Conhecimento e percepção de enfermeiros frente à sedação paliativa na oncologia / Knowledge and perception of nurses dealing with palliative sedation in oncology / Conocimiento y percepción de los enfermeros frente a la sedación paliativa en oncología

Objetivo: compreender o conhecimento e a percepção de enfermeiros quanto à sedação paliativa em oncologia. Método: estudo qualitativo, exploratório e descritivo, com delineamento transversal. Participaram do estudo 16 enfermeiros atuantes na oncologia de um hospital de referência localizado ao norte do Rio Grande do Sul. A coleta de dados ocorreu por meio de entrevista gravada com duração de aproximadamente 10 minutos, sendo aplicado um roteiro de perguntas fechadas com a finalidade de caracterizar os enfermeiros participantes da pesquisa, e perguntas abertas e específicas para contemplar o objetivo do estudo. O método utilizado para o diagnóstico e verificação dos dados da pesquisa foi a análise de conteúdo de Bardin. Os dados foram analisados e codificados por meio do software NVivo 10, que gerou categorias de similaridade e correlações. Resultados: surgiram cinco categorias intituladas "Conhecimento sobre sedação paliativa; Percepção sobre sedação paliativa na oncologia; Sentimentos em relação à sedação paliativa aos pacientes oncológicos; Vivência em relação à sedação paliativa em pacientes oncológicos e Participação do enfermeiro no procedimento de sedação paliativa". Conclusão: o enfermeiro atua de forma efetiva e fundamental na prestação do cuidado e na avaliação do paciente em sedação paliativa, mas ainda encontram-se diversos obstáculos relacionados à participação na tomada de decisões. Evidencia-se a importância de novas pesquisas sobre a temática, como também a implementação de protocolos que subsidiem na indicação da sedação paliativa.(AU)

Objective: to understand the knowledge and perception of nurses dealing with palliative sedation in oncology. Method: this is a qualitative, exploratory, and descriptive study, with a cross-sectional design. The study included 16 nurses working in oncology at a reference hospital located in the north of Rio Grande do Sul. Data were collected through recorded interviews lasting approximately 10 minutes, with a script of closed questions being applied to characterize the nurses participating in the research, and open and specific questions, to contemplate the objective of the study. The method used for the diagnosis and verification of research data was Bardin's content analysis. Data were analyzed and coded using the NVivo 10 software, which generated categories of similarity and correlations. Results: five categories emerged: (i) Knowledge about palliative sedation; (ii) Perception of palliative sedation in oncology; (iii) Feelings regarding palliative sedation in cancer patients; (iv) Experience with palliative sedation in cancer patients; and (v) Participation of the nurse in the palliative sedation procedure. Conclusion: nurses act effectively and fundamentally in providing care and evaluating patients undergoing palliative sedation, but there are still several obstacles related to their participation in decision-making. The importance of new research on the subject is evident, as well as the implementation of protocols that support the indication of palliative sedation.(AU)

Objetivo: comprender el conocimiento y la percepción de los enfermeros sobre la sedación paliativa en oncología. Método: estudio cualitativo, exploratorio y descriptivo, con diseño transversal. El estudio abarcó 16 enfermeros que trabajaban en oncología en un hospital de referencia localizado en el norte de Rio Grande do Sul. La colecta de datos ocurrió por medio de entrevista grabada con duración aproximada de 10 minutos, siendo aplicado un guión de preguntas cerradas con la finalidad de caracterizar los enfermeros participantes de la investigación, y preguntas abiertas y específicas para contemplar el objetivo del estudio. El método utilizado para el diagnóstico y verificación de los datos de la investigación fue el análisis de contenido de Bardin. Los datos fueron analizados y codificados utilizando el software NVivo 10, que generó categorías de similitud y correlaciones. Resultados: surgieron cinco categorías tituladas "Conocimientos sobre sedación paliativa; Percepción de la sedación paliativa en oncología; Sentimientos con respecto a la sedación paliativa para pacientes con cáncer; Experiencia con sedación paliativa en pacientes oncológicos y participación de Enfermeros en el procedimiento de sedación paliativa". Conclusión: el enfermero actúa de forma eficaz y fundamental en la prestación del cuidado y en la evaluación del paciente en sedación paliativa, pero aún existen varios obstáculos relacionados con la participación en la toma de decisiones. Es evidente la importancia de seguir investigando sobre el tema, así como la implementación de protocolos que sustenten la indicación de la sedación paliativa.(AU)

Nurse-Administered Propofol Continuous Infusion Sedation: A New Paradigm for Gastrointestinal Procedural Sedation.

