Title: Outcomes of Early Deep Sedation of the Mechanically-Ventilated Patient (Submitted by Andrew Deitchman) <br/>Author: Kami Hu<br/><a href='http://umem.org/profiles/faculty/742/'>[Click to email author]</a><hr/><p dir="ltr" style="line-height:1.295;margin-top:0pt;margin-bottom:8pt;">
<span style="font-size:12px;"><strong><span color:="" font-weight:="" new="" style="background-color: transparent;" times="" vertical-align:="" white-space:="">Background:</span></strong><span color:="" new="" style="background-color: transparent;" times="" vertical-align:="" white-space:=""><strong> </strong>Sedation and analgesia are key components for mechanically ventilated patients. While significant data exists regarding how to manage sedation and analgesia </span><span font-size:="" new="" style="color: rgb(0, 0, 0); font-family: " times="" white-space:="">in the ICU setting, </span><span font-size:="" new="" style="background-color: transparent; color: rgb(0, 0, 0); font-family: " times="" white-space:="">very little data exists on management in the ED. </span></span></p>
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<span style="font-size:12px;"><span font-size:="" new="" style="background-color: transparent; color: rgb(0, 0, 0); font-family: " times="" white-space:=""><strong>Data: </strong>A prospective, single-center, observational study of mechanically-ventilated adult patients </span><span font-size:="" new="" style="color: rgb(0, 0, 0); font-family: " times="" white-space:="">used linear regression to identify ED sedation practices and outcomes, </span><span font-size:="" new="" style="background-color: transparent; color: rgb(0, 0, 0); font-family: " times="" white-space:="">with a focus on sedation characteristics using the Richmond Agitation-Sedation Scale (RASS).</span></span></p>
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<span style="font-size:12px;"><span font-size:="" font-weight:="" new="" style="background-color: transparent; color: rgb(0, 0, 0); font-family: " times="" white-space:="">Findings:</span></span></p>
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<span style="font-size:12px;"><span id="docs-internal-guid-8354b4d3-3190-c16c-e683-af5dadaef991"><span background-color:="" color:="" new="" times="" vertical-align:="" white-space:="">15% of intubated patients had no sedation or analgesia ordered</span></span></span></li>
<li style="line-height: 1.295; margin-top: 0pt; margin-bottom: 8pt;">
<span style="font-size:12px;"><span id="docs-internal-guid-8354b4d3-3190-c16c-e683-af5dadaef991"><span background-color:="" color:="" new="" times="" vertical-align:="" white-space:="">64% of intubated patients were documented as deeply-sedated (RASS -3 to -5)</span></span></span></li>
<li style="line-height: 1.295; margin-top: 0pt; margin-bottom: 8pt;">
<span style="font-size:12px;"><span id="docs-internal-guid-8354b4d3-3190-c16c-e683-af5dadaef991"><span background-color:="" color:="" new="" times="" vertical-align:="" white-space:="">Deep sedation was not only associated with more ventilator days, but also <em>increased mortality,</em> with an adjusted OR of 0.77 (95% CI 0.54-0.94) favoring patients with lighter sedation.</span></span></span></li>
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<span style="font-size:12px;"><span id="docs-internal-guid-8354b4d3-3190-c16c-e683-af5dadaef991"><strong><span background-color:="" color:="" font-weight:="" new="" times="" vertical-align:="" white-space:="">Bottom line: </span></strong><span background-color:="" color:="" new="" times="" vertical-align:="" white-space:=""> Avoid early deep sedation in your intubated patients as this may be directly associated with increased mortality. Instead, a goal RASS of 0 to -2 should be appropriate for most non-paralyzed, mechanically-ventilated ED patients, extrapoloating from ICU guidelines. </span></span></span></p>
<fieldset><legend>References</legend>
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<span id="docs-internal-guid-e8ea54f1-31c5-418c-984b-a417fc5ac40b"><span style="font-size: 11pt; font-family: Calibri; color: rgb(0, 0, 0); background-color: transparent; vertical-align: baseline; white-space: pre-wrap;">Stephens, R.J., et al., Analgosedation Practices and the Impact of Sedation Depth on Clinical Outcomes Among Patients Requiring Mechanical Ventilation in the ED: A Cohort Study. Chest, 2017 [Epub ahead of print].</span></span></p>
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<span id="docs-internal-guid-e8ea54f1-31c5-418c-984b-a417fc5ac40b"><span style="font-size: 11pt; font-family: Calibri; color: rgb(0, 0, 0); background-color: transparent; vertical-align: baseline; white-space: pre-wrap;">Barr J, Fraser GL, Puntillo K, Ely EW, Gélinas C, Dasta JF, Davidson JE, Devlin JW, Kress JP, Joffe AM, et al.; American College of Critical Care Medicine. Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit. Crit Care Med 2013;41:263–306.</span></span></p>
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