Exploring the impact of augmenting sedation assessment with physiologic monitors.

BACKGROUND: Pharmacological sedation is a necessary tool in the management of critically ill, mechanically ventilated patients. The intensive care unit (ICU) sedation strategy is to use the least amount of medication to meet safety and comfort goals. Titration of pharmacological agents is currently guided by clinical assessment tools. The purpose of this study was to determine whether the addition of a neurophysiological monitor, bispectral index (BIS), aided the ICU nurse in reducing the amount of drug used, compared to a clinical tool alone, in a general critical care population. METHODS: In this prospective clinical trial, mechanically ventilated adults (N=300) were randomised to sedation assessment using only the observational assessment tool (RASS) or a combination of observational and physiologic measures (RASS+BIS). Subjects were enrolled from a medical ICU (N=154), a trauma ICU (N=72) and a general mixed-use ICU (N=74). RESULTS: BIS-augmented sedation was only associated with the reduction of drug use when patients were sedated with propofol or narcotic agents (propofol [1.61 mg/kg/h vs. 1.77 mg/kg/h; p<0.0001], fentanyl [54.73 mcg/h vs. 66.81 mcg/h; p<0.0001], and hydromorphone [0.97 mg/h vs. 4.00 mg/h: p<0.0001] compared to RASS alone. In contrast, patients sedated with dexmedetomidine or benzodiazepines were given higher doses under the BIS-augmented dexmedetomidine [0.46 mcg/kg/h vs. 0.33 mcg/kg/h; p<0.0001], lorazepam [4.13 mg/h vs. 3.29 mg/h p<0.0001], and midazolam [3.73 mg/h vs 2.86 mg/h; p<0.0001]) protocol compared to clinical assessment alone. CONCLUSION: The clinical evaluation of depth of sedation remains the most reliable method for the titration of pharmacological sedation in the critical care unit. However, BIS-augmented assessment is helpful in reducing the amount of propofol and narcotic medication used and may be considered an adjunct when these agents are utilised.

Effects of nursing interventions on intracranial pressure.

BACKGROUND: Intracranial pressure is a frequent target for goal-directed therapy to prevent secondary brain injury. In critical care settings, nurses deliver many interventions to patients having intracranial pressure monitored, yet few data documenting the immediate effect of these interventions on intracranial pressure are available. OBJECTIVE: To examine the relationship between intracranial pressure and specific nursing interventions observed during routine care. METHODS: Secondary analysis of prospectively collected observational data. RESULTS: During 3118 minutes of observation, 11 specific nursing interventions were observed for 28 nurse-patient dyads from 16 hospitals. Family members talking in the room, administering sedatives, and repositioning the patient were associated with a significantly lower intracranial pressure. However, intracranial pressure was sometimes higher, lower, or unchanged after each intervention observed. CONCLUSION: Response of intracranial pressure to nursing interventions is inconsistent. Most interventions were associated with inconsistent changes in intracranial pressure at 1 or 5 minutes after the intervention.

Significant practice pattern variations associated with intracranial pressure monitoring.

PURPOSE: The purpose of this study was to describe nursing practice in the care of patients with intracranial pressure monitoring. Although standards for care of such patients have been established, there continue to be variations in the nursing practice. METHODS: This was an observational study in which data were collected from 28 nurse-patient dyads at 16 different hospitals across the United States. Each dyad was observed for 2 hours; nursing actions and patient responses including intracranial pressure readings were documented. RESULTS: Differences in the care of patients with intracranial pressure monitoring were prevalent. Variations in practice were prompted by healthcare provider prescriptions as well as nursing decisions. Prescriptions and interventions were often not supported by the available scientific evidence. VIDEO ABSTRACT: For more insights from the authors, see Supplemental Digital Content 1, at http://links.lww.com/JNN/A7.