Does implementation of a goal sedation score improve management of mechanically ventilated adults?
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KeywordsMorphine Physical Restraint Sedation Management Sedation Protocol Prospective Audit
Sedation management of mechanically ventilated patients has been a source of concern for intensive care nursing and medical staff worldwide in recent years. An earlier prospective audit of 48 ventilated patients showed that our sedation management was suboptimal. Patients were oversedated 45% of the time, with the most frequent management strategy being use of morphine and midazolam infusions. Despite this, 23% of patients were physically restrained. A literature review suggested that a move away from sedative infusions would reduce the length of ventilation, length of ICU stay and tracheostomy incidence. Use of sedation scales, setting of goal sedation scores and implementation of a nurse-initiated sedation protocol were also deemed best practice.
To determine whether introduction of a goal sedation score would be associated with improved management of sedation as indicated by a reduction in incidence of oversedation and in use of physical restraints.
The study design was prospective and exploratory. Following multidisciplinary staff training, an optimal sedation goal score was set daily by senior medical staff and changed when clinically indicated. Nurses titrated intravenous infusions of analgesia and sedation with the aim of achieving the desired goal sedation score. Sedation patterns were collected on 52 ventilated patients. Institutional ethics approval was obtained.
The median APACHE II score was 19 (range 8–33); median age was 65.9 years (range 18–88); sex ratio, male/female, was 7:3. For patients ventilated for more than 5 days only sedation patterns for the first 5 days are presented. The goal sedation score was achieved in 45% of patient-hours, with only 7% of patient-hours recorded as agitated. Incidence of oversedation was unchanged from the previous audit (45% of time). Patients deemed at risk of oversedation had a goal score compliance of 48.6%. Patients at risk of undersedation had a goal score compliance of 34.4%. When compared with prior audit results, there was an increase in the use of physical restraints from 11/48 (23%) to 21/52 (40%) (Fishers exact P = 0.086). Morphine and midazolam infusion use was unchanged with use in 63% and 65% of patients, respectively, and propofol was used in 73% of patients. Incidence of deliberate self-extubation was 0.9/100 ventilated days, median length of ventilation was 3.9 days and incidence of tracheostomy was 7.6%.
Despite a sedation goal score being set daily, patients reached their goal score for less than one-half of ventilated hours. Oversedation continued to be a problem and may be associated with the frequent use of morphine and midazolam infusions. Considering agitation appeared to be well managed, the increased use of physical restraints is concerning. Due to the limited success of use of goal sedation scores alone to improve sedation management, we are now prospectively evaluating the use of a sedation management algorithm in conjunction with goal scores.