INTRODUCTION: Nurse-Administered Propofol Continuous Infusion Sedation (NAPCIS) is a new nonanesthesia propofol delivery method for gastrointestinal endoscopy. NAPCIS is adopted from the computer-assisted propofol sedation (CAPS) protocol. We evaluated the effectiveness, efficiency, and safety of NAPCIS in low-risk subjects. METHODS: Between December 2016 and July 2017, patients who underwent esophagogastroduodenoscopy or colonoscopy with NAPCIS at our center were compared against 2 historical control groups of similar patients who had undergone procedures with CAPS or midazolam and fentanyl (MF) sedation. RESULTS: The mean age of the NAPCIS cohort (N = 3,331) was 55.2 years (45.8% male) for 945 esophagogastroduodenoscopies and 57.8 years (48.7% male) for 2,386 colonoscopies. The procedural success rates with NAPCIS were high (99.1%-99.2%) and similar to those seen in 3,603 CAPS (98.8%-99.0%) and 3,809 MF (99.0%-99.3%) controls. NAPCIS recovery times were shorter than both CAPS and MF (24.8 vs 31.7 and 52.4 minutes, respectively; P < 0.001). On arrival at the recovery unit, 86.6% of NAPCIS subjects were recorded as "Awake" compared with 82.8% of CAPS and 40.8% of MF controls (P < 0.001). Validated clinician and patient satisfaction scores were generally higher for NAPCIS compared with CAPS and MF subjects. For NAPCIS, there were only 4 cases of oxygen desaturation requiring transient mask ventilation and no serious sedation-related complications. These low complication rates were similar to those seen with CAPS (8 cases of mask ventilation) and MF (3 cases). DISCUSSION: NAPCIS seems to be a safe, effective, and efficient means of providing moderate sedation for upper endoscopy and colonoscopy in low-risk patients.

Nurse Administered Propofol Sedation (NAPS) versus On-call Anesthesiologist Administered Propofol Sedation (OAPS) in Elective Colonoscopy.

BACKGROUND AND AIMS: As on-call anesthesiologist administered propofol sedation (OAPS) is costly and not readily available in all endoscopy units, endoscopy nurse administered propofol sedation (NAPS) can be an effective alternative. This study aimed to compare the dosage of propofol used by NAPS versus OAPS, cardiopulmonary adverse events and recovery time in low risk patients undergoing outpatient elective colonoscopy. METHODS: A retrospective propensity score-matched cohort study was conducted. Electronic medical records of elective colonoscopies performed by 3 experienced endoscopists from January 2016 to December 2019 were retrieved. OAPSs were performed by 10 certified anesthesiologists while NAPSs were performed by 8 experienced registered endoscopy nurses. Baseline characteristics, performing endoscopist, cecal intubation time, withdrawal time, propofol dosage per procedure, and adverse events were collected and analyzed using 3:1 (NAPS:OAPS) propensity score matching by age, performing endoscopist and difficulty of colonoscopy as co-variates with standardized mean deviation of <0.1. RESULTS: 278 eligible patients were included. After propensity score matching, there were 189 patients in NAPS and 63 in OAPS group for analysis. Demographic data were not different between the two groups. All procedures were technically successful with no difference in cecal intubation time (6.0±4 min vs 6.8±4 min; p=0.13) or total procedural time (17.2±16 min vs 16.3±6 min; p=0.66). Propofol dosage/kg/hour were significantly lower in the NAPS group, (11.4±4 mg/kg/hour vs. 16.6±8 mg/kg/hour; p<0.001). There were less minor cardiopulmonary adverse events in NAPS when compared to the OAPS group (2.2% vs 4.7%; p=0.014). CONCLUSIONS: NAPS in elective colonoscopy in low-risk patients is as effective as OAPS but requires a significant lower dosage of propofol. Minor cardiopulmonary adverse events were recorded in the NAPS group compared to OAPS.

Relación entre factores del paciente, del profesional de enfermería y de la institución con el logro de un objetivo de sedoanalgesia en una UCI de adultos de Medellín, Colombia / Relationship between factors of the patient, the nursing professional and the institution with the achievement of a sedoanalgesia goal in an adult ICU in Medellín, Colombia

Objetivo: Analizar la relación existente entre los factores del paciente, del profesional de enfermería y de la institución con el logro de un objetivo de sedoanalgesia en una UCI de adultos de Medellín, Colombia. Metodología: Estudio cuantitativo, descriptivo, transversal, correlacional, realizado con 79 pacientes adultos de una UCI de una Institución de Medellín (ANT), durante 6 meses entre el 2019 y el 2020. Se revisaron historias clínicas de los pacientes para analizar las variables independientes: estado nutricional, función renal, nivel de adherencia al protocolo de sedoanalgesia institucional por parte de los profesionales de enfermería, carga laboral; y la variable dependiente: logro del objetivo de sedoanalgesia, y, si se encontró asociación estadística entre las variables a través de la aplicación del Coeficiente de correlación de Spearman. Resultados: el 86% de los pacientes obtuvieron un riesgo nutricional alto según la NUTRIC. El 53,4% del total de pacientes masculinos y el 19,4% del género femenino tuvo un nivel de creatinina superior al normal. El 56,9% de los pacientes tuvo un IFG inferior al normal. En el 94% de los pacientes se encontró un nivel de adherencia al protocolo alto por parte de enfermería. El 96% de los pacientes tuvo un grado IV según la clasificación de la TISS-28. El 57% de los pacientes alcanzaron el objetivo de sedoanalgesia. Se encontró asociación positiva débil (0,263) estadísticamente significativa (p=0,019) entre la variable NUTRIC con el logro del objetivo de sedoanalgesia Conclusiones: Existe relación entre el estado nutricional y el logro de un objetivo de sedoanalgesia. (AU)

