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VOLUME 18 , ISSUE 9 ( September, 2014 ) > List of Articles


Current practices of mobilization, analgesia, relaxants and sedation in Indian ICUs: A survey conducted by the Indian Society of Critical Care Medicine

Sananta Kumar Dash

Keywords : Analgesia, early mobilization, muscle relaxants, sedation

Citation Information : Dash SK. Current practices of mobilization, analgesia, relaxants and sedation in Indian ICUs: A survey conducted by the Indian Society of Critical Care Medicine. Indian J Crit Care Med 2014; 18 (9):575-584.

DOI: 10.4103/0972-5229.140146

License: CC BY-ND 3.0

Published Online: 01-10-2007

Copyright Statement:  Copyright © 2014; The Author(s).


Background and Aim: Use of sedation, analgesia and neuromuscular blocking agents is widely practiced in Intensive Care Units (ICUs). Our aim is to study the current practice patterns related to mobilization, analgesia, relaxants and sedation (MARS) to help in standardizing best practices in these areas in the ICU. Materials and Methods: A web-based nationwide survey involving physicians of the Indian Society of Critical Care Medicine (ISCCM) and the Indian Society of Anesthesiologists (ISA) was carried out. A questionnaire included questions on demographics, assessment scales for delirium, sedation and pain, as also the pharmacological agents and the practice methods. Results: Most ICUs function in a semi-closed model. Midazolam (94.99%) and Fentanyl (47.04%) were the most common sedative and analgesic agents used, respectively. Vecuronium was the preferred neuromuscular agent. Monitoring of sedation, analgesia and delirium in the ICU. Ramsay′s Sedation Scale (56.1%) and Visual Analogue Scale (48.07%) were the preferred sedation and pain scales, respectively. CAM (Confusion Assessment Method)-ICU was the most preferred method of delirium assessment. Haloperidol was the most commonly used agent for delirium. Majority of the respondents were aware of the benefit of early mobilization, but lack of support staff and safety concerns were the main obstacles to its implementation. Conclusion: The results of the survey suggest that compliance with existing guidelines is low. Benzodiazepines still remain the predominant ICU sedative. The recommended practice of giving analgesia before sedation is almost non-existent. Delirium remains an underrecognized entity. Monitoring of sedation levels, analgesia and delirium is low and validated and recommended scales for the same are rarely used. Although awareness of the benefits of early mobilization are high, the implementation is low.

