title: Effect of an analgo-sedation protocol for neurointensive patients: a two-phase interventional non-randomized pilot study.
abstract: BACKGROUND
  Sedation protocols are needed for neurointensive patients. The aim of this pilot study was to describe sedation practice at a neurointensive care unit and to assess the feasibility and efficacy of a new sedation protocol. The primary outcomes were a shift from sedation-based to analgesia-based sedation and improved pain management. The secondary outcomes were a reduction in unplanned extubations and duration of sedation.
  
  
  METHODS
  This was a two-phase (before-after), prospective controlled study at a university-affiliated, 14-bed neurointensive care unit in Denmark. The sample included patients requiring mechanical ventilation for at least 48 hours treated with continuous sedative and analgesic infusions or both. During the observation phase the participants (n = 106) were sedated as usual (non-protocolized), and during the intervention phase the participants (n = 109) were managed according to a new sedation protocol.
  
  
  RESULTS
  Our study showed a shift toward analgo-sedation, suggesting feasibility of the protocol. We found a significant reduction in the use of propofol (P < .001) and midazolam (P = .001) and an increase in fentanyl (P < .001) and remifentanil (P = .003). Patients selected for daily sedation interruption woke up faster, and estimates of pain free patients increased from 56.8% to 82.7% (P < .001), suggesting efficacy of the protocol. The duration of sedation and unplanned extubations were unchanged.
  
  
  CONCLUSIONS
  Our pilot study showed feasibility and partial efficacy of our protocol. Some neurointensive patients might not benefit from protocolized practice. We recommend an interdisciplinary effort to target patients requiring less sedation, as issues of oversedation and inadequate pain management still need more attention.
  
  
  BACKGROUND
  ISRCTN80999859.
authors.affiliation: Copenhagen University Hospital, Rigshospitalet, Department 7331, UCSF, Blegdamsvej 9, Copenhagen O, Denmark. ie@ucsf.dk
authors.forename: Ingrid
authors.initials: I
authors.lastname: Egerod
authors.forename: Malene Brorsen
authors.initials: MB
authors.lastname: Jensen
authors.forename: Suzanne Forsyth
authors.initials: SF
authors.lastname: Herling
authors.forename: Karen-Lise
authors.initials: KL
authors.lastname: Welling
mesh_terms: D000328:Adult; D000368:Aged; D000700:Analgesics / Q000008:administration & dosage / Q000627:therapeutic use*; D002985:Clinical Protocols; D005240:Feasibility Studies; D005260:Female; D006801:Humans; D006993:Hypnotics and Sedatives / Q000008:administration & dosage / Q000627:therapeutic use*; D007362:Intensive Care Units; D008297:Male; D008875:Middle Aged; D010146:Pain / Q000188:drug therapy; D010865:Pilot Projects; D011446:Prospective Studies; D016896:Treatment Outcome
chemical_list: D000700:Analgesics; D006993:Hypnotics and Sedatives
references.citation: Br Med J. 1974 Jun 22;2(5920):656-9
references.pmid: 4835444
references.citation: Chest. 2008 Feb;133(2):552-65
references.pmid: 18252923
references.citation: Intensive Crit Care Nurs. 2003 Dec;19(6):350-62
references.pmid: 14637295
references.citation: Qual Health Res. 2009 May;19(5):687-96
references.pmid: 19380504
references.citation: Anesthesiology. 2007 Apr;106(4):687-95; quiz 891-2
references.pmid: 17413906
references.citation: Acta Anaesthesiol Scand. 2004 Sep;48(8):944-50
references.pmid: 15315610
references.citation: Minerva Anestesiol. 2004 Apr;70(4):137-43
references.pmid: 15173687
references.citation: Lancet. 2010 Feb 6;375(9713):475-80
references.pmid: 20116842
references.citation: Br J Anaesth. 2001 Aug;87(2):186-92
references.pmid: 11493487
references.citation: Minerva Anestesiol. 2006 Oct;72(10):769-805
references.pmid: 17006417
references.citation: Intensive Care Med. 2000 Mar;26(3):275-85
references.pmid: 10823383
references.citation: Crit Care Med. 2008 Jul;36(7):2054-60
references.pmid: 18552689
references.citation: Crit Care Med. 2008 May;36(5):1444-50
references.pmid: 18434914
references.citation: Crit Care. 2005 Feb;9(1):R32-6
references.pmid: 15693964
references.citation: Curr Opin Crit Care. 2003 Apr;9(2):120-6
references.pmid: 12657974
references.citation: Intensive Care Med. 2006 Jan;32(1):60-6
references.pmid: 16283160
references.citation: Crit Care Med. 2008 Jul;36(7):2092-9
references.pmid: 18552687
references.citation: Crit Care Med. 1996 Oct;24(10):1743-8
references.pmid: 8874315
references.citation: Eur J Emerg Med. 1996 Jun;3(2):109-27
references.pmid: 9028756
references.citation: Crit Care Med. 2007 Sep;35(9):2031-6
references.pmid: 17855817
references.citation: J Emerg Med. 2009 Nov;37(4):451-5
references.pmid: 19272743
references.citation: Crit Care. 2004 Aug;8(4):R268-80
references.pmid: 15312228
references.citation: Crit Care Med. 2008 Feb;36(2):427-33
references.pmid: 18091554
references.citation: Crit Care Med. 2009 Mar;37(3):825-32
references.pmid: 19237884
references.citation: Neurol Res. 2001 Mar-Apr;23(2-3):237-59
references.pmid: 11320605
references.citation: Curr Treat Options Neurol. 2008 Mar;10(2):111-25
references.pmid: 18334134
references.citation: Intensive Care Med. 2009 Feb;35(2):291-8
references.pmid: 18949456
references.citation: Crit Care Med. 2006 Feb;34(2):374-80
references.pmid: 16424717
references.citation: Crit Care Med. 2002 Jan;30(1):119-41
references.pmid: 11902253