title: [A first step towards safer sedation and analgesia: A systematic evaluation of outcomes and level of sedation and analgesia in the mechanically ventilated critically ill patient].
abstract: BACKGROUND
  Safe analgesia and sedation strategies are necessary in order to avoid under or over sedation, as well as improving the comfort and safety of critical care patients.
  
  
  OBJECTIVE
  To compare and contrast a multidisciplinary protocol of systematic evaluation and management of analgesia and sedation in a group of critical care patients on mechanical ventilation with the usual procedures.
  
  
  METHODS
  A cohort study with contemporary series was conducted in a tertiary care medical-surgical ICU February to November during 2013 and 2014. The inclusion criteria were mechanical ventilation ≥ 24h and use of sedation by continuous infusion. Sedation was monitored using the Richmond agitation-sedation scale or bispectral index, and analgesia were measured using the numeric rating scale, or behavioural indicators of pain scale. The study variables included; mechanical ventilation time, weaning time, ventilation support time, artificial airway time, continuous sedative infusion time, daily dose and frequency of analgesic and sedative drug use, hospital stay, and ICU and hospital mortality, Richmond agitation-sedation scale, bispectral index, numeric rating scale, and behavioural indicators of pain scale measurements. Kruskal Wallis and Chi2, and a significance of p<.05 were used.
  
  
  RESULTS
  The study included 153 admissions, 75 pre-intervention and 78 post-intervention, with a mean age of 55.7±13 years old, and 67% men. Both groups showed similarities in age, reason for admission, and APACHE. There were non-significant decreases in mechanical ventilation time 4 (1.4-9.2) and 3.2 (1.4-8.1) days, respectively; p= 0.7, continuous sedative infusion time 6 (3-11) and 5 (3-11) days; p= 0.9, length of hospital stay 29 (18-52); 25 (14-41) days; p= 0.1, ICU mortality (8 vs. 5%; p= 0.4), and hospital mortality (10.6 vs. 9.4%: p= 0.8). Daily doses of midazolam and remifentanil decreased 347 (227-479) mg/day; 261 (159-358) mg/day; p= 0.02 and 2175 (1427-3285) mcg/day; 1500 (715-2740) mcg/day; p= 0.02, respectively. There were increases in the use of remifentanil (32% vs. 51%; p= 0.01), dexmedetomidine (0 vs.6%; p= 0.02), dexketoprofen (60 vs. 76%; p= 0.03), and haloperidol (15 vs.28%; p= 0.04). The use of morphine decreased (71 vs. 54%; p= 0.03). There was an increase in the number of measurements and Richmond agitation-sedation scale scores 6 (3-17); 21 (9-39); p< 0.0001, behavioural indicators of pain scale 6 (3-18); 19(8-33); p< 0.001 and numeric rating scale 4 (2-6); 8 (6-17); p< 0.0001.
  
  
  CONCLUSIONS
  The implementation of a multidisciplinary protocol of systematic evaluation of analgesia and sedation management achieved an improvement in monitoring and adequacy of dose to patient needs, leading to improved outcomes.
authors.affiliation: UCI Polivalente, Hospital Universitario 12 de Octubre, Madrid, España. Electronic address: mariajesusfrade@yahoo.es.
authors.forename: M J
authors.initials: MJ
authors.lastname: Frade-Mera
authors.affiliation: UCI Polivalente, Hospital Universitario 12 de Octubre, Madrid, España.
authors.forename: N
authors.initials: N
authors.lastname: Regueiro-Díaz
authors.affiliation: UCI Polivalente, Hospital Universitario 12 de Octubre, Madrid, España.
authors.forename: L
authors.initials: L
authors.lastname: Díaz-Castellano
authors.affiliation: UCI Polivalente, Hospital Universitario 12 de Octubre, Madrid, España.
authors.forename: L
authors.initials: L
authors.lastname: Torres-Valverde
authors.affiliation: UCI Polivalente, Hospital Universitario 12 de Octubre, Madrid, España.
authors.forename: L
authors.initials: L
authors.lastname: Alonso-Pérez
authors.affiliation: UCI Polivalente, Hospital Universitario 12 de Octubre, Madrid, España.
authors.forename: M M
authors.initials: MM
authors.lastname: Landívar-Redondo
authors.affiliation: UCI Polivalente, Hospital Universitario 12 de Octubre, Madrid, España.
authors.forename: R
authors.initials: R
authors.lastname: Muñoz-Pasín
authors.affiliation: Servicio de Medicina Intensiva, Hospital Universitario 12 de Octubre, Madrid, España.
authors.forename: L J
authors.initials: LJ
authors.lastname: Terceros-Almanza
authors.affiliation: Servicio de Medicina Intensiva, Hospital Universitario 12 de Octubre, Madrid, España.
authors.forename: S
authors.initials: S
authors.lastname: Temprano-Vázquez
authors.affiliation: Servicio de Medicina Intensiva, Hospital Universitario 12 de Octubre, Madrid, España.
authors.forename: J Á
authors.initials: JÁ
authors.lastname: Sánchez-Izquierdo-Riera
mesh_terms: D000698:Analgesia; D015331:Cohort Studies; D016292:Procedural Sedation; D016638:Critical Illness; D054810:Deep Sedation; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D012121:Respiration, Artificial; D012189:Retrospective Studies; D016896:Treatment Outcome
keywords: Analgesia; Enfermería; Paciente crítico; Protocolo; Sedación; Ventilación mecánica; critical patient; mechanical ventilation; nursing; protocol; sedation