The implementation of an analgesia-based sedation protocol reduced deep sedation and proved to be safe and feasible in patients on mechanical ventilation.

INTRODUCTION: Deep sedation in critically ill patients is associated with a longer duration of mechanical ventilation and a prolonged length of stay in the intensive care unit. Several protocols have been used to improve these outcomes. We implement and evaluate an analgesia-based, goal-directed, nurse-driven sedation protocol used to treat critically ill patients who receive mechanical ventilation. METHODS: We performed a prospective, two-phase (before-after), non-randomized multicenter study that involved 13 intensive care units in Chile. After an observational phase (observational group, n=155), we designed, implemented and evaluated an analgesia-based, goal-directed, nurse-driven sedation protocol (intervention group, n=132) to treat patients who required mechanical ventilation for more than 48 hours. The primary outcome was to achieve ventilator-free days by day 28. RESULTS: The proportion of patients in deep sedation or in a coma decreased from 55.2% to 44.0% in the interventional group. Agitation did not change between the periods and remained approximately 7%. Ventilator-free days to day 28, length of stay in the intensive care unit and mortality were similar in both groups. At one year, post-traumatic stress disorder symptoms in survivors were similar in both groups. CONCLUSIONS: We designed and implemented an analgesia-based, goal-directed, nurse-driven sedation protocol in Chile. Although there was no improvement in major outcomes, we observed that the present protocol was safe and feasible and that it resulted in decreased periods of deep sedation without increasing agitation.

Implantacao de protocolo de reducao de sedacao profunda baseado em analgesia comprovadamente seguro e factivel em pacientes submetidos a ventilacao mecanica / The implementation of an analgesia-based sedation protocol reduced deep sedation and proved to be safe and feasible in patients on mechanical ventilation

INTRODUÇÃO: A sedação profunda em pacientes gravemente enfermos se associa a uma maior duração da ventilação mecânica e à permanência mais longa na unidade de terapia intensiva. Diversos protocolos foram utilizados para melhorar esses desfechos. Implantamos e avaliamos um protocolo de sedação baseado em analgesia, direcionado por objetivos e cuidado por enfermeiros, em pacientes gravemente enfermos submetidos à ventilação mecânica. MÉTODOS: Realizamos um estudo multicêntrico prospectivo em duas fases (antes e depois), que envolveu 13 unidades de terapia intensiva localizadas no Chile. Após uma fase observacional (grupo observacional, N=155), delineamos, implantamos e avaliamos um protocolo de sedação cuidado por enfermeiros, direcionado por objetivos (grupo de intervenção, N=132) para tratar pacientes que necessitaram de ventilação mecânica por mais do que 48 horas. O parâmetro primário de avaliação foi a obtenção de dias livres de ventilador até o dia 28. RESULTADOS: No grupo de intervenção, a proporção de pacientes com sedação profunda ou coma diminuiu de 55,2 para 44,0%. A incidência de agitação não se alterou entre os períodos, permanecendo em cerca de 7%. Dias livres de ventilador até o dia 28, permanência na unidade de terapia intensiva e mortalidade foram similares em ambos os grupos. Após 1 ano, a presença de sintomas de desordem de estresse pós-traumático nos sobreviventes foi similar entre os grupos. CONCLUSÕES: Delineamos e implantamos no Chile um protocolo de sedação baseado em analgesia, direcionado por objetivos e cuidado por enfermeiros. Embora não se tenha observado melhora nos principais desfechos, observamos que o presente protocolo foi ...

INTRODUCTION: Deep sedation in critically ill patients is associated with a longer duration of mechanical ventilation and a prolonged length of stay in the intensive care unit. Several protocols have been used to improve these outcomes. We implement and evaluate an analgesia-based, goal-directed, nurse-driven sedation protocol used to treat critically ill patients who receive mechanical ventilation. METHODS: We performed a prospective, two-phase (before-after), non-randomized multicenter study that involved 13 intensive care units in Chile. After an observational phase (observational group, n=155), we designed, implemented and evaluated an analgesia-based, goal-directed, nurse-driven sedation protocol (intervention group, n=132) to treat patients who required mechanical ventilation for more than 48 hours. The primary outcome was to achieve ventilator-free days by day 28. RESULTS: The proportion of patients in deep sedation or in a coma decreased from 55.2% to 44.0% in the interventional group. Agitation did not change between the periods and remained approximately 7%. Ventilator-free days to day 28, length of stay in the intensive care unit and mortality were similar in both groups. At one year, post-traumatic stress disorder symptoms in survivors were similar in both groups. CONCLUSIONS: We designed and implemented an analgesia-based, goal-directed, nurse-driven sedation protocol in Chile. Although there was no improvement in major outcomes, we observed that the present protocol was safe and feasible and that it resulted in decreased periods of deep sedation without increasing agitation. .