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  1. Brook AD, Ahrens TS, Schaiff R, Prentice D, Sherman G, Shannon W, et al. Effect of a nursing-implemented sedation protocol on the duration of mechanical ventilation. Crit Care Med 1999;27:2609-15.
  2. Girard TD, Kress JP, Fuchs BD, Thomason JW, Schweickert WD, Pun BT, et al. Efficacy and safety of a paired sedation and ventilator weaning protocol for mechanically ventilated patients in intensive care (Awakening and Breathing Controlled trial): A randomised controlled trial. Lancet 2008;371:126-34.
  3. Kress JP, Pohlman AS, O′Connor MF, Hall JB. Daily interruption of seda-tive infusions in critically ill patients undergoing mechanical ventila-tion. N Engl J Med 2000;342:1471-7.
  4. Treggiari MM, Romand JA, Yanez ND, Deem SA, Goldberg J, Hudson L, et al. Randomized trial of light versus deep sedation on mental health after critical illness. Crit Care Med 2009;37:2527-34.
  5. Kollef MH, Levy NT, Ahrens TS, Schaiff R, Prentice D, Sherman G. The use of continuous i.v. seda-tion is associated with prolongation of mechanical ventilation. Chest 1998;114:541-8.
  6. Fraser GL, Prato BS, Riker RR, Berthiaume D, Wilkins ML. Frequency, severity, and treat-ment of agitation in young versus elderly patients in the ICU. Phar-macotherapy 2000;20:75-82.
  7. Conti J, Smith D. Haemodynamic responses to extubation after cardiac surgery with and without continued sedation. Br J Anaesth 1998;80:834-6.
  8. Barr J, Zomorodi K, Bertaccini EJ, Shafer SL, Geller E. A double-blind, random-ized comparison of i.v.lorazepam versus midazolam for sedation of ICU patients via a pharmacologic model. Anesthesiology 2001;95:286-98.
  9. Swart EL, Zuideveld KP, de Jongh J, Danhof M, Thijs LG, Strack van Schijndel RM. Comparative population pharmacokinetics of lorazepam and midazolam during long-term continuous infusion in critically ill patients. Br J Clin Pharmacol 2004;57:135-45.
  10. Rello J, Lode H, Cornaglia G, Masterton R. VAP Care Bundle Contributors: A European care bundle for prevention of ventilator-associated pneu-monia. Intensive Care Med 2010;36:773-80.
  11. Rello J, Lorente C, Bodí M, Diaz E, Ricart M, Kollef MH. Why do physicians not follow evi-dence-based guidelines for preventing ventilator-associated pneu-monia? A survey based on the opinions of an international panel of intensivists. Chest 2002;122:656-61.
  12. Akça O, Melischek M, Scheck T, Hellwagner K, Arkiliç CF, Kurz A, et al. Postoperative pain and subcu-taneous oxygen tension. Lancet 1999;354:41-2.
  13. Hedderich R, Ness TJ. Analgesia for trauma and burns. Crit Care Clin 1999;15:167-84.
  14. Botha J, Le Blanc V. The State of Sedation in the Nation: Results of an Australian Survey. Crit Care Resusc 2005;7:92-6.
  15. Reschreiter H, Maiden M, Kapila A. Sedation practice in the intensive care unit: A UK national survey. Crit Care 2000;12:R152.
  16. Soliman HM, Mélot C, Vincent JL. Sedative and analgesic practice in the intensive care unit: The results of a European survey. Br J Anaesth 2001;87:186-92.
  17. Mehta S, Burry L, Fischer S, Martinez-Motta JC, Hallett D, Bowman D, et al. Canadian Critical Care Trials Group. Canadian survey of the use of sedatives, analgesics, and neuromuscular blocking agents in critically ill patients. Crit Care Med 2006;34:374-80.
  18. Barr J, Fraser GL, Puntillo K, Ely EW, Gélinas C, Dasta JF, et al. Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit. Crit Care Med 2013;41:263-306.
  19. Wunsch H, Kahn JM, Kramer AA, Rubenfeld GD. Use of intravenous infu-sion sedation among mechanically ventilated patients in the United States. Crit Care Med 2009;37:3031-9.
  20. Szumita PM, Baroletti SA, Anger KE, Wechsler ME. Sedation and analgesia in the intensive care unit: Evaluating the role of dexmedetomidine. Am J Health Syst Pharm 2007;64:37-44.
  21. Tan JA, Ho KM. Use of dexmedetomidine as a sedative and anal-gesic agent in critically ill adult patients: A meta-analysis. Intensive Care Med 2010;36:926-39.
  22. Oldenhof H, de Jong M, Steenhoek A, Janknegt R. Clinical pharmacokinet-ics of midazolam in intensive care patients, a wide interpatient vari-ability? Clin Pharmacol Ther 1988;43:263-9.
  23. Triltsch AE, Welte M, von Homeyer P, Grosse J, Genähr A, Moshirzadeh M, et al. Bispectral index-guided sedation with dexmedetomidine in intensive care: A prospective, randomized, double blind, placebo-controlled phase II study. Crit Care Med 2002;30:1007-14.
