Sedation in ICU: are we achieving goals?

OBJECTIVE: The purpose of this study was to examine whether sedation goals, utilizing a validated sedation assessment scale, the Riker Sedation-Agitation Scale (SAS), and a standardized sedation protocol, were achieved in Intensive Care Unit (ICU) patients. DESIGN: This is a nested prospective cohort study SETTING: The study was conducted in a tertiary care medical-surgical ICU. PATIENTS: All mechanically ventilated adult patients who were judged by their treating intensivists to require intravenous sedation for more than 24 hours, were included in the study. INTERVENTIONS: A goal-directed protocol using the SAS was initiated following an educational program to the medical and nursing staff. MEASUREMENTS AND MAIN RESULTS: The following data was collected: patients' demographics, Acute Physiology and Chronic Health Evaluation (APACHE) II score, reason for admission, and outcome. For the first five ICU days, the bedside nurse documented ordered and average achieved SAS scores, every 4 hours. We compared the targeted versus achieved SAS scores using a paired Student's t-test. One hundred and five (105) patients were included in the study with mean age (+/-SD) of 47 (+/-23) and APACHE II (+/-SD) of 21 (+/-9). Achieved sedation scores were consistently lower than the requested goals during daytime and nighttime shifts throughout the study period. This did not change even after 3 months of implementing the protocol. CONCLUSION: Achieved levels of SAS score were consistently lower than what was requested by physicians despite an educational program and the use of a standardized protocol. Differences between targeted and achieved SAS scores persisted throughout the whole study period even three months after protocol implementation. These data suggest the need for alternative, more sensitive and precise approaches, to titrate sedation to targeted levels.