Objective: To analyze the relationship between the factors of the patient, the nursing professional and the institution with the achievement of a sedoanalgesia objective in an ICU for adults in Medellín, Colombia. Methodology: Quantitative, descriptive, cross-sectional, correlational study, carried out with 79 adult patients from an ICU of an Institution of Medellín (ANT), during 6 months between 2019 and 2020. Medical records of the patients were reviewed to analyze the independent variables : nutritional status, kidney function, level of adherence to the institutional sedoanalgesia protocol by nursing professionals, workload; and the dependent variable: achievement of the sedoanalgesia objective, and, if a statistical association was found between the variables through the application of the Spearman correlation coefficient. Results: 86% of the patients obtained a high nutritional risk according to NUTRIC. 53.4% of the total male patients and 19.4% of the female gender had a creatinine level higher than normal. 56.9% of the patients had a lower than normal GFR. In 94% of the patients, a high level of adherence to the protocol was found by the nursing staff. 96% of the patients had a grade IV according to the TISS-28 classification. 57% of the patients reached the goal of sedoanalgesia. We found a weak positive association (0.263) statistically significant (p = 0.019) between the NUTRIC variable with the achievement of the sedoanalgesia goal. Conclusions: There is a relationship between the nutritional status and the achievement of a sedoanalgesia goal. (AU)

Grado de implementación de las estrategias preventivas del síndrome post-UCI: estudio observacional multicéntrico en España / Degree of implementation of preventive strategies for post-ICU syndrome: Multi-centre, observational study in Spain

Objetivo: Evaluar el nivel de implementación de los protocolos asociados a la prevención de la debilidad muscular adquirida en la unidad de cuidados intensivos (UCI), así como la presencia del fisioterapeuta en distintas UCI de España. Método: Estudio descriptivo, transversal realizado en 86 UCI de adultos de España entre los meses de marzo a junio de 2017. Se excluyeron UCI neuroquirúrgicas y de grandes quemados. Se utilizó encuesta multirrespuesta que incluía preguntas sobre los protocolos de: control de glucemia, sedación, valoración del dolor, prevención del delirium, manejo del delirium y movilización precoz. La encuesta fue rellenada a través de un aplicativo protegido por usuario y contraseña. Análisis inferencial con t de Student o U de Mann-Whitney y de correlación con Pearson o Rho de Spearman. Resultados: El 89,5% de las UCI tenían protocolo de control de glucemia, con rango predominante de 110-140 mg/dl. El 74,4% evaluaban el nivel de sedación, si bien solo tenían protocolos de sedación el 36% de ellas. Con relación a la valoración del dolor se realizaba en el 73,7% de los pacientes comunicativos, mientras que en los no comunicativos solo era del 47,5%. Solo el 37,2% realizaban screening diario para detectar el delirium, y disponían de protocolos de prevención del delirium el 31,4% de las UCI, del manejo del delirium el 26,7% y de movilización precoz el 14% de las UCI. En el 34,9% de los casos se solicita interconsulta al servicio de rehabilitación. Conclusiones: La implementación de los diferentes protocolos asociados a la prevención de la debilidad muscular adquirida ha sido elevada en relación con los protocolos de control de glucemia, valoración del nivel de sedación y del dolor de pacientes comunicativos, mientras que baja en los de movilización precoz y screening y prevención del delirio. Asimismo, es poco frecuente la presencia del fisioterapeuta en la UCI

Aim: To evaluate the degree of implementation of protocols associated with the prevention of intensive-care-unit (ICU) acquired muscle weakness, and the presence of the physiotherapist in various ICU in Spain. Method: A descriptive, cross-sectional study performed in 86 adult ICU in Spain between March and June 2017. Neurosurgical and major burns ICU were excluded. A multiple-choice survey was used that included questions on protocols for glycaemia control, sedation, pain assessment, delirium prevention, delirium management and early mobilisation. The survey was completed using a user-protected application and password. The Student's t-test or Mann-Whitney U test and Pearson's correlation or Spearman's Rho test were used for the inferential analysis. Results: Eighty-nine point five percent of the ICU had a glycaemia control protocol, with a predominating range of 110-140 mg/dl. Seventy-four point four percent evaluated sedation levels, although only 36% had sedation protocols. Pain assessment was carried out on communicative patients in 73.7%, and on uncommunicative patients in only 47.5%. Only 37.2% performed daily screening to detect delirium and 31.4% of the ICU had delirium prevention protocols, 26.7% had delirium management protocols and 14% had protocols for early mobilisation. Thirty-four point nine percent requested cross consultation with the rehabilitation department. Conclusions: The implementation of the different protocols associated with the prevention of ICU-acquired muscle weakness was high in relation to glycaemia control protocols, sedation level and pain assessment in communicative patients, and was low for early mobilisation and delirium screening and prevention. Similarly, the physiotherapist was seldom present in the ICU

µImpact of a nursing-driven sedation protocol with criteria for infusion initiation in the surgical intensive care unit.

PURPOSE: Analgesia and sedation protocols (ASPs) reduce duration of mechanical ventilation (MV) in the medical intensive care unit (ICU), but data in the surgical ICU (SICU) are limited. The objective of this study was to determine the impact of a nursing-driven ASP with criteria for infusion initiation in the SICU. MATERIALS AND METHODS: A single-center, retrospective study compared ventilator-free days at day 28 from start of MV (VFD28) before and after ASP implementation. Secondary endpoints included cumulative opioid and sedative requirements, level of sedation, incidence of delirium, SICU and hospital length of stay. RESULTS: One hundred thirty two patients were included (66 per group). The protocol group had greater VFD28 compared to the control group (21 vs. 14.5 days, p = .04). Lower rates of benzodiazepine (42.4% vs. 84.8%, p < .001) and opioid (24.2 vs. 78.8, p < .001) infusion use occurred in the protocol group, resulting in lower cumulative doses per ventilator-day through day 7. The protocol group had more documented sedation scores within target range. There were no differences in ICU delirium, SICU or hospital length of stay. CONCLUSIONS: A nursing-driven ASP with criteria for infusion initiation in mechanically-ventilated SICU patients may increase ventilator-free time, maintain patients at the target sedation goal, and reduce opioid and benzodiazepine utilization.

