Impact of the use of propofol remifentanil goal-directed sedation adapted by nurses on the time to extubation in mechanically ventilated ICU patients: the experience of a French ICU.
OBJECTIVE
Inappropriate sedation could prolong the duration of mechanical ventilation. The present "before-after" study assessed the impact of a goal-directed sedation using an algorithm with a combination of propofol and remifentanil on the time to extubation.


METHODS
During 16 months, ICU-patients requiring sedation greater than 24 h were prospectively studied. In the first eight months, sedation was achieved using continuous infusions of a benzodiazepine (flunitrazepam or midazolam) and an opioid (fentanyl or sufentanil). In the following eight months, sedation using a propofol-remifentanil combination was given and adapted by the nurses according to the Ramsay score and a pain scale. The main endpoint was the time to extubation (from the cessation of sedation to extubation). The secondary endpoints were the duration of mechanical ventilation, the length of ICU stay, the ICU mortality rate, the need of vasopressive support, the occurrence of self-extubations and Ventilator-Associated Pneumonia (VAP).


RESULTS
Forty-six and 39 patients were included in the first and second periods, respectively. The durations of sedation were similar. The time to extubation was shorter in the second period (10 versus 92h, p<0.0001). The duration of mechanical ventilation, the length of stay in ICU, the mortality rate, the need for vasopressor support and the occurrence of VAP were similar. Five self-extubations occurred in the second period versus one in the first one (p=0.02).


CONCLUSIONS
Sedation with adapted infusions of propofol and remifentanil according to the Ramsay score and a pain scale decreases the time to extubation in ICU patients requiring sedation longer than 24h but increases the rate of self-extubations.
Muller
L
L
Division anesthésie-réanimation-douleur-urgences, groupe hospitalo-universitaire Caremeau, centre hospitalier universitaire de Nîmes, place du Professeur-Robert-Debré, 30029 Nîmes cedex 9, France.
Chanques
G
G
Bourgaux
C
C
Louart
G
G
Jaber
S
S
Fabbro-Peray
P
P
Ripart
J
J
de La Coussaye
J-E
JE
Lefrant
J-Y
JY
D018686:Anesthetics, Intravenous / Q000008:administration & dosage / Q000627:therapeutic use; D005445:Flunitrazepam / Q000008:administration & dosage / Q000627:therapeutic use; D005602:France; D006801:Humans; D006993:Hypnotics and Sedatives / Q000627:therapeutic use*; D007262:Infusions, Intravenous / Q000379:methods / Q000401:mortality / Q000451:nursing; D007362:Intensive Care Units; D008874:Midazolam / Q000008:administration & dosage / Q000627:therapeutic use; D010147:Pain Measurement / Q000379:methods; D010880:Piperidines / Q000008:administration & dosage / Q000627:therapeutic use*; D015742:Propofol / Q000627:therapeutic use*; D000077208:Remifentanil; D012121:Respiration, Artificial / Q000379:methods* / Q000401:mortality / Q000451:nursing; D015996:Survival Rate; D016896:Treatment Outcome
D018686:Anesthetics, Intravenous; D006993:Hypnotics and Sedatives; D010880:Piperidines; D005445:Flunitrazepam; D000077208:Remifentanil; D008874:Midazolam; D015742:Propofol