What do you mean by "palliative sedation"? : Pre-explicative analyses as preliminary steps towards better definitions.

BACKGROUND: Sedation in palliative care is frequently but controversially discussed. Heterogeneous definitions and conceptual confusion have been cited as contributing to different problems 1) relevant to empirical research, for example, inconsistent data about practice, the 'data problem', and 2) relevant for an ethically legitimate characterisation of the practice, the 'problem of ethical pre-emption'. However, little is known about how exactly definitions differ, how they cause confusion and how this can be overcome. METHOD: Pre-explicative analyses: (A) systematic literature search for guidelines on sedation in palliative care and systematic decomposition of the definitions of the practice in these guidelines; (B) logical distinction of different ways through which the two problems reported might be caused by definitions; and (C) analysis of how content of the definitions contributes to the problems reported in these different ways. RESULTS: 29 guidelines from 14 countries were identified. Definitions differ significantly in both structure and content. We identified three ways in which definitions can cause the 'data problem' - 1) different definitions, 2) deviating implicit concepts, 3) disagreement about facts. We identified two ways to cause the problem of ethical pre-emption: 1) explicit or 2) implicit normativity. Decomposition of definitions linked to the distinguished ways of causing the conceptual problems shows how exactly single parts of definitions can cause the problems identified. CONCLUSION: Current challenges concerning empirical research on sedation in palliative care can be remediated partly by improved definitions in the future, if content and structure of the used definitions is chosen systematically. In addition, future research should bear in mind that there are distinct purposes of definitions. Regarding the 'data problem', improving definitions is possible in terms of supplementary information, checking for implicit understanding, systematic choice of definitional elements. 'Ethical pre-emption', in contrast, is a pseudo problem if definitions and the relationship of definitions and norms of good practice are understood correctly.

Identification of delirium and subsyndromal delirium in intensive care patients.

OBJECTIVE: identify delirium and subsyndromal delirium in intensive care patients; age, hospitalization time, and mortality. METHOD: a retrospective, quantitative study conducted in the Intensive Care Unit, using the Richmond Agitation-Sedation Scale to evaluate sedation and the Intensive Care Delirium Screening Checklist for the identification of delirium, with the participation of 157 patients. For statistical analysis, the t-test and the Chi-square test was carried out. RESULTS: the majority presented subsyndromal delirium (49.7%). Mortality was 21.7%. The relationship between delirium and its subsyndromal with hospitalization time was statistically significant for both (p=0.035 and p <0.001), while age was significant only in the subsyndromal delirium (p=0.009). CONCLUSION: the majority of the patients presented subsyndromal delirium. The length of hospital stay was statistically significant in delirium and subsyndroma delirium. Age was significant only in subsyndromal delirium. The mortality of patients with delirium was higher than the others.

Identification of delirium and subsyndromal delirium in intensive care patients / Identificación de delirio y delirio subsindromático en pacientes de terapia intensiva / Identificação de delirium e delirium subsindromático em pacientes de terapia intensiva

ABSTRACT Objective: identify delirium and subsyndromal delirium in intensive care patients; age, hospitalization time, and mortality. Method: a retrospective, quantitative study conducted in the Intensive Care Unit, using the Richmond Agitation-Sedation Scale to evaluate sedation and the Intensive Care Delirium Screening Checklist for the identification of delirium, with the participation of 157 patients. For statistical analysis, the t-test and the Chi-square test was carried out. Results: the majority presented subsyndromal delirium (49.7%). Mortality was 21.7%. The relationship between delirium and its subsyndromal with hospitalization time was statistically significant for both (p=0.035 and p <0.001), while age was significant only in the subsyndromal delirium (p=0.009). Conclusion: the majority of the patients presented subsyndromal delirium. The length of hospital stay was statistically significant in delirium and subsyndroma delirium. Age was significant only in subsyndromal delirium. The mortality of patients with delirium was higher than the others.

RESUMEN Objetivo: identificar delirio y delirio subsindromáico en pacientes de terapia intensiva; relacionar con edad, tiempo de internación y demostrar la mortalidad. Método: el estudio retrospectivo, cuantitativo, realizado en Unidad de Terapia Intensiva, a través de la escala Richmond Agitation-Sedation Scale para evaluar la sedación y la escala Intensive Care Delirium Screening Checklist para identificación de delirio, con participación de 157 pacientes. Para el análisis estadístico, se aplicó la prueba t y el Qui-cuadrado. Resultados: la mayoría presentó delirio subsindromático (49,7%). La mortalidad fue del 21,7%. La relación entre el delirio y su subsíndrome con el tiempo de internación fue estadísticamente significativa para ambos (p = 0,035 y p <0,001), mientras que la edad fue significativa sólo en el subsindromático (p = 0,009). Conclusión: la mayoría de los pacientes presentó delirio subsindromático. El tiempo de internación fue estadísticamente significativo en el delirio y en el subsindromático. La edad fue significativa sólo en el subsindromático. La mortalidad del paciente con delirio fue mayor que los demás.