The common meanings and shared practices of sedation assessment in the context of managing patients with an opioid: A phenomenological study.

AIMS AND OBJECTIVES: To examine the common meanings of opioid-induced sedation and shared practices in the context of post-operative pain management in expert Post-Anesthesia Care Unit nurses during patient's pain management with opioids. BACKGROUND: Within the clinical setting, linear pain and sedation scales are not enough to support clinical judgement with acute pain management. Because sedation measurement rests along a fluctuating continuum, it is possible for a patient to be sedated and then shift to increasing alertness, and then to drift back to a sedated state. This potential for acute clinical transition can be challenging to nurses of all levels, even for expert nurses. DESIGN: Interpretive phenomenology. METHODS: Twenty expert Post-Anesthetic Care Unit nurses, with more than 7 years of nursing experience, participated in qualitative interviews regarding their lived experiences. Interviews were analysed using a modified seven-stage process for interpretation by Diekelmann, Allen and Tanner. The manuscript was developed utilising the COREQ guidelines for reporting qualitative studies. RESULTS: Four themes identified through the participant's stories were recognising every patient is different, engaging in iterative knowing, walking a fine line, and looking beyond and anticipating. This study identified a constitutive pattern of interpreting sedation by integrating practical understanding and anticipating beyond. CONCLUSIONS: This study indicates a deeper complexity in the way opioid-induced sedation is assessed and balanced with pain management by nurses in the Post-Anesthetic Care Unit. RELEVANCE TO PRACTICE: Nurses in the study adapted their practices around pain management with opioids, in response to their patient's level of sedation; incorporating practices such as giving small, incremental doses and changing the drug. Nurses valued the importance of having "eyeballs on everybody" and being ready to meet the needs of their patient. They appreciate the time to watch and wait for their patient to respond, to better judge the result of their interventions.

A first contribution to the validation of the Italian version of the Behavioral Pain Scale in sedated, intubated, and mechanically ventilated paediatric patients.

BACKGROUND AND AIM OF THE WORK: Numerous negative outcomes of inadequate pain management among children have been cited in the literature. Inadequate pain management may be particularly detrimental to children and adolescents facing life-threatening injury or illness on a Paediatric Intensive Care Unit (PICU). It is therefore absolutely necessary that professionals utilize effective and efficient tools in order to evaluate a person's sensations of pain in the most objective way possible. The COMFORT-B scale is recognised as the gold standard in such patients. However, the use of this instrument in the clinical PICU setting is disputed. It requires long periods of observation to ensure an adequate utilization. Boerlage et al. noted that nurses are often impatient and do not always observe the patient for the recommended 2 minutes period. The Behavioral Pain Scale (BPS), instead, is considered to be the gold standard for pain assessment in deeply sedated, mechanically ventilated adult patients. This observational pain scale requires shorter observation time compared to the COMFORT-B. Moreover, BPS three subscales are included in other observational pain scales for paediatric patients. Therefore, the objective of this study was to assess the applicability of the BPS for use with paediatric patients. METHODS: Firstly, a questionnaire was administered to physicians and nursing staff that work in the units where the study was conducted in order to investigate the actual use of observational pain scales in their units. A second questionnaire was administered to a group of experts regarding the BPS, to assess both face validity and content validity, and to gain opinions on the relative appropriateness of each item. A descriptive, comparative design was used. A convenience sample of non-verbal, sedated and mechanically ventilated critical care paediatric patients was included. 39 observations were collected from 9 patients, all in their first year of age. Patient pain was assessed concurrently with the three observational scales, before, during and after routine procedures that are considered painful and non-painful. RESULTS: The data collected through questionnaires for professionals gave a useful insight into pain assessment in the investigated units: only 46% of respondents stated that they assessed patients' pain levels, with an average of 2.8 times per shift; 60% of respondents declared to be unhappy with the observational scales that they utilise. Regarding the observations, internal consistency was α = .865. Correlations between BPS and the other instruments were high, demonstrating a good concurrent validity of the test. T test and ROC curves demonstrated a good discriminant validity as well. CONCLUSIONS: Although the current study is based on a small sample of participants, these first results encourage us to continue working in the validation of the BPS in paediatric patients.

Level of knowledge, emotional impact and perception about the role of nursing professionals concerning palliative sedation.

