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Critical Care

, 18:580

First Online: 24 October 2014Received: 17 May 2014Accepted: 07 October 2014

Abstract

IntroductionOversedation frequently occurs in ICUs. We aimed to evaluate a minimal sedation policy, using sedative consumption as a monitoring tool, in a network of ICUs targeting decrement of oversedation and mechanical ventilation MV duration.

MethodsA prospective quality improvement project was conducted in ten ICUs within a network of nonteaching hospitals in Brazil during a 2-year period 2010 to 2012. In the first 12 months the preintervention period, we conducted an audit to identify sedation practice and barriers to current guideline-based practice regarding sedation. In the postintervention period, we implemented a multifaceted program, including multidisciplinary daily rounds, and monthly audits focusing on sedative consumption, feedback and benchmarking purposes. To analyze the effect of the campaign, we fit an interrupted time series ITS. To account for variability among the network ICUs, we fit a hierarchical model.

ResultsDuring the study period, 21% of patients received MV 4,851-22,963. In the postintervention period, the length of MV was lower 3.91 ± 6.2 days versus 3.15 ± 4.6 days; mean difference -0.76 95% CI -1.10; -0.43, P <0.001 and 28 ventilator-free days were higher 16.07 ± 12.2 days versus 18.33 ± 11.6 days; mean difference, 2.30 95% CI, 1.57; 3.00, P <0.001 than in the preintervention period. Midazolam consumption in milligrams per day of MV decreased from 329 ± 70 mg-day to 163 ± 115 mg-day mean difference -167 95% CI -246; -87, P <0.001. In contrast, consumption of propofol P = 0.007, dexmedetomidine P = 0.017 and haloperidol P = 0.002 increased in the postintervention period, without changes in the consumption of fentanyl. Through ITS, age P = 0.574 and Simplified Acute Physiology Score III P = 0.176 remained stable. The length of MV showed a secular effect secular trend β1β=-0.055, P = 0.012 and a strong decrease immediately after the intervention intervention β2 = -0.976, P <0.001. The impact was maintained over the course of one year, despite the waning trend for the intervention’s effect postintervention trend β3 = 0.039, P = 0.095.

ConclusionsBy using a light sedation policy in a group of nonteaching hospitals, we reproduced the benefits that have previously been demonstrated in controlled settings. Furthermore, systematic monitoring of sedative consumption should be a feasible instrument for supporting the implementation of a protocol on a large scale.

AbbreviationsARIMAAutoregressive integrated moving average

CRFCase report formulary

HMOHealth maintenance organization

ICUIntensive care unit

IQRInterquartile range

ITSInterrupted time series

MVMechanical ventilation

QIQuality improvement program

SAPS IIISimplified Acute Physiology Score III

VAPVentilator-associated pneumonia

Electronic supplementary materialThe online version of this article doi:10.1186-s13054-014-0580-3 contains supplementary material, which is available to authorized users.

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Author: Otavio T Ranzani - Evelyn Senna Simpson - Talita Barbosa Augusto - Sylas Bezerra Cappi - Danilo Teixeira Noritomi

Source: https://link.springer.com/







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