RESUMO Objetivo: identificar delirium e delirium subsindromáico em pacientes de terapia intensiva; relacionar com idade, tempo de internação e demonstrar a mortalidade. Método: estudo retrospectivo, quantitativo, realizado em Unidade de Terapia Intensiva, por meio da escala Richmond Agitation-Sedation Scale para avaliar sedação e a escala Intensive Care Delirium Screening Checklist para identificação de delirium, com participação de 157 pacientes. Para análise estatística, foram aplicados o teste t e o Qui-quadrado. Resultados: a maioria apresentou delirium subsindromático (49,7%). A mortalidade foi de 21,7%. A relação entre o delirium e sua subsíndrome com o tempo de internação foi estatisticamente significativo para ambos (p=0,035 e p<0,001), enquanto a idade foi significativa apenas no subsindromático (p=0,009). Conclusão: a maioria dos pacientes apresentou delirium subsindromático. O tempo de internação foi estatisticamente significativo no delirium e no subsindromático. A idade foi significativa apenas no subsindromático. A mortalidade do paciente com delirium foi maior do que os demais.

Sedation scales: Do they capture the concept of opioid-induced sedation?

AIM: The purpose of this study was to explore the concept of opioid-induced sedation and how nurses define and measure sedation in the hospital setting. BACKGROUND: Opioid medications are the primary treatment for acute pain in the postoperative setting. One of the most serious side effects of opioid therapy is excessive sedation and respiratory depression. Nurses have the responsibility of providing effective pain management, while keeping the patient safe from adverse sedation and respiratory depression. Thus, the assessment of sedation becomes an integral part of the nurses' responsibilities. REVIEW METHOD: A review of the literature on the concept of opioid-induced sedation, and how it is measured by nurses in the hospital setting was performed using the Walker and Avant's (2011) framework. RESULTS: Sedation is an ambiguous concept that challenges nurse's critical thinking skills. The linear sedation scales can assist with the measurement of sedation, but may lack sensitivity and specificity in detecting the small changes on the continuum of levels of consciousness. Additionally, the scales may not capture the entire aspects of the concept of sedation. CONCLUSIONS: Sedation, as defined by the linear sedation scales is limiting nurses' appreciation of the small changes in level of cognition as well as consciousness that occurs as an adverse and potentially dangerous side effect of opioid medications used for acute pain management. Through developing a better understanding of sedation as a clinical concept, nurses may enhance their clinical skillset in safer postoperative pain management. Additionally, linear sedation scales could be further developed to better capture all aspects of sedation.

Valoración de la tolerancia y seguridad de 5 modelos de sedación durante la realización de la ecobroncoscopia / Tolerance and Safety of 5 Models of Sedation During Endobronchial Ultrasound

Introducción: La sedación durante la ecobroncoscopia es importante debido a la duración prolongada de esta exploración. Evaluamos distintos modelos de sedación y sus complicaciones. Método: Se realizó un estudio multicéntrico, prospectivo y observacional en el que recogieron distintas variables en 307 pacientes con distintos modelos de sedación: a) midazolam en bolo; b)propofol en perfusión; c) midazolam en bolo y propofol en perfusión; d) propofol en perfusión y remifentanilo en perfusión, y e) midazolam en bolo y fentanilo en bolo. Finalizada la prueba, los pacientes contestaron una encuesta de satisfacción. Resultados: Los pacientes por modelo de sedación fueron: A 24, B 37, C 107, D 62 y E 77. Las puntuaciones de las sensaciones percibidas de recuerdo, dolor, tos, disnea y exploración prolongada (0,65 ± 1,11; 0,3 ± 0,73; 0,46 ± 0,9; 0,29 ± 0,73; 0,59 ± 0,96) fueron menores frente a miedo y nerviosismo antes de la exploración (1,26 ± 1,37 y 1,5 ± 1,41). Los valores elevados de indiferencia ante la repetición (1,49 ± 1,3) y de sensación agradable de la prueba (1,23 ± 1,17), junto con cifras bajas la sensación de angustia (0,49 ± 0,85) e incomodidad de la exploración (0,62 ± 1,1), muestran que los distintos modelos de sedación fueron bien tolerados. El 46,6% de los pacientes no encontraron ningún momento malo y el 89,6% se repetiría la prueba. Los modelos E y C fueron los que menos complicaciones presentaron (12,9 y 31,7%) y, en todos los casos, se resolvieron con medidas terapéuticas sencillas. Conclusiones: Los modelos de sedación analizados fueron bien tolerados y la mayoría aceptarían la repetición de la ecobroncoscopia. Las complicaciones fueron escasas y sencillas de resolver

