)
    
0.067
  
  

    
MRI
    
1 (1%)
    
1 (2%)
    
1.000
  
  

    
EEG
    
4 (4%)
    
1 (2%)
    
0.333
  
  

    
Cardiac and/ or Hemodynamic
    
88 (88%)
    
38 (84%)
    
1.000
  
  

    
Duration of catecholamines (days)
    
7 [4; 11.5]
    
5 [3; 10]
    
0.416
  
  

    
Renal Injury
    
66 (66%)
    
35 (78%)
    
0.098
  
  

    
Resort to RRT
    
50 (50%)
    
25 (56%)
    
0.66
  
  

    
SOFA Score
    
 
    
 
    
 
  
  

    
D0
    
7 [5; 10]
    
9 [6; 11]
    
0.088
  
  

    
D3
    
6 [3; 9]
    
6 [4; 10]
    
0.474
  
  

    
D7
    
4 [2; 7]
    
4 [2; 8]
    
0.579
  
  

    
D14
    
4 [1; 7]
    
3.5 [1; 7]
    
0.982
  
  

    
D28
    
3 [1; 7]
    
5 [3; 7.5]
    
0.114
  
  

    
ICU discharge 
    
0 [0; 1]
    
1 [0; 2]
    
0.071 
  
  

    
Death 
    
28 (28 %)
    
18 (40 %)
    
0.228
  

Table 3: Patient characteristics related to complications of critical illness.

Adverse events related to an inappropriate depth of sedation were not different between the two periods.

The occurrence of VAP and delirium were significantly decreased during the « After » period (55% vs 24%, p = 0.004, and 41% vs 27%, p = 0.015, respectively). There was no significant difference in mortality between the two periods.

Discussion

The present study showed that implementation of a sedation analgesia protocol in a surgical ICU improved the management of sedation and decreased the duration of MV after inclusion, the incidence of VAP and delirium. Furthermore, the decrease in hypnotic drugs and opioid consumption resulted in a 50% decrease in cost of sedation analgesia.

Complications associated with excessive sedation negatively impact the morbidity and mortality of patients. [2,3,8] Kollef et al, were the first to showed in 1998 that patients receiving intravenous continuous sedation had durations of MV, ICU and hospital lengths of stay longer than those who did not receive sedation or intermittent sedation.8 Subsequently, several studies have shown that sedation protocols managed by the nursing team reduced the duration of MV [17-19].

Our study is far from being the first to be reported, but few studies have been carried out in an exclusively surgical ICU, and few have reported on the serious adverse effects that excessive sedation can induce, such as the occurrence of VAP [19,20].

In contrast to the previously mentioned precursors, but similar to some others, [21,22] we were unable to demonstrate a significant difference regarding duration of MV in patients with sedationanalgesia protocol managed by the nursing team, according to objectives of RASS and BPS, compared to those whose sedation was managed by the medical team outside of any protocol. Frawley et al. [23] showed a decreased mean duration of MV in a retrospective study from before to after the introduction of a new sedation protocol. They changed the first-line analgesic/sedative agents from pharmacokinetic long-acting agents to pharmacokinetic brief-acting agents. Perhaps we should not have left the choice of the hypnotic (Midazolam^® or Propofol^®) to the discretion of the physician because Midazolam^® was more widely chosen, although there was a significant difference in its use between the « Before » and « After » periods. Another mistake might have been not to change the opioid between the two periods.

However, the duration of MV after inclusion was significantly shorter in the « After » group (11 [7, 18] vs 8 [5, 11.5], p = 0.042). Moreover, there is a trend toward a reduced ICU length of stay (10 days) in patients of equivalent severity (see SAPS II). Similarly, the duration of sedation was significantly shorter in the « After » group and correlated with doses of sedatives as well as cost. The target RASS (-2 to 0) was significantly longer, and the RASS « exceeded » (› - 2) shorter in the « After » group. The duration of weaning from MV also showed a downward trend in the « After » group. All of this contributes to suggesting a reduction in the morbidity and mortality of patients and a considerable benefit in terms of hospital economics.

In fact, the introduction of and adherence to the A (Assess, prevent and manage pain) B (Both awakening and spontaneous breathing trial coordination) C (Choice of analgesic and sedation) D (Delirium: assess, prevent and manage) E (Early mobility and exercise) F (Family engagement and empowerment) bundle [24] is associated with improved patient-centred outcomes such decreased MV [25,26], hospital length of stay and so hospital cost [25], as well as improved ICU readmission rates and discharge disposition of ICU survivors [26].

Nevertheless, the A was not easy to achieve in our study because if the implementation of the protocol was beneficial regarding some parameters without major adverse events, there was a parameter that was worse in the 2nd period: BPS. There is a balance to obtain, which is not easy.

