Patients in intensive care units (ICUs) are generally sedated for prolonged periods. Over-sedation and under-sedation both have negative effects on patient safety and resource use. We conducted a systematic review of the literature in order to establish the incidence of sub-optimal sedation (both over- and under-sedation) in ICUs.

https://link.springer.com/content/pdf/10.1186%2Fcc8212.pdf

The incidence of sub-optimal sedation in the ICU: a systematic review.

Background: critically ill patients require life-support technologies such as mechanical ventilation (breathing machines) and can experience pain, anxiety, and sleep deprivation related to their illness. Good pain control and adequate sedation are important but too much sedative drug can increase the time on breathing machines and the chance of harmful effects such as pneumonia.
Medications that are available have many properties that make them difficult to use in critically ill patients. Without careful adjustments these properties can lead to a build up of drug in the body. These medications are given as continuous infusions, so that blood levels remain stable, and dose changes are left to clinician judgement. In order to avoid drug build up, several methods can be used to adjust doses. Some studies claim that an interruption, or stopping the drug for a period of time each day, will allow the body to clear the drugs and lead to patients being more awake and ready for earlier liberation from the breathing machine.
Search date: current to February 2014.
Study characteristics: we included nine studies involving 1282 critically ill patients receiving mechanical ventilation. Studies compared daily sedation interruption to strategies that did not include an interruption. Studies were conducted worldwide and involved both medical and surgical critically ill patients.
Key results: we did not find strong evidence that daily sedation interruption reduced the duration of mechanical ventilation, length of stay in the intensive care unit (ICU) or hospital, death, or the amount of drug used. The effect on adverse events such as accidental removal of the breathing tube or invasive devices, or the rate of delirium was uncertain. However, tracheostomy was performed less often in those who were managed with daily sedation interruption. Sedation practices are known to vary worldwide, and as such an analysis of studies conducted in North America showed a reduction in time on the breathing machine for those who were managed with daily sedation interruption compared to those who were not.
Quality of the evidence: we advise caution should be applied when interpreting and applying our study findings. The results are based upon a small number of studies that were heterogeneous or not uniform in terms of methods, patients studied, and clinical management and our overall results only marginally crossed the no-effect line.

/pdf/daily-sedation-interruption-versus-no-daily-sedation-2d7rwcbbyv.pdf

Daily sedation interruption versus no daily sedation interruption for critically ill adult patients requiring invasive mechanical ventilation

https://www.criticalcare.theclinics.com/article/S0749-0704(09)00035-9/pdf

Current Sedation Practices: Lessons Learned from International Surveys

Our aim was to describe analgo-sedation and antipsychotic and neuromuscular blocking drug (NMBD) use in critically ill patients, management strategies, and variables associated with these practice patterns This prospective observational study in 51 intensive care units (ICUs) included all patients who underwent invasive mechanical ventilation (MV) over a two-week period during 2008-2009 We included 712 patients representing 3,620 patient-days Median MV duration was 30 days (interquartile range 2-6) During MV, 92% of patients received analgo-sedation, 32% an adjunct agent (eg, acetaminophen), 18% NMBDs, and 10% antipsychotics Opioids were used more frequently than benzodiazepines or propofol (848% vs 622% vs 101% patients, respectively, P < 00001) Independent predictors of opioid and benzodiazepine use were a longer MV duration, assessment scales, physical restraints, and university-affiliated hospital Although more than 50% of ICUs reported that assessment tools, protocols, and daily sedation interruption (DSI) were available for use, application was modest: sedation scale 530%, pain scale 191%, delirium scale 52%, protocol 250%, DSI 421% Accidental device removal occurred in 46% of patients, with 758% of events during DSI Daily sedation interruption was associated with protocol use, physical restraints, university-affiliated hospital, and short-duration MV Variables associated with protocol use included assessment scales, longer MV duration, lack of physical restraints, and admission to a community hospital Nearly all MV patients received analgo-sedation Opioids were used more often than sedatives despite infrequent use of pain scales Few patients received antipsychotic therapy, but physical restraint was common Protocol use was poor compared to DSI Duration of MV predicted the use of either

Analgesic, sedative, antipsychotic, and neuromuscular blocker use in Canadian intensive care units: a prospective, multicentre, observational study.

The purpose of this study was to evaluate sedation practice in UK intensive care units (ICUs), particularly the implementation of daily sedation holding, written sedation guidelines, sedation scoring tools and choice of agents. A national postal survey was conducted in all UK ICUs. A total of 192 responses out of 302 addressed units were received (63.5%). Of the responding ICUs, 88% used a sedation scoring tool, most frequently the Ramsey Sedation Scale score (66.4%). The majority of units have a written sedation guideline (80%), and 78% state that daily sedation holding is practiced. A wide variety of sedating agents is used, with the choice of agent largely determined by the duration of action rather than cost. The most frequently used agents were propofol and alfentanil for short-term sedation; propofol, midazolam and morphine for longer sedation; and propofol for weaning purposes. Most UK ICUs use a sedation guideline and sedation scoring tool. The concept of sedation holding has been implemented in the majority of units, and most ICUs have a written sedation guideline.

/pdf/sedation-practice-in-the-intensive-care-unit-a-uk-national-1ibgwpaqls.pdf

Sedation practice in the intensive care unit: a UK national survey

SIAARTI recommendations for analgo-sedation in intensive care unit.

The performance of antimicrobial therapy depends on the drug, the host, and the infecting agent [1]. In the clinical setting, the interactions between these three factors are complex and they result in a dose-response relationship that is difficult to predict [2]. However, the choice of the appropriate drug at the appropriate dosage is fundamental for therapeutic success and for avoiding the emergence of resistant strains [3].

The classifications of antibiotics

The increase in endothelial capillary permeability represents one of the early and significant hallmarks of sepsis. An inflammatory-induced damage in endothelial glycocalyx has been identified as the mechanism involved in this increase in permeability in the condition of ischemia–reperfusion [1]. To date no data are available for glycocalyx damage in sepsis. The aim of this study was to evaluate whether sepsis-associated increase of permeability is due to glycocalyx alteration.

/pdf/sepsis-induces-an-early-impairment-of-endothelial-glycocalyx-4u7p5rcpt0.pdf

Sepsis induces an early impairment of endothelial glycocalyx in glomerular capillaries

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SIAARTI recommendations for analgo-sedation in intensive care unit.

The classifications of antibiotics

Sepsis induces an early impairment of endothelial glycocalyx in glomerular capillaries