Introduction: Sedation during endobronchial ultrasound (EBUS) is essential due to the long duration of this procedure. We evaluated different models of sedation and their complications. Method: A multicenter, prospective, observational study of 307 patients undergoing EBUS was conducted. Patients were sedated with: a) midazolam bolus; b) propofol infusion; c) midazolam bolus and propofol infusion; d) propofol infusion and remifentanil infusión, or e)midazolam bolus and fentanyl bolus, and clinical variables were collected. Patients were asked to complete a satisfaction survey following the test. Results: Patients per sedation model were: A 24, B 37, C 107, D 62 and E 77. Scores for perceived sensations of recall, pain, cough, dyspnea and prolonged examination (0.65 ± 1.11; 0 3 ± 0.73, 0.46 ± 0.9, 0.29 ± 0.73, and 0.59 ± 0.96, respectively) were lower compared to fear and nervousness before the examination (1.26 ± 1.37 and 1.5 ± 1.41, respectively). High levels of indifference to repeating the procedure (1.49±1.3) and a reported pleasant feeling during the test (1.23±1.17), with low levels of anxiety (0.49 ± 0.85) and discomfort (0.62 ± 1.1), show that different models of sedation were well tolerated. Almost half the patients (46.6%) did not report any "worst momento" during the procedure, and 89.6% were willing to undergo a repeat test. The E and C models presented fewest complications (12.9 and 31.7%, respectively), and all were resolved with simple therapeutic measures. Conclusions: The models of sedation evaluated were well tolerated and most patients were willing to undergo repeat EBUS. Complications were few and easily resolved

Pharmacodynamic considerations for moderate and deep sedation.

Moderate and deep sedation can be provided using various classes of drugs, each having unique mechanisms of action. While drugs within a given classification share similar mechanisms and effects, certain classes demonstrate superior efficacy but added concern regarding safety. This continuing education article will highlight essential principles of pharmacodynamics and apply these to drugs commonly used to produce moderate and deep sedation.

Utility of bispectral index monitoring during intravenous sedation in the dental office.

PURPOSE: This research sought to compare two different systems to monitor sedated patients undergoing implant surgery in the dental office: the bispectral index (BIS) and the Ramsay scale. This information was used to establish an optimal BIS range for surgery in these patients and to calculate differences in drug consumption in both groups. MATERIALS AND METHODS: Consecutive patients undergoing implant surgery were studied and randomly assigned to two groups. Patients were sedated using intravenous propofol, fentanyl, and midazolam. The sedation level in group A was measured using the Ramsay scale. In group B, the Ramsay scale and the BIS were used together. Heart rate, blood pressure, and peripheral oxygen saturation were monitored in all patients. The levels of anxiety, satisfaction, and drug consumption were compared between groups. RESULTS: Forty-three patients were included; 20 were placed in group A and 23 were included in group B. There were no differences in the hemodynamic and respiratory parameters monitored or in anxiety or satisfaction levels in both groups. In group B patients, the BIS values stabilized around 85; the Ramsay scale stabilized around 3 in both groups and remained at these levels until the end of the procedure. Drug consumption was significantly lower in the BIS group. CONCLUSION: The optimal BIS value during intravenous sedation in sedated ambulatory patients in dental surgery should be within the 80 to 85 range. BIS monitoring allows for reduced consumption of propofol, fentanyl, and midazolam.

Sedation management in Australian and New Zealand intensive care units: doctors' and nurses' practices and opinions.