  24. Belleville JP, Ward DS, Bloor BC, Maze M. Effects of intravenous dex-medetomidine in humans. I. Sedation, ventilation, and metabolic rate. Anesthesiology 1992;77:1125-33.
  25. Riker RR, Shehabi Y, Bokesch PM, Ceraso D, Wisemandle W, Koura F, et al. SEDCOM (Safety and Efficacy of Dexmedetomidine Compared with Midazolam) Study Group: Dexmedetomidinevs midazolam for sedation of critically ill patients: A randomized trial. JAMA 2009;301:489-99.
  26. Pandharipande PP, Pun BT, Herr DL, Maze M, Girard TD, Miller RR, et al. Effect of sedation with dexmedetomidinevslorazepam on acute brain dysfunction in mechanically ventilated patients: The MENDS randomized con-trolled trial. JAMA 2007;298:2644-53.
  27. Carson SS, Kress JP, Rodgers JE, Vinayak A, Campbell-Bright S, Levitt J, et al. A randomized trial of inter-mittent lorazepam versus propofol with daily interruption in mechani-cally ventilated patients. Crit Care Med 2006;34:1326-32.
  28. Dasta JF, Kane-Gill SL, Pencina M, Shehabi Y, Bokesch PM, Wisemandle W, et al. A cost-minimization analysis of dexmedetomidine compared with midazolam for long-term seda-tion in the intensive care unit. Crit Care Med 2010;38:497-503.
  29. Detriche O, Berré J, Massaut J, Vincent JL. The Brussels sedation scale: Use of a simple clinical sedation scale can avoid excessive sedation in patients undergoing mechanical ventilation in the intensive care unit. Br J Anaesth 1999;83:698-701.
  30. Brattebü G, Hofoss D, Flaatten H, Muri AK, Gjerde S, Plsek PE. Effect of a scoring system and protocol for sedation on duration of patients′ needs for ventilator support in a surgical intensive care unit. BMJ 2002;324:1386-9.
  31. MacLaren R, Plamondon JM, Ramsay KB, Rocker GM, Patrick WD, Hall RI. A prospective evaluation of empiric versus protocol-base sedation and analgesia. Pharmacotherapy 2000;20:662-72.
  32. Arabi Y, Haddad S, Hawes R, Moore T, Pillay M, Naidu B. Changing sedation practices in the intensive care unit-Protocol implementation, multifaceted mul-tidisciplinary approach and teamwork. Middle East J Anesthesiol 2007;19:429-47.
  33. Arias-Rivera S, Sánchez-Sánchez Mdel M, Santos-Díaz R, Gallardo-Murillo J, Sánchez-Izquierdo R, Frutos-Vivar F, et al. Effect of a nursing-implemented sedation protocol on weaning outcome. Crit Care Med 2008;36:2054-60.
  34. Brattebü G, Hofoss D, Flaatten H, Muri AK, Gjerde S, Plsek PE. Effect of a scoring system and protocol for sedation on duration of patients′ need for ven-tilator support in a surgical intensive care unit. BMJ 2002;324:1386-9.
  35. Quenot JP, Ladoire S, Devoucoux F, Doise JM, Cailliod R, Cunin N. Effect of a nurse-imple-mented sedation protocol on the incidence of ventilator-associated pneumonia. Crit Care Med 2007;35:2031-6.
  36. Robinson BR, Mueller EW, Henson K, Branson RD, Barsoum S, Tsuei BJ. An analgesia-delirium-sedation protocol for critically ill trauma patients reduces ventilator days and hospital length of stay. J Trauma 2008;65:517-26.
  37. Bucknall TK, Manias E, Presneill JJ. A randomized trial of protocol-directed sedation management for mechanical ventilation in an Aus-tralian intensive care unit. Crit Care Med 2008;36:1444-50.
  38. Elliott R, McKinley S, Aitken LM, Hendrikz J. The effect of an algorithm-based sedation guideline on the duration of mechanical ventilation in an Aus-tralian intensive care unit. Intensive Care Med 2006;32:1506-14.
  39. Mascia MF, Koch M, Medicis JJ. Pharmacoeconomic impact of rational use guidelines on the provision of analgesia, sedation, and neuromuscular blockade in critical care. Crit Care Med 2000;28:2300-6.
  40. Marshall J, Finn CA, Theodore AC. Impact of a clinical pharma-cist-enforced intensive care unit sedation protocol on duration of mechanical ventilation and hospital stay. Crit Care Med 2008;36:427-33.
  41. DuBose JJ, Inaba K, Shiflett A, Trankiem C, Teixeira PG, Salim A, et al. Measurable outcomes of quality improvement in the trauma intensive care unit: The impact of a daily quality rounding checklist. J Trauma 2008;64:22-7.
  42. Devlin JW, Holbrook AM, Fuller HD. The effect of ICU sedation guidelines and pharmacist interventions on clinic. Ann Pharmacother 1997;31:689-95.
  43. Chanques G, Jaber S, Barbotte E, Violet S, Sebbane M, Perrigault PF. Impact of systematic evalu-ation of pain and agitation in an intensive care unit. Crit Care Med 2006;34:1691-9.
