Analgesia and sedation of mechanically ventilated patients - a national survey of clinical practice

摘要

The importance of high quality pain treatment and sedation in the intensive care unit (ICU) is well documented. Stressful and uncomfortable daily medical and nursing interventions constitute an important part of ICU treatment. Critically ill patients treated on mechanical ventilation therefore generally need both pain treatment and sedation. A shift from deep to light sedation has been introduced into ICU treatment, allowing the ICU patient to be awake and breathe spontaneously. The major advantages of this approach are decreased ventilator time and that the patient is able to communicate pain and discomfort, to describe treatment effects, and to mobilize. Despite the proven benefits of this strategy, a substantial incidence of suboptimal analgesia and sedation is documented, and ICU professionals struggle to implement feasible methods that support this approach. The application of pain treatment and sedation guidelines, assessment tools, and daily sedation interruption is strongly recommended, but is still not routine in the ICU. In 2007, there was a lack of knowledge about pain treatment and sedation practice in Norwegian ICUs, and there were no indications that Norwegian practice was better organized than in other countries. The aim of this dissertation was to study the processes of analgesia and sedation in intensive care. This was accomplished by a national survey and the implementation of a systematic approach in two Norwegian ICUs. The purpose was to achieve an accurate balance between adequate pain treatment and sedation in critically ill mechanically ventilated patients, and to recognize delirium at an early stage.The first empirical study was a national survey that aimed to describe Norwegian ICU nurses’ and physicians’ perceptions of practice, cooperation, and problems in the daily use of procedures for analgesia and sedation in ICU (study I). One nurse and one physician representing each of the 54 Norwegian ICUs were included. In the second empirical study, a prospective descriptive two-site study was developed to explore the effect of introducing a systematic approach to pain, sedation and delirium management in the ICU by the implementation of four assessment tools (study IIa and IIb). Frequency of pain and sedation documentation, the number of days when a sedation level was prescribed, patients’ levels of pain and sedation, and the amount of analgesics and sedatives used were documented for 39 patients corresponding to 281 ICU days before implementation of the tools versus 139 patients corresponding to 958 ICU days after implementation (study IIa). This substudy also included data from a questionnaire completed by 55 ICU nurses before and after implementation on their perceived benefit of the assessment tools. In substudy IIb, we also tested the usefulness of the Confusion Assessment Method for Intensive Care (CAM-ICU) in the ICU population and described the incidence of delirium in the same cohort. Finally, through the use of focus group interviews we explored how 14 ICU nurses at the two study sites experienced their ability to perform clinical judgments of patient pain, sedation and confusion levels 1 month and 3 months after implementation of assessment tools, and how the tools influenced these judgments (study III).List of papers. The papers are removed from the thesis due to publisher restrictions.Paper I: Wøien H, Stubhaug A, Bjørk IT. Analgesia and sedation of mechanically ventilated patients - a national survey of clinical practice. Acta Anaesthesiologica Scandinavica 2012; 56, 23-29. Paper II: Wøien H, Balsliemke S, Stubhaug A. The incidence of delirium in Norwegian intensive care units; deep sedation makes assessment difficult. Acta Anaesthesiologica Scandinavica 2013; 57, 294-302. Paper III: Wøien H, Værøy H, Aamodt G, Bjørk IT. Improving the systematic approach to pain and sedation management in the ICU by using assessment tools. Journal of Clinical Nursing 2012; Early View. Paper IV: Wøien H, Bjørk IT. Intensive care pain treatment and sedation: Nurses’ experiences of the conflict between clinical judgment and standardized care: An explorative study. Intensive and Critical Care Nursing. 2013; 29, 128-136.