OBJECTIVE: To explore the use of sedatives and analgesics, tools for scoring level of sedation, sedation and pain protocols, and daily interruptions in sedation in Australian and New Zealand intensive care units and to examine doctors' and nurses' opinions about the sedation management of critically ill patients. METHODS: A cross-sectional Internet-based survey design was used. In total, 2146 members of professional critical care organizations in Australia and New Zealand were e-mailed the survey during a 4-month period in 2006 through 2007. RESULTS: Of 348 members (16% response rate) who accessed the survey, 246 (71%) completed all sections. Morphine, fentanyl, midazolam, and propofol were the most commonly used medicines. Newer medicines, such as dexmedetomidine and remifentanil, and inhalant medications, such as nitrous oxide and isoflurane, were rarely used by most respondents. Respondents used protocols to manage sedatives (54%) and analgesics (51%), and sedation assessment tools were regularly used by 72%. A total of 62% reported daily interruption of sedation; 23% used daily interruption for more than 75% of patients. A disparity was evident between respondents' opinions on how deeply patients were usually sedated in practice and how deeply patients should ideally be sedated. CONCLUSIONS: Newer medications are used much less than are traditional sedatives and analgesics. Sedation protocols are increasingly used in Australasia, despite equivocal evidence supporting their use. Similarly, daily interruption of sedation is common in management of patients receiving mechanical ventilation. Research is needed to explore contextual and personal factors that may affect sedation management.

Frequency and clinical impact of preserved bispectral index activity during deep sedation in mechanically ventilated ICU patients.

OBJECTIVE: Despite an overall correlation between the bispectral index of the EEG (BIS) and clinical sedation assessment, unexpectedly high BIS values can be observed at deep sedation levels. We assessed the frequency, interindividual variability and clinical impact of high BIS values during clinically deep sedation. DESIGN AND SETTING: Prospective observational study in two university-affiliated intensive care units. PATIENTS: Sixty-two mechanically ventilated patients requiring intravenous sedation and analgesia for >or=24 h. MEASUREMENTS AND MAIN RESULTS: Paired measurements of BIS and sedation measured on the adaptation to intensive care environment (ATICE) score were obtained every 3 h until awakening. A paired measurement with BIS >60 at deep sedation (ATICE Awakeness

Anestesia-analgesia frente a sedación profunda para pruebas diagnósticas o terapéuticas en pacientes pediátricos. ¿Quién debe realizarla? / No disponible

No disponible

Sedación y analgesia en el politraumatismo pediátrico / Sedation and analgesics in pediatric polytraumatism

No disponible

[Protocol based sedation versus conventional treatment in critically ill patients on mechanical ventilation]. / Sedación guiada por protocolo versus manejo convencional en pacientes críticos en ventilación mecánica.

BACKGROUND: Sedatives and analgesic drugs give comfort and allow adequate respiratory support to critically ill patients in mechanical ventilation (MV). Its improper use may increase the duration of MV. Clinical guidelines suggest implementation of protocols, however this is seldom done in clinical practice. AIM: To compare in MV patients, nurse-applied guided by protocol administration of sedatives and analgesic drugs (protocol: group P) with the habitual practice using physicians criteria (control: group C). MATERIAL AND METHODS: Inclusion criteria was the need of MV more than 48 h. The exclusion criteria were acute neurological diseases, hepatic cirrhosis, chronic renal failure and limitation of therapeutic efforts. Midazolam and fentanyl were used in both groups. The level of sedation was monitored with the Sedation Agitation Scale (SAS). In the P group, trained nurses applied algorithms to adjust the sedative doses according to a predefined SAS goal. RESULTS: Forty patients were included, 22 aged 65+/-19 years in group P and 18 aged 54+/-21 years in group C. Apache II scores were 16+/-8 and 19+/-8 in each group. SAS score was more frequently evaluated within goal boundaries in group P than in group C (44% and 32%, respectively p =0.001). No differences in the proportion of patients with inadequate sedation were observed between treatment groups. Midazolam doses were lower in P than in C group (0.04 (0.02-0.07) and 0.06 (0.03-0.08) mg/kg/h respectively, p =0.005). CONCLUSIONS: The implementation of sedation protocol applied by nurses improved the quality of sedation and reduced the doses of Midazolam in mechanically ventilated patients.

