We can´t justify a deep sedation due to enough staff. In this context, the role of the interruption of sedation would be limited to a rescue measure in cases of drug accumulation. “Goodbye daily sedation stops: hello frequent titration protocols”.
In this strategy, it is essential to make an adequate choice of the sedative and evidence goes in favour of the use of drugs non-benzodiazepine (propofol, remifentanil, dexmedetomidine). Probably, benzodiazepines should be limited to selected cases as some patients requiring deep sedation, abstinence, or seizures.
Routine and frequent monitoring of pain, sedation and delirium with validated tools is required to achieve these objectives. Because of the interpersonal variability in the dosage of sedatives and analgesics for a same effect, it is mandatory to maintain a strict monitoring to manage the minimum effective dose to achieve the desired objective.
3. Patient-centered care. In this approach, even when the aim is to maintain a superficial sedation, not all are drugs. It is important to establish care based on the needs of the patient, and probably also of the family. Emotional support to the patient and the family are a fundamental part.
The inability to speak is stressful and inefficient communication impacts negatively on the patient, generating sensations such as helplessness, frustration, anxiety, or fear. It is important to try to optimize communication and work to find alternative methods to improve it.
We have to apply measures of reorientation and environmental stimulation, including clear explanations about the disease and the actions that will be performed, allowing the availability of familiar objects, etc.
In addition, it is important to adapt the environment, trying to make it more comfortable. Reducing noises, lights or unnecessary manoeuvres, especially during rest periods, to facilitate sleep. Improving the privacy and comfort of patients. Limiting the use of physical restraint and promote the early mobilization and collaboration of the patient in rehabilitation. Facilitating the family presence and their participation in care, always under adequate supervision.
Recently, the results of a study conducted in seven ICU in California has been published, including more than 6,000 patients: the application of similar measures, the “ABCDEF bundle”, is associated with an increase in the free days of delirium or coma, and an increase in survival, related to the degree of fulfilment of the same (4).
There are no excuses, it is time to change. Time to evaluate in every ICU, not only the analgesia and sedation practices, also other measures that imply that our units are no longer a hostile place. There is sufficient evidence to improve care, implementing strategies as the concept eCASH concept of the ABCDEF bundle. This is a challenge but the result can be very positive for the patient, improving not only the evolution, but also making their ICU experience more human and less traumatic.
To succeed, attitude and commitment of the whole team of professionals involved in the care is essential.
Dr. Miguel Ángel Romera
Hospital Universitario Puerta de Hierro-Majadahonda ICU
1.- Barr J, Fraser GL, Puntillo K, Ely EW, Gélinas C 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.
2.- Baron R, Binder A, Biniek R, Braune S, Buerkle H et al. Evidence and consensus based guideline for the management of delirium, analgesia, and sedation in intensive care medicine. Revision 2015 (DAS-Guideline 2015) -short version. Ger Med Sci 2015; 13: Doc19.
3.- Vincent JL, Shehabi Y, Walsh TS, Pandharipande PP, Ball JA et al. Comfort and patient-centred care without excessive sedation: the eCASH concept. Intensive Care Med 2016 Apr 13
4.- Barnes-Daly MA, Phillips G, Ely EW. ICU liberation: using the ABCDEF bundle to improve outcomes in 7 California community ICUS. Crit Care Med 2015; 43 (Suppl): A41