  44. Payen JF, Bosson JL, Chanques G, Mantz J, Labarere J; DOLOREA Investigators: Pain assessment is associated with decreased duration of mechani-cal ventilation in the intensive care unit: A post Hoc analysis of the DOLOREA study. Anesthesiology 2009;111:1308-16.
  45. Arbour C, Gélinas C, Michaud C. Impact of the implementation of the Critical-Care Pain Observation Tool (CPOT) on pain management and clinical outcomes in mechanically ventilated trauma intensive care unit patients: A pilot study. J Trauma Nurs 2011;18:52-60.
  46. Strüm T, Martinussen T, Toft P. A protocol of no sedation for criti-cally ill patients receiving mechanical ventilation: A randomised trial. Lancet 2010;375:475-80.
  47. Breen D, Karabinis A, Malbrain M, Morais R, Albrecht S, Jarnvig IL. Decreased duration of mechanical ventilation when comparing analgesia-based seda-tion using remifentanil with standard hypnotic-based sedation for up to 10 days in intensive care unit patients: A randomised trial [ISRCTN47583497]. Crit Care 2005;9:R200-10.
  48. Changing intensive care to improve life afterward. Avail-able from: 604576144321242020948.html.[Last accessed on 2014 Aug 07].
  49. Available from: Hospitals fight a form of delirium that often strikes ICU patients-The Washington Post. Available from: fight-a-form-of-delirium-that-often-strikes-icu-patients/2011/03/23/AF518nMD_story.html. [Last accessed on 2014 Aug 07].
  50. Milbrandt EB, Deppen S, Harrison PL, Shintani AK, Speroff T, Stiles RA, et al. Costs associated with delirium in mechanically ventilated patients. Crit Care Med 2004;32:955-62.
  51. McNicoll L, Pisani MA, Zhang Y, Ely EW, Siegel MD, Inouye SK, et al. Delirium in the intensive care unit: Occurrence and clinical course in older patients. J Am Geriatr Soc 2003;51:591-8.
  52. Shehabi Y, Riker RR, Bokesch PM, Wisemandle W, Shintani A, Ely EW. SEDCOM (Safety and Efficacy of Dexmedetomidine Compared with Midazolam) Study Group: Delirium duration and mortality in lightly sedated, mechani-cally ventilated intensive care patients. Crit Care Med 2010;38:2311-8.
  53. Pisani MA, Kong SY, Kasl SV, Murphy TE, Araujo KL, Van Ness PH. Days of delirium are associated with 1-year mortality in an older intensive care unit population. Am J Respir Crit Care Med 2009;180:1092-7.
  54. Ely EW, Shintani A, Truman B, Speroff T, Gordon SM, Harrell FE Jr, et al. Delirium as a predictor of mor-tality in mechanically ventilated patients in the intensive care unit. JAMA 2004;291:1753-62.
  55. Ely EW, Gautam S, Margolin R, Francis J, May L, Speroff T, et al. The impact of delirium in the intensive care unit on hospital length of stay. Intensive Care Med 2001;27:1892-900.
  56. Girard TD, Jackson JC, Pandharipande PP, Pun BT, Thompson JL, Shintani AK, et al. Delirium as a pre-dictor of long-term cognitive impairment in survivors of critical ill-ness. Crit Care Med 2010;38:1513-20.
  57. Martin J, Heymann A, Bäsell K, Baron R, Biniek R, Bürkle H, et al. Evidence and consensus-based German guidelines for the management of analgesia, sedation and delirium in intensive care-Short version. Ger Med Sci 2010;8:1-31.
  58. Michaud L, Büla C, Berney A, Camus V, Voellinger R, Stiefel F, et al. Delirium: Guidelines for general hospitals. J Psychosom Res 2007;62:371-83.
  59. Tropea J, Slee JA, Brand CA, Gray L, Snell T. Clinical practice guidelines for the management of delirium in older people in Australia. Australas J Ageing 2008;27:150-6.
  60. Schweickert WD, Pohlman MC, Pohlman AS, Nigos C, Pawlik AJ, Esbrook CL, et al. Early physical and occupational therapy in mechanically ventilated, critically ill patients: A randomised controlled trial. Lancet 2009;373:1874-82.
  61. Bailey P, Thomsen GE, Spuhler VJ, Blair R, Jewkes J, Bezdjian L, et al. Early activityis feasible and safe in respiratory failure patients. Crit Care Med 2007;35:139-45.
  62. Morris PE, Goad A, Thompson C, Taylor K, Harry B, Passmore L, et al. Early intensivecare unit mobility therapy in the treatment of acuterespiratory failure. Crit Care Med 2008;36:2238-43.
  63. Stiller K, Phillips, AC, Lambert P. The safety of mobilisationand its effects on haemodynamic and respiratorystatus of intensive care patients. Physio Theory Pract 2004;20:175-85.
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