AIMS AND OBJECTIVES: To explore aspects related to the fulfilment of the role of nurses in palliative sedation. BACKGROUND: Palliative sedation demands knowledge and a proper attitude for maintaining comfort, preserving dignity and contributing to a peaceful death. In some developed countries, nurses have a well-established role in palliative sedation. However, studies on their role and its fulfilment are limited, particularly in the developing world. DESIGN: An exploratory, mixed, qualitative and quantitative study was conducted. A self-administered questionnaire was used to examine the level of knowledge of palliative sedation and the level of confidence in skills and knowledge about palliative sedation. Also, focus groups were conducted to explore the emotional impact and the perceived role of nurses. METHODS: Forty-one nurses from three advanced-care hospitals with palliative care units in Colombia completed the questionnaire. Also, four focus groups were conducted with 22 participants selected from the first phase. RESULTS: A high level of knowledge regarding palliative sedation was found, but the level of confidence in skills was higher than the confidence in knowledge. The participants expressed their belief that their knowledge was derived from experience but believed that it was not enough to fulfil their role with confidence. A negative emotional impact about the patients' condition was found. For some, it served as motivation to provide better care. For others, it was difficult to face, especially when assisting children. They also expressed satisfaction and gratification about providing relief from suffering through sedation. CONCLUSIONS: The role of nursing is essential in palliative sedation. Although the nurses' knowledge is adequate, it primarily derives from experience and not from formal training, which impacts on their perceived confidence and their distress. RELEVANCE TO CLINICAL PRACTICE: Formal training for the optimal fulfilling of the nursing role in palliative sedation is crucial to provide better end-of-life care, particularly in developing countries.

"Sedation is tricky": A qualitative content analysis of nurses' perceptions of sedation administration in mechanically ventilated intensive care unit patients.

INTRODUCTION: Critical care nurses are responsible for administering sedative medications to mechanically ventilated patients. With significant advancements in the understanding of the impact of sedative exposure on physiological and psychological outcomes of ventilated patients, updated practice guidelines for assessment and management of pain, agitation, and delirium in the intensive care unit were released in 2013. The primary aim of this qualitative study was to identify and describe themes derived from critical care nurses' comments regarding sedation administration practices with mechanically ventilated patients. METHODS: This is a qualitative content analysis of secondary text data captured through a national electronic survey of members of the American Association of Critical-Care Nurses. A subsample (n = 67) of nurses responded to a single, open-ended item at the end of a survey that evaluated nurses' perceptions of current sedation administration practices. FINDINGS: Multiple factors guided sedation administration practices, including individual patient needs, nurses' synthesis of clinical evidence, application of best practices, and various personal and professional practice perspectives. Our results also indicated nurses desire additional resources to improve their sedation administration practices including more training, better communication tools, and adequate staffing. CONCLUSIONS: Critical care nurses endorse recommendations to minimise sedation administration when possible, but a variety of factors, including personal perspectives, impact sedation administration in the intensive care unit and need to be considered. Critical care nurses continue to encounter numerous challenges when assessing and managing sedation of mechanically ventilated patients.

Rapid tranquilization: An audit of Irish mental health nursing practice.

Rapid tranquillization is a pharmacological intervention sometimes employed in mental health care for the management of acute behavioural disturbance. It is a form of restrictive practice, which, along with seclusion and restraint, is a conventional and controversial intervention in the therapeutic management of risk in mental health settings. This study surveyed mental health nurses practice in rapid tranquillization. A self-report questionnaire was utilized which addressed aspects such as definitions of rapid tranquillization, presence of rapid tranquillization policy, types of incidents where it is used and postintervention monitoring. The results demonstrate that rapid tranquillization is an intervention used in the management of acute behavioural disturbance in various mental health settings in Ireland. Respondents showed a basic understanding of rapid tranquillization as an intervention; however, some areas reported not having a specific rapid tranquillization policy. There was some evidence of a variation in postrapid tranquillization monitoring of psychiatric/mental health and physical health. Service user debriefing following rapid tranquillization was reported to be common; however, the content of this was not elaborated on. In the light of variations in practice, specific training and the development of rapid tranquillization policies are recommended.

Nurse titrated analgesia and sedation in intensive care increases the frequency of comfort assessment and reduces midazolam use in paediatric patients following cardiac surgery.

BACKGROUND: Pain and sedation protocols are suggested to improve the outcomes of patients within paediatric intensive care. However, it is not clear how protocols will influence practice within individual units. OBJECTIVES: Evaluate a nurse led pain and sedation protocols impact on pain scoring and analgesic and sedative administration for post-operative cardiac patients within a paediatric intensive care unit. METHODS: A retrospective chart review was performed on 100 patients admitted to a tertiary paediatric intensive care unit pre and post introduction of an analgesic and sedative protocol. Stata12 was used to perform Chi-squared or Student's t-test to compare data between the groups. RESULTS: Post protocol introduction documentation of pain assessments increased (pre protocol 3/24h vs post protocol 5/24h, p=0.006). Along with a reduction in administration of midazolam (57.6mcg/kg/min pre protocol vs 24.5mcg/kg/min post protocol, p=0.0001). Children's pain scores remained unchanged despite this change, with a trend towards more scores in the optimal range in the post protocol group (5 pre protocol vs 12 post protocol, p=0.06). CONCLUSIONS: Introducing a pain and sedation protocol changed bedside nurse practice in pain and sedation management. The protocol has enabled nurses to provide pain and sedation management in a consistent and timely manner and reduced the dose of midazolam required to maintain comfort according to the patients COMFORT B scores. Individual evaluation of practice change is recommended to units who implement nurse led analgesic and sedative protocols to monitor changes in practice.

Retrospective Evaluation of the Procedural Sedation Practices of Expert Nurses During Abortion Care.