Sedación guiada por protocolo versus manejo convencional en pacientes críticos en ventilación mecánica / Protocol based sedation versus conventional treatment in critically ill patients on mechanical ventilation

Background: Sedatives and analgesic drugs give comfort and allow adequate respiratory support to critically ill patients in mechanical ventilation (MV). Its improper use may increase the duration of MV. Clinical guidelines suggest implementation of protocols, however this is seldom done in clinical practice. Aun: To compare in MV patients, nurse-applied guided by protocol administration of sedatives and analgesic drugs (protocol: group P) with the habitual practice using physicians criteria (control: group C). Material and methods: Inclusión criteria was the need of MV more than 48 h. The exclusión criteria were acute neurological diseases, hepatic cirrhosis, chronic renal failure and limitation of therapeutic efforts. Midazolam and fentanyl were used in both groups. The level of sedation was monitored with the Sedation Agitation Scale (SAS). In the P group, trained nurses applied algorithms to adjust the sedative doses according to a predefined SAS goal. Results: Forty patients were included, 22 aged 65±19 years in group P and 18 aged 54±21 years in group C. Apache II scores were 16±8 and 19±8 in each group. SAS score was more frequently evaluated within goal boundaries in group P than in group C (44 percent and 32 percent, respectively p =0.001). No differences in the proportion of patients with inadequate sedation were observed between treatment groups. Midazolam doses were lower in P than in C group (0.04 (0.02-0.07) and 0.06 (0.03-0.08) mg/kg/h respectively, p =0.005). Conclusions: The implementation of sedation protocol applied by nurses improved the quality of sedation and reduced the doses of Midazolam in mechanically ventilated patients.

Clinical sedation scores as indicators of sedative and analgesic drug exposure in intensive care unit patients.

BACKGROUND: It is unclear how best to measure sedative/analgesic drug exposure in the clinical care of critically ill patients. Large doses and prolonged use of sedatives and analgesics in the intensive care unit (ICU) may lead to oversedation and adverse effects, including delirium and long-term cognitive impairment. These issues are of particular concern in elderly patients (aged > or =65 years), who account for at least half of all ICU admissions and nearly two thirds of ICU days. OBJECTIVE: This pilot study explored the relationships between clinical sedation scores, sedative/analgesic drug doses, and plasma drug concentrations in critically ill patients, the majority of whom were elderly. METHODS: This was a prospective, observational study conducted in a 500-bed, tertiary care community hospital. Study patients included a cohort of mechanically ventilated, medical ICU patients who were admitted to the hospital between April and June 2004 who required use of fentanyl, lorazepam, or propofol. Sedative/analgesic medications were administered according to clinical guidelines. Patients' sedation levels were measured twice daily using the Richmond Agitation-Sedation Scale (RASS). Dosing of fentanyl, lorazepam, and propofol was recorded. Blood was sampled twice daily for up to 5 days to analyze plasma drug concentrations. To specifically evaluate the effects of acute, extended (rather than chronic) sedative and analgesic exposure, the study focused on an ICU population receiving these agents for at least 48 hours but <2 weeks. RESULTS: Eighteen medical ICU patients (11 females, 7 males; mean [SD] age, 66.1 [18.1] years) on mechanical ventilation comprised the study cohort. Fifteen patients were aged >62 years, and 11 of those were aged > or =71 years. Plasma drug concentrations (median and interquartile range) were as follows: fentanyl--2.1 ng/mL, 0.9-3.4 ng/mL; lorazepam--266 ng/mL, 112-412 ng/mL; and propofol--845 ng/mL, 334-1342 ng/mL. Maximum concentrations were 3- to 12-fold higher than medians (fentanyl, 7.3 ng/mL; lorazepam, 3108 ng/mL; propofol, 10,000 ng/mL). Medication doses were only moderately correlated with RASS scores (Spearman rho): fentanyl--rho = -0.39, P = 0.002; lorazepam--rho = -0.28, P = 0.001; and propofol--rho = -0.46, P < 0.001. Plasma drug concentrations of fentanyl and lorazepam demonstrated moderate correlations with sedation scores (fentanyl--rho = -0.46, P = 0.002; lorazepam: rho = -0.49, P < 0.001), while propofol concentrations correlated poorly with sedation scores (rho = -0.18, P = 0.07). Associations between interval drug doses and plasma concentrations were as follows: fentanyl, rho = 0.84; lorazepam, rho = 0.76; and propofol, rho = 0.61 (all, P < 0.001). Instructive examples of discrepant dose versus plasma concentration profiles and drug interactions are provided, including 3 cases with patients aged > or =64 years. CONCLUSIONS: Elderly patients are commonly encountered in the ICU setting. Only moderate correlations existed between clinical sedation levels and dose or plasma concentration of sedative/analgesic medications in this study population. Further work is needed to understand appropriate and feasible measures of exposure to sedatives/analgesics relating to clinical outcomes.