Perceived versus Actual Sedation Practices in Adult Intensive Care Unit Patients Receiving Mechanical Ventilation

Kimberly Varney Gill PharmD BCPS; Stacy A Voils PharmD BCPS; Gregory A Chenault PharmD; Gretchen M Brophy PharmD BCPS FCCP FCCM

Disclosures

The Annals of Pharmacotherapy. 2012;46(10):1331-1339. 

In This Article

Abstract and Introduction

Abstract

Background: With drug shortages, newer sedative medications, and updates in research, management of sedation and delirium in patients receiving mechanical ventilation continues to evolve.
Objective: To compare perceived and actual sedation practices for adults receiving mechanical ventilation in intensive care units (ICUs).
Methods: This was a multicenter, 2-part study conducted in adult ICUs in US hospitals. It included a sedation practice survey completed by ICU pharmacists and an observational study evaluating actual sedation practices over a 24-hour period.
Results: Surveys were completed for 85 ICUs; observational data for 496 patients were collected. Preferred sedatives from the survey data were propofol (short-term); propofol, midazolam, or lorazepam (intermediate); and lorazepam (long-term). Propofol was the most commonly used agent overall during the observational period (primarily for short-term and intermediate-length sedation); midazolam was the most commonly used for long-term sedation. Fentanyl was the preferred analgesic, and haloperidol and quetiapine were the preferred antipsychotics. Sedation treatment algorithms were used in only 50% of observed ICUs. Use of daily interruption of sedation was perceived to be 66% but was only observed in 36% of patients. Monitoring for delirium was reported among 25% of those surveyed but was observed in only 10% of patients. Targeted sedation goals were most frequently achieved when a treatment algorithm was used or when an opiate infusion was the single agent used for sedative management.
Conclusions: These data suggest differences in perceived and actual sedation practice in the US, as well as underutilization of evidence-based interventions. Most notable was the limited use of sedation treatment algorithms, daily interruption of sedation, and monitoring for delirium. Individual sedation and delirium protocols should be evaluated and updated based on evidence-based recommendations.

Introduction

Management of sedation and analgesia in critically ill patients is a frequently researched and debated topic in critical care medicine. The Society of Critical Care Medicine (SCCM) published guidelines in 2002 to assist clinicians in the management of sedation and analgesia.[1] However, applying a single guideline to a diverse and dynamic patient population is challenging and has led to inconsistent practice across intensive care units (ICUs). Additionally, a number of recent trials have been published suggesting the utility of alternative strategies for sedation,[2–6] as well as a greater emphasis on the prevention and screening of delirium.[7–9]

Since the publication of sedation guidelines, international surveys have been completed to assess the impact of clinical trials and evidence-based guidelines on sedation and monitoring strategies.[10–20] However, surveys report variable response rates, and information from questionnaires may differ significantly from actual practice. Despite these known limitations of survey data, valuable information may be obtained on current sedation practices that may be used to guide research and educational initiatives. In the US, a large-scale survey regarding sedation strategies with a practice component to verify the perceived sedation approach has not been performed. The purpose of our study was 2-fold: (1) to characterize general sedation practices in the US via survey data obtained from critical care clinicians and (2) to conduct an observational study for real-time evaluation of actual sedation practices. To our knowledge, this is the first US sedation study that directly compares survey data with clinical practice data.

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