OBJECTIVE: To evaluate the provision of procedural sedation during abortion by expert nurses and to describe the factors that are associated with time to discharge for women who receive this sedation. DESIGN: Retrospective chart review. METHODS: Descriptive statistics were generated to describe a retrospective cohort of women presenting for abortion under procedural sedation. Analysis of variance was used to determine significant characteristics that influenced time to discharge. SETTING: A single clinical site that employs seven expert nurses. PARTICIPANTS: A total of 194 medical records were available for this analysis. RESULTS: All women were discharged home with accompaniment, and no incidents of respiratory distress or other adverse complications occurred. Most women (n = 136) received at least 150 µg fentanyl and 3 mg midazolam, and 71% of women in the first trimester and 83% of women in the second trimester entered the recovery area with no pain. Variables significantly associated with time spent in the recovery area were gestational age at time of abortion (t = -2.68, p = .008), pain at entry to recovery area (t = -0.254, p = .008), and pain at 15 minutes (t = 0.25, p = .038). CONCLUSION: Expert nurses can administer procedural sedation for pain control associated with abortion and are capable of monitoring women and helping them return to baseline status after the procedure.

Relatos de vida y fotografía de pacientes sedados en UCI: ¿estrategia de humanización posible? / Relatos de vida e fotografia de pacientes sedados em UTI: estratégia de humanização possível? / Life stories and photographs of sedated patients in the ICU: a possible humanization strategy?

Objetivos: (1) Identificar la influencia del contexto del paciente sedado a través de las historias de vida y fotografía en la percepción del cuidar del personal de enfermería y (2) evaluar la intervención que se propone como una estrategia de humanización para cuidar al paciente sedado. Método: Investigación cualitativa de intervención con 43 profesionales del equipo de enfermería de una Unidad de Cuidados Intensivos. La colecta de datos consistió en una entrevista previa, la intervención (fijación de los cuadros de los pacientes sedados en la cabecera y orientación para que los profesionales los leyesen; la intervención duró 10 días) y entrevista posterior a la intervención. Tres cuadros fueron fijados, que contenían las fotos y las historias de vida de los pacientes planteadas por sus familias. Resultados: En la pre-intervención, los discursos mostraron que la interacción verbal aporta una mayor seguridad durante el cuidado, hay razones para la preferencia del cuidado de los pacientes inconscientes, como el reto de la complejidad y la recompensa de la recuperación, como la no disponibilidad para cumplir con las solicitudes frecuentesdel paciente, la atención se valora independientemente del nivel de conciencia, el conocimiento sobre los aspectos de la vida del paciente mejora el compromiso y existe la preocupación de no juzgar al paciente y rescatar lo mejor del otro. En la post-intervención se encontró que el contexto del paciente rescató elementos importantes para el cuidado como la emoción, promoviendo sensibilidad, el despertar de la empatía con la contextualización, la implicación y el compromiso con el cuidado, por otra parte era evidente el conflicto entre el cambio actitud y salir a la defensiva. Conclusión: La intervención propuesta ha sido validada como una estrategia para humanizar la atención de los pacientes sedados (AU)

Objetivos: (1) Identificar a influência da contextualização do paciente sedado por meio de relatos de vida e fotografia na percepção do cuidar da equipe de enfermagem e (2) avaliar a intervenção proposta como uma estratégia de humanização para o cuidado ao paciente sedado. Método: Pesquisa qualitativa e de intervenção com 43 profissionais da equipe de enfermagem de uma Unidade de Terapia Intensiva. A coleta de dados consistiu de uma entrevista prévia, intervenção (fixação de quadros de pacientes sedados à beira do leito e orientação para que os profissionais os lessem; a intervenção teve duração de 10 dias) e entrevista pós-intervenção. Três quadros foram fixados e estes continham fotografia e relatos de vida dos pacientes levantados por meio de seus familiares. Resultados: Na pré-intervenção, os discursos mostraram que a interação verbal traz mais segurança durante o cuidado, há razões para preferência do cuidar de pacientes inconscientes, como o desafio da complexidade e a recompensa da recuperação, como a indisponibilidade para atender solicitações frequentes do paciente, o cuidado é valorizado independentemente do nível de consciência, conhecimento sobre aspectos da vida do paciente melhora o envolvimento e há uma preocupação de não julgar o paciente e resgatar o melhor do outro. Na pós-intervenção constatou-se que a contextualização do paciente resgatou elementos importantes para o cuidar, como a emoção promovendo sensibilização, o despertar da empatia com a contextualização, o envolvimento e o compromisso com o cuidado, além disso foi aparente um conflito entre mudar de atitude e sair da defensiva. Conclusão: A intervenção proposta foi validada como estratégia para humanização no cuidado de pacientes sedados (AU)

Aims: (1) To identify the influence of the contextualization of sedated patient, by means of life reports and photographs, from the perception of care of the nursing team and (2) to evaluate the proposed intervention as a strategy for humanization in the care for sedated patients. Method: Qualitative intervention study, with 43 professionals of the nursing team of an Intensive Care Unit. Data collection consisted of a prior interview, the intervention (fixing of pictures and life reports of sedated patients to the bedside and orientation for the professionals to read them, with the intervention lasting 10 days) and a post-intervention interview. Three frames were fixed and these contained a photograph and life reports of the patients collected through their family members. Results: In the pre-intervention, the discourses showed that verbal interaction provides more security during the care, there are reasons for preferring to care for unconscious patients, such as the challenge of the complexity and the reward with recovery, as well as the unavailability to attend to frequent requests of the conscious patient. The care was valorized independent of the level of consciousness, knowledge about aspects of the patient’s life increased involvement and there was a concern not to judge the patient and to rescue the best of the other. In the post-intervention, it was observed that the contextualization of the patient rescued important elements for the care, such as emotion promoting sensitization, the awakening of empathy with the contextualization, and the involvement and commitment to the care. In addition, a conflict between change of attitude and being defensive was apparent. Conclusion: The proposed intervention was validated as a strategy for humanization in the care for sedated patients (AU)

A Survey of Hospice and Palliative Care Clinicians' Experiences and Attitudes Regarding the Use of Palliative Sedation.