The objective of implementing a sedation protocol is to decrease the duration of MV and, consequently, the risk of VAP associated with it [27]. This disease, with its significant mortality and considerable morbidity, particularly in terms of prolonging ICU and hospital length of stay, is relatively frequent [28,29]. Thus, in our study, 66 patients (45.5%) experienced VAP, which is in line with the literature. However, in the « After » group, patients whose total duration of MV was shorter by 3.5 days, only 11 (24.4%) patients experienced VAP compared to 55 (55%) in the « Before » group (p = 0.004). This result is consistent with the results of Quenot et al., who showed a decrease in the VAP rate from 15 to 6% (p = 0.005), while the duration of MV decreased from 8 [2.2-22] to 4.2 [2.1-9.5] days (p = 0.001) following the implementation of a sedation protocol managed by nurses [30].

Therefore, the reduction of doses and duration of sedation and MV should be a constant objective, although the current recommendations include avoiding sudden withdrawal of drugs in order to limit the risk of withdrawal syndrome [1,31]. However, its incidence remains high, varying from 11 to 80% according to other studies. Ouimet et al., in a prospective observational study dating from 2007, estimated withdrawal at 31.8%. The use of sedationanalgesia multiplied the risk of experiencing delirium by 3.2 [1.5- 6.8] [32]. In our study, the incidence of delirium was 36.5%, but the implementation of the protocol allowed a significant reduction of its incidence, as well as the recent studies on the ABCDEF bundle [26,33].

Similar to the studies cited above, it is important to note that in our study, there was no significant difference between the two groups regarding the occurrence of adverse events due to an inappropriate depth of sedation, or even a tendency to decrease them. Therefore, it is safe to entrust the management of sedation to the paramedical team according to a previously established protocol.

Finally, the studies all raise the importance of a regular monitoring of the state of vigilance, pain and confusion of critically ill patients.

Our study has several limitations, which must require prudent conclusions and interpretations to be made. First, it was a monocentric study.

Second is the lack of power; the study was interrupted for logistical reasons before reaching the number of subjects needed to demonstrate a significant result. Indeed, there is only a tendency to decrease the duration of MV by 3.5 days.

Third, the sedation protocol may not be optimal, for example, by a greater reduction in sedative drugs at each assessment in order to achieve the RASS objectives more quickly. The principal investigators were able to note that a low RASS score did not systematically result in a corresponding decrease in the administered doses. This weak adherence to the sedation protocol has already been noted, and other studies proposed suggesting the participation of a pharmacist [34] or focusing on initial team education [35,36]. Nevertheless, our teams had been using the RASS and BPS scores for more than 3 years at the start of the study, and ten meetings were held at the protocol implementation and before the « After » period. We can assume that the nurse/patient ratio was too low in our service and did not always allow dose changes when the RASS was excessive. Sometimes, a different nurse alert the nurse of the excessive RASS if the nurse in charge of the patient is busy, but without touching the syringes, just to move the protocol forward. We can also point out their timidity in regard to having more responsibilities: they are not all motivated in the same way. Nevertheless, the difference in RASS was significant even if the practices were imperfect and are perfectible.

The fourth limitation is the non-randomized nature of the study, which may limit its impact; the two groups did not show any significant difference on the criteria studied, except for the significantly lower consumption of tobacco in the « After » group, which may have a beneficial impact on the occurrence of delirium. Indeed, a history of active smoking is an independent factor of agitation in intubated patients, as seen in Lucidarme et al. in 2010 [37].

Conclusion

This study did not demonstrate a reduction in the duration of MV when the « comfort » sedation of ICU patients was managed by the nursing team using a protocol. However, ICU length of stay had a tendency to decrease, correlated with a significant decrease in sedative drugs and their cost and possibly associated with a significant reduction in incidence of VAP and delirium.

Moreover, the association of a daily interruption of sedation with the implementation of a protocol, 9, 11, [38] the decline of benzodiazepines in favor of Dexmedetomidine^® [31,39,40], or respect for the sleep-wake cycle [41] or music therapy, are all research tracks that invite us to carry out complementary studies aimed at improving the prognosis and the experience of patients admitted to the ICU, which is a source of reduction in post-traumatic stress disorder [42] and in mortality [43].

Acknowledgment

In addition to the authors of this article, we thank all other physicians in the Surgical ICU for their participation in the data collection. We also thank the nursing staff, residents, and secretaries of the intensive care unit for their cooperation with the protocol.

A particularly great thanks to the Department of Clinical Research, Pr Jean-Jacques Parienti for the opening of the E-crf, Jean- Jacques Dutheil for the making of the booklets.

Conflict of Interest and Source of Funding

The authors have no conflicts of interest to declare.

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