Table 1 |
|||||||||
|
Incidence of optimal and sub-optimal sedation in included studies |
|||||||||
|
Study |
Study design and comparisons made |
Number |
Treatment arms (if relevant) |
Incidence of sub-optimal sedation |
Incidence of over-sedation |
Incidence of under-sedation |
Incidence of optimal sedation |
Sedation scale/monitoring system used |
Definition of optimal sedation |
|
|
|||||||||
|
Weinert, et al., 2007 [44] |
Cohort study |
274 |
326 (2.6%) of 12,414 assessments. 111 patients (40%) had ≥ 1 rating of over-sedation. Patients were unarousable/minimally arousable 32% of the time. |
1,731 (13.9%) of 12,414 assessments. 211 (76.2%) had ≥ 1 rating of under-sedation. |
10,357 (83%) of 12,414 |
Minnesota Sedation Assessment Tool -- nurse assessment |
Arousal level 3-5 (of 6-point scale) |
||
|
Martin, et al., 2006 [30] |
Cohort study |
305 (from 220 ICUs) |
42.6% of 49 patients sedated 24-72 hours, 39.5% of 157 patients sedated >72 hours, and 43.9% of 57 patients under weaning had significantly deeper sedation than desired level |
5.2% of 157 patients sedated >72 hours and 3.5% of 57 patients under weaning had significantly lower sedation than desired level |
In patients sedated >72 hours, the desired Ramsay score was 0-4 in 44% of cases -- this was achieved in 28%; in 55% of patients, the desired value was 4-5, which was achieved in 68%; in 1% of patients, the desired score was 6, which was achieved in 6%. |
Ramsay scale |
Individual to each patient |
||
|
Payen, et al., 2007 [43] |
Cohort study |
1,381 |
258 (57%) of 451 patients on sedation day 2; 169 (48%) of 355 patients on day 4; 109 (41%) of 266 patients on day 6 |
Multiple: most commonly Ramsay, RASS, Sedation-Agitation scale |
Over-sedation defined as Ramsay 5-6, RASS -5 or --4, Sedation-Agitation scale 1-2 |
||||
|
Sandiumenge, et al., 2000 [36] |
RCT/observational study of sedative drugs |
63 |
Midazolam |
19 (7%) of 266 hours |
247 (93%) of 266 hours |
Modified Ramsay scale |
Equivalent of Ramsay 5-6 (for deep sedation) |
||
|
2% propofol |
14 (9%) of 156 hours |
142 (91%) of 156 hours |
|||||||
|
Carrasco, et al., 1993 [26] |
RCT (with economic study) of sedative drugs |
88 |
Midazolam |
18% of time (hours) |
82% of time (hours) |
Ramsay scale; Glasgow coma scale (modified by Cook and Palma) |
Ramsay scale 2-5, Glasgow coma scale 8-13 |
||
|
Propofol |
7% of time (hours) |
93% of time (hours) |
|||||||
|
McCollam, et al., 1999 [23] |
RCT of sedative drugs |
30 |
Lorazepam |
32% of assessments |
14% of assessments |
18% of assessments |
68% of assessments |
Ramsay scale |
Ramsay scale 2-4 |
|
Midazolam |
21% of assessments |
6% of assessments |
16% of assessments |
79% of assessments |
|||||
|
Propofol |
38% of assessments |
7% of assessments |
31% of assessments |
62% of assessments |
|||||
|
Chinachoti, et al., 2002 [40] |
RCT of sedative drugs |
152 |
Remifentanil |
28% of patients; 17.3% of time (hours) |
13% of time (hours) |
4% of time (hours) |
78% of patients (without midazolam), 83% of time (hours) (maintenance phase) |
SAS |
SAS 4 with no or mild pain |
|
Morphine |
27% of patients; 16% of time (hours) |
13% of time (hours) |
3% of time (hours) |
73% of patients (without midazolam), 84% of time (hours) (maintenance phase) |
|||||
|
Harper, et al., 1991 [25] |
RCT of sedative drugs |
37 |
Alfentanil low, moderate and high doses -- results reported together |
4 patients had >10% of time at sedation level 6 |
3 patients had >10% of time at sedation level 1 |
Ramsay (assessed hourly) |
2-5 |
||
|
Manley, et al., 1997 [46] |
RCT (and economic study) of sedative drugs |
26 |
Morphine + midazolam |
56.8% of time |
43.2% of time |
North Staffordshire ICU (modification of Ramsay/Addenbrooke's scores) |
3-4 |
||
|
Alfentanil + propofol |
57.8% of time |
42.2% of time |
|||||||
|
Millane, 1992 [21] |
RCT of sedative drugs |
24 |
Isoflurane for 24 hours followed by propofol |
3.4% |
Ramsay plus subjective nurse assessment |
2-3 (plus subjective nurse assessment) |
|||
|
Propofol for 24 hours followed by isoflurane |
3.6% |
||||||||
|
Muellejans, et al., 2004 [41] |
RCT of sedative drugs |
152 |
Remifentanil |
11.7% of time (hours) |
88.3% of time (hours) |
SAS |
4 |
||
|
Fentanyl |
10.7% of time (hours) |
89.3% of time (hours) |
|||||||
|
Muellejans, et al., 2006 [47] |
RCT of sedative drugs |
80 |
Remifentanil -- propofol |
41% of time |
28% of time |
13% of time |
59% of time |
3 level sedation score specific to study |
Level 2 |
|
Midazolam -- fentanyl |
30% of time |
19% of time |
11% of time |
70% of time |
|||||
|
Chamorro, et al., 1996 [45] |
RCT of sedative drugs |
98 |
Propofol |
332 assessments -- 3% (after first hour) |
