Báo cáo y học: Sedation practice: is it time to wake up and embrace change

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Báo cáo y học: "Sedation practice: is it time to wake up and embrace change" Available online http://ccforum.com/content/12/1/102CommentarySedation practice: is it time to wake up and embrace change?Kate Regan and Owen BoydIntensive Care Unit, Royal Sussex County Hospital, Eastern Road, Brighton, BN2 5BE, UKCorresponding author: Owen Boyd, owen.boyd@bsuh.nhs.ukPublished: 8 January 2008 Critical Care 2008, 12:102 (doi:10.1186/cc6203)This article is online at http://ccforum.com/content/12/1/102© 2008 BioMed Central LtdSee related research by Martin et al., http://ccforum.com/content/11/6/R124Abstract everyday practice. This is despite strong endorsements for the use of sedation scales, patient-targeted sedation andRecommendations for sedation regimes in the intensive care unit daily sedation holds from the Society for Critical Care(ICU) have evolved over the last decade based on findings that Medicine (SCCM) guidelines for sedation [4], the Survivingrelate the clinical approach to improved patient outcomes. Martinand co-workers conducted two surveys into German sedation Sepsis Campaign guidelines [5] for the management ofpractice covering the time period during which these changes severe sepsis and the National Institute for Health ventilatoroccurred and as such provide an insight into how these recom- care bundles.mendations are being incorporated into everyday clinical practice. The current survey also allows us to look at the changes inIn the previous issue of Critical Care, Martin and co-workers, the use of different sedative agents. In the ICUs that[1] report the results of a survey examining changes in responded to the survey, broadly, there is a trend away from asedation management in German intensive care units (ICUs). hypnosis-based approach with benzodiazepines, and towardsThis review of 214 ICUs is made more informative by their a more analgesia-based approach. However the idealuse of the same questionnaire used by this group in 2002, sedative agent has yet to be developed, and despite theallowing changes in practice to be evaluated. plethora of recommendations on sedative practice in the above publications, there are no high-quality, large-scale,The recommended targets of sedation within the ICU have randomised controlled trials of different sedative agents in theevolved over recent years, led by a number of consensus ICU [4,6]. This lack of guidance is apparent in the largestatements. Patients that used to be heavily sedated, to keep number of agents reportedly used by respondents in thethem compliant for invasive procedures, are now easily current survey. The increased use of short-acting opioids androused for assessment, communication and reassurance. regional analgesia with epidural and peripheral nerve blocksDrug regimes have changed from being “carer-orientated” suggests a greater focus on analgesia within the ICU. This iscontinuous infusions, to “patient-orientated” regimes targeted backed up by evidence that effective treatment of pain in thearound sedation scales. Furthermore daily interruptions in ICU can lead to a reduction in the duration of mechanicalinfusions avoid the build up of sedative drugs in the changing ventilation when used in conjunction with pain scores againstpharmacological environment of the ICU patient. Both of which to titrate analgesia [7]. In the current survey only 21%these strategies have been shown to reduce duration of of units have introduced pain scores, again, despite themechanical ventilation and ICU stay [2,3]. The survey of endorsement of such scores - in particular, the numericalMartin et al. reports the impact of these changes to the rating score - by the SCCM sedation guidelines [4].clinical practice of sedation in the German ICUs between2002 and 2006, at a time when these international trends The purpose of national guidelines and consensus state-were being developed. They show that 51% of units are now ments is to aid the development of local protocols. Perhapsusing a sedation scale compared to 8% in 2002. Sedation this survey suggests there remains resistance amongstprotocols are used in 46% of ICUs, compared with 21% in clinicians to the adoption and use of such protocols, perhaps2002, and 34% have introduced daily sedation holds. This is because it may remove their autonomy and override clinicalsignificant change, but the survey shows how it clearly takes judgement. A protocol itself does not guarantee improvementtime for the impact of clinical research to be incorporated into in outcomes, however it remains a tool with which to directICU = intensive care unit; SCCM = Society for Critical Care Medicine. ...