[Characteristics and factors associated with mortality in patients receiving mechanical ventilation: first Chilean multicenter study]. / Características de los pacientes que reciben ventilación mecánica en unidades de cuidados intensivos: primer estudio multicéntrico chileno.

BACKGROUND: The outcome of mechanically ventilated patients can be influenced by factors such as the indication of mechanical ventilation (MV) and ventilator parameters. AIM: To describe the characteristics of patients receiving MV in Chilean critical care units. MATERIAL AND METHODS: Prospective cohort of consecutive adult patients admitted to 19 intensive care units (ICU) from 9 Chilean cities who received MV for more than 12 hours between September lst, 2003, and September 28th, 2003. Demographic data, severity of illness, reason for the initiation of MV, ventilation modes and settings as well as weaning strategies were registered at the initiation and then, daily throughout the course of MV for up to 28 days. ICU and hospital mortality were recorded. RESULTS: Of 588 patients admitted, 156 (26.5%) received MV (57% males). Mean age and Simplified Acute Physiology Score-II (SAPS II) were 54.6+/-18 years and 40.6+/-16.4 points respectively The most common indications for MV were acute respiratory failure (71.1%) and coma (22.4%). Assist-control mode (71.6%) and synchronized intermittent mandatory ventilation (SIMV) (14,2%) were the most frequently used. T-tube was the main weaning strategy. Mean duration of MV and length of stay in ICU were 7.8+/-8.7 and 11.1+/- 14 days respectively. Overall ICU mortality was 33.9% (53 patients). The main factors independently associated with increased mortality were (1) SAPS II > or =60 points (Odds Ratio (OR), 10.5; 95% CI, 1.04-106.85) and (2) plateau pressure > or =30 cm H2O at second day (OR, 3.9; 95% CI, 1.17-12.97). CONCLUSIONS: Conditions present at the onset of MV and ventilator management were similar to those reported in the literature. Magnitude of multiorgan dysfunction and high plateau pressures are the most important factors associated with mortality.

Características de los pacientes que reciben ventilación mecánica en unidades de cuidados intensivos: primer estudio multicéntrico chileno / Characteristics and factors associated with mortality in patients receiving mechanical ventilation

Background: The outcome oí' mechanically ventilated patients can be inñuenced byfactors such as the indication of mechanical ventilation (MV) and ventilator parameters. Aim: To describe the characterístics of patients receiving MV in Chilean critical care uníts. Material and methods: Prospective cohort of consecutive adult patients admitted to 19 intensive care uníts ([CU) from 9 Chilean cities who received MV for more than 12 hours between September lst, 2003, and September 28th, 2003. Demographic data, severity of illness, reason for the initiation of MV, ventilation modes and settings as well as weaning strategies were registered at the initiation and then, daily throughout the course of MV for up to 28 days. ¡CU and hospital mortality were recorded. Resulte: Of 588 patients admitted, 156 (26.5 percent) received MV (57 percent males). Mean age and Simplified Acute Physiology Score-II (SAPSII) were 54.6±18years and 40.6±16.4 points respectively The most common indications for MV were acute respiratory failure (71.1 percent) and coma (22.4 percent). Assist-control mode (71.6 percent) and synchronized intermittent mandatory ventilation (SIMV) (14,2 percent) were the most frequently used. T-tube was the main weaning strategy. Mean duration of MV and length of stay in ICU were 7.8±8.7 and 11.1± 14 days respectively. OverallICUmortality was 33.9 percent (53patients). The main factors independently associated with increased mortality were (1) SAPS II ≥ 60 points (Odds Patio (OR), 10.5; 95 percent CI, 1.04-106.85) and (2) plateaupressure ≥ 30 cm Hfi atsecond day (OR, 3.9; 95 percent CI, 1.17-12.97). Conclusions: Conditionspresent at the onsetofMVand ventilator management were similar to those reported in the literature. Magnitude ofmultiorgan dysfunction and high plateau pressures are the most important factors associated with mortality).

Impacto del intensivista en el manejo y gestion en una Unidad de Cuidados Intensivos / Impact of the intensivist in the handling and management in an intensive care unit

The development of medicine in the different ambits, has placed lately a strong emphasis in what refers to management which in the area of Critical Medicine has a major relevance due to the high costs invested in this type of patients. There are several publications waiting to show the role of the specialist in intensive therapy and how his work, vision and handling of critical patients impacts on the general operation of these units on its performance and eventually on administrative management. At the Coquimbo Hospital, there is an Intensive Care Unit since 1993, which began to function with interns. Since 1997, and in sequence, two of the doctors who work there, specialize in Critical Medicine, with studies abroad, and one of them becomes chief of the unit. This report analyzes, in a retrospective way, both periods: before and after the incorporation of these specialists; showing a better performance on the epidemiological parameters in the second stage; not being able to complement it with costs data. On the other hand, advances in techniques and clinical guides are mentioned. The Intensive Care Units are benefited by the presence of specialists within their team.