BACKGROUND: A variety of terms and attitudes surround palliative sedation (PS) with little research devoted to hospice and palliative care (HPC) clinicians' perceptions and experiences with PS. These factors may contribute to the wide variability in the reported prevalence of PS. OBJECTIVE: This study was designed to better identify hospice and palliative care (HPC) clinician attitudes toward, and clinical experiences with palliative sedation (PS). METHODS: A 32-question survey was distributed to members of the American Academy of Hospice and Palliative Medicine (n = 4678). The questions explored the language clinicians use for PS, and their experiences with PS. RESULTS: Nine hundred thirty-six (20% response rate) responded to the survey. About 83.21% preferred the terminology of PS compared with other terms. A majority felt that PS is a bioethically appropriate treatment for refractory physical and nonphysical symptoms in dying patients. Most felt PS was not an appropriate term in clinical scenarios when sedation occurred as an unintended side effect from standard treatments. Hospice clinicians use PS more consistently and with less distress than nonhospice clinician respondents. Benzodiazepines (63.1%) and barbiturates (18.9%) are most commonly prescribed for PS. CONCLUSION: PS is the preferred term among HPC clinicians for the proportionate use of pharmacotherapies to intentionally lower awareness for refractory symptoms in dying patients. PS is a bioethically appropriate treatment for refractory symptoms in dying patients. However, there is a lack of clear agreement about what is included in PS and how the practice of PS should be best delivered in different clinical scenarios. Future efforts to investigate PS should focus on describing the clinical scenarios in which PS is utilized and on the level of intended sedation necessary, in an effort to better unify the practice of PS.

Palliative sedation challenging the professional competency of health care providers and staff: a qualitative focus group and personal written narrative study.

BACKGROUND: Despite recent advances in palliative medicine, sedating a terminally ill patient is regarded as an indispensable treatment to manage unbearable suffering. With the prospect of widespread use of palliative sedation, the feelings and representations of health care providers and staff (carers) regarding sedation must be carefully explored if we are to gain a better understanding of its impact and potential pitfalls. The objective of the study was to provide a comprehensive description of the opinions of carers about the use of sedation practices in palliative care units (PCU), which have become a focus of public attention following changes in legislation. METHODS: Data were collected using a qualitative study involving multi-professional focus groups with health care providers and staff as well as personal narratives written by physicians and paramedical staff. A total of 35 medical and paramedical providers volunteered to participate in focus group discussions in three Palliative Care Units in two French hospitals and to write personal narratives. RESULTS: Health care provider and staff opinions had to do with their professional stance and competencies when using midazolam and practicing sedation in palliative care. They expressed uncertainty regarding three aspects of the comprehensive care: biomedical rigour of diagnosis and therapeutics, quality of the patient/provider relationship and care to be provided. Focusing on the sedative effect of midazolam and continuous sedation until death, the interviewed health care providers examined the basics of their professional competency as well as the key role played by the health care team in terms of providing support and minimizing workplace suffering. Nurses were subject to the greatest misgivings about their work when they were called upon to sedate patients. CONCLUSIONS: The uncertainty experienced by the carers with regard to the medical, psychosocial and ethical justification for sedation is a source of psychological burden and moral distress, and it has proved to be a major source of suffering in the workplace. Lastly, the study shows the uncertainty can have the positive effect of prompting the care team to devise ways to deal with it.

Manejo farmacológico de la sedación paliativa en la agonía / Pharmacological treatment in end-of-life sedation

Objetivo. Para el control de los síntomas físicos en situación de últimos días el manejo farmacológico supone la intervención principal. El objetivo de este artículo es revisar las cuestiones relevantes en el manejo enfermero de las situación clínicas y los fármacos comúnmente usados en sedación paliativa en la agonía. Metodología. Se seleccionan las intervenciones sobre manejo enfermero de fármacos en sedación paliativa recomendadas por la literatura científica mediante búsqueda realizada en Scopus, CINAHL, Medline-PubMed y Google Académico con las palabras clave «sedación paliativa», «farmacología», «cuidados de enfermería» y «cuidados paliativos». Resultados. El objetivo de la sedación paliativa (SP) es disminuir el nivel de conciencia como única forma de aliviar un sufrimiento intenso en pacientes en situación terminal, tal como delirium, dolor o disnea refractarias, hemorragia masiva, estado convulsivo, estertores premortem o sufrimiento psicológico refractario. La vía de elección en SP es la vía subcutánea (sc). Son fármacos de 1.ª línea en sedación el midazolam y la levomepromazina. Los opioides deben mantenerse en dosis equianalgésicas, siendo el cloruro mórfico el de uso más extendido. El papel fundamental de enfermería en SP es la monitorización del nivel de sedación según la escala de Ramsay (o similar) y el reconocimiento de los signos indicativos de malestar para la administración de rescate de medicación sedante o analgésica o despistaje de proceso intercurrente tratable (globo vesical, fecaloma, obstrucción de vía, efecto final de dosis, etc.) (AU)

Objetive. To control the physical symptoms in end-of-life pharmacological management involves major intervention. The aim of this article is to review the relevant issues in the management of clinical nursing situation and drugs commonly used in palliative sedation in agony. Methodology. Nursing management in Palliative Sedation recommended by scientific literature search in Scopus, CINAHL, Medline-PubMed and Google Scholar, with key words: «palliative sedation», «pharmacology», «nursing care» and «palliative care» are selected. Results. The goal of palliative sedation (PS) is to reduce the level of consciousness as the only way to relieve intense suffering in terminally ill patients, such as refractory delirium or dyspnea, massive bleeding, convulsive status, crackles premortem or refractory psychological suffering. The route of choice in PS is subcutaneous injection (sc). First line drugs in sedation are midazolam and levomepromazina. Opioids should be kept at equi-analgesic doses, morphine chloride being the most widely used. The fundamental role of nursing in SP is monitoring the level of sedation based on the Ramsay scale (or similar) and recognition of the indicative signs of discomfort for administration rescue sedative or analgesic medication and/or screening treatable intercurrent process (distended bladder, constipation, obstruction way, final dose effect, etc.) (AU)

Sedation scoring and managing abilities of intensive care nurses post educational intervention.

BACKGROUND: Inappropriate sedation assessment can jeopardize patient comfort and safety. Therefore, nurses' abilities in assessing and managing sedation are vital for effective care of mechanically ventilated patients. AIMS AND OBJECTIVES: This study assessed nurses' sedation scoring and management abilities as primary outcomes following educational interventions. Nurses' perceived self-confidence and barriers to effective sedation management were assessed as secondary outcomes. DESIGN: A post-test-only quasi-experimental design was used. Data were collected at 3 and 9 months post-intervention. METHODS: A total of 66 nurses from a 14-bed intensive care unit of a Malaysian teaching hospital participated. The educational interventions included theoretical sessions, hands-on sedation assessment practice using the Richmond Agitation Sedation Scale, and a brief sedation assessment tool. Nurses' sedation scoring and management abilities and perceived self-confidence level were assessed at both time points using self-administered questionnaires with case scenarios. Sedation assessment and management barriers were assessed once at 9 months post-intervention. RESULTS: Median scores for overall accurate sedation scoring (9 months: 4·00; 3 months: 2·00, p = 0·0001) and overall sedation management (9 months: 14·0; 3 months: 7·0, p = 0·0001) were significantly higher at 9 months compared to 3 months post-intervention. There were no significant differences in the perceived self-confidence level for rating sedation level. Overall perceived barrier scores were low (M = 27·78, SD = 6·26, possible range = 11·0-55·0). Patient conditions (M = 3·68, SD = 1·13) and nurses' workload (M = 3·54, SD = 0·95) were the greatest barriers to effective sedation assessment and management. Demographic variables did not affect sedation scoring or management abilities. CONCLUSIONS: Positive changes in nurses' sedation assessment and management abilities were observed, indicating that adequate hands-on clinical practice following educational interventions can improve nurses' knowledge and skills. RELEVANCE TO CLINICAL PRACTICE: Educational initiatives are necessary to improve ICU practice, particularly in ICUs with inexperienced nurses.

Implementation of a Nurse-Driven Sedation Protocol in a PICU Decreases Daily Doses of Midazolam.

OBJECTIVES: To evaluate the impact of a nurse-driven sedation protocol on the length of mechanical ventilation, total daily doses of sedatives, and complications of sedation. DESIGN: A single-center prospective before and after study was conducted from October 2010 to December 2013. SETTING: Twelve-bed surgical and medical PICU of the university-affiliated hospital in Nantes, France. PATIENTS: A total of 235 patients, between 28 days and 18 years old, requiring mechanical ventilation for at least 24 hours were included in the study; data from 194 patients were analyzed. INTERVENTIONS: During the first study phase, no protocol was used. During the second phase, patients were sedated according to a nurse-driven protocol. MEASUREMENTS AND MAIN RESULTS: In the whole population, the length of mechanical ventilation did not differ between protocol and control groups (protocol, 4 [3-8] vs control, 5 [3-7.5]; p = 0.44). Analyzing age subgroups, the length of mechanical ventilation was significantly shorter in the protocol group than in the control group in children older than 12 months (4 [3-8] vs 5 [2.75-11.25] d; p = 0.04). Daily dose of midazolam decreased during the protocol phase compared with the control phase (1 [0.56-1.8] and 1.2 [0.85-2.4] mg/kg/d, respectively; p = 0.02). No differences were shown regarding other daily dose of drugs. In the control group, 68% of children had more than 20% of COMFORT-behavior scale assessment under the target (oversedation) versus 59% in the protocol group (p = 0.139). CONCLUSIONS: Implementation of a nurse-driven sedation protocol in a PICU is feasible and safe, allowed a decrease in daily dose of benzodiazepines, and decreased the duration of mechanical ventilation in older patients.