332 assessments -- 76.5% effective, 20.5% acceptable |
Study-specific (modified Glasgow coma scale). Patients monitored at 1 and 6 hours and then every 12 hours. |
4 = effective, 3 = acceptable less than 3 = ineffective |
||
|
Midazolam |
355 assessments -- 7.6% |
355 assessments -- 66.2% effective, 26.2% acceptable |
|||||||
|
Barr, et al., 2001 [34] |
RCT of sedative drugs |
24 |
Lorazepam |
51% of time |
47% of time |
49% of time |
Modified Ramsay |
3-4 (5-6 = over-sedation) |
|
|
Midazolam |
31% of time |
22% of time |
69% of time |
||||||
|
Finfer, et al., 1999 [33] |
RCT of sedative drugs |
40 |
Diazepam (intermittent) |
9 (64.3%) of 14 patients; 15.0% of time (hours) |
2.8% of time (hours) |
21.1% of time (hours) |
5 (35.7%) of 14 patients; 85.0% of time (hours) |
Modified Ramsay |
1-4 |
|
Midazolam (continuous) |
6 (35.3%) of 17 patients; 40.8% of time (hours) |
14.8% of time (hours) |
0% of time (hours) |
11 (64.7%) of 17 patients; 59.2% of time (hours) |
|||||
|
Richman, et al., 2006 [37] |
RCT of sedative drugs |
30 |
Midazolam |
Mean 9.1 hours/day (SD 4.9) |
Modified Ramsay |
Individual to each patient |
|||
|
Midazolam and fentanyl |
Mean 4.2 hours/day (SD 2.4) |
||||||||
|
Karabinis, et al., 2004 [39] |
RCT of sedative drugs |
161 |
Remifentanil |
4.4% of time |
95.6% of time (median) |
SAS |
1-3 |
||
|
Fentanyl |
1.9% of time |
98.1% of time (median) |
|||||||
|
Morphine |
1.0% of time |
99.0% of time (median) |
|||||||
|
Pandharipande, et al., 2007 [48], Pandharipande, et al., 2006 [59] |
RCT of sedative drugs |
106 |
Dexmedetomidine |
20% of patients according to nurse goals; 33% according to physician goals |
15% of patients |
80% of patients within 1 point of nurse goal; 67% within 1 point of physician goal |
RASS, confusion-assessment method for the ICU (CAM-ICU) |
Individual to each patient |
|
|
Lorazepam |
33% of patients according to nurse goals; 45% according to physician goals |
33% of patients |
67% within 1 point of nurse goal; 55% within 1 point of physician goal |
||||||
|
Swart, et al., 1999 [50] |
RCT of sedative drugs |
64 |
Lorazepam |
13% of time |
87.0% of time (SD 10.5) |
Addenbrooke's Hospital's ICU sedation scale |
Individual to each patient |
||
|
Midazolam |
34% of time |
66.2% of time (SD 23.1) |
|||||||
|
Carson, et al., 2006 [22] |
RCT of sedative drugs |
132 |
Intermittent lorazepam |
42.8% (ventilator hours) |
37.9% (ventilator hours) |
15.1% (ventilator hours) |
Ramsay |
2-3 |
|
|
Continuous propofol |
49.9% (ventilator hours) |
38.6% (ventilator hours) |
11.5% (ventilator hours) |
||||||
|
RCT of sedative drugs |
156 |
Propofol |
39.8% of time |
12.0% of time |
11.2% of time |
60.2% of time |
Ramsay |
Individual to each patient |
|
|
Midazolam |
56.0% of time |
18.4% of time |
8.1% of time |
44.0% of time |
|||||
|
Park, et al., 2007 [49] |
RCT of sedative drugs |
134 (111 analysed) |
Analgesia-based sedation |
50% of time |
50% of time on SIMV (median) |
Assessor judgement |
Adequate judged as awake or easily rousable |
||
|
Hypnotic-based sedation |
81% of time |
19% of time on SIMV (median) |
|||||||
|
Cigada, et al., 2005 [32] |
Observational study of sedative drugs |
42 |
Propofol or midazolam with enteral hydroxyzine with or without supplemental lorazepam. IV drugs were tapered after 48 hours. |
36.9% of assessments as judged by Ramsay score; 17% by nurse assessment |
421 (24.6%) of 1,711 assessments (Ramsay score) 42 (7.3%) of 577 assessments (nurse judgement) |
211 (12.3%) of 1,711 assessments (Ramsay score) 56 (9.8%) of 577 assessments (nurse judgement) |
1,079 (63.1%) of 1,711 assessments (Ramsay score) 479 (83%) of 577 assessments (nurse judgement) |
Ramsay score plus nurse assessment |
Adequate sedation defined as the achievement of the planned Ramsay score or nurse judgement as adequate |
|
Barrientos-Vega, et al., 2001 [29] |
Observational study of sedative drugs |
51 |
2% propofol (compared with historical cohort on 1% propofol -- not reported here) |
8 (15.6%) of 51 patients judged therapeutic failure on 2% propofol (inadequate level of sedation) |
Ramsay score |
4-5 |
|||
|
MacLaren, et al., 2007 [42] |
Observational study of sedative drugs |
40 |
Dexmedetomidine as adjunct to lorazepam/midazolam/propofol |
35% of patients with dexmedetomidine; 52% without |
12 (30%) patients with dexmedetomidine; 9 (23%) without |
4 (10%) patients with dexmedetomidine; 12 (30%) without |
65% of patients with dexmedetomidine; 48% without |
SAS |
3-4 |
|
Shehabi, et al., 2004 [24] |
Observational study of sedative drugs |
20 |
Dexmedetomidine with supplemental midazolam if required |
455 (33%) of 1,381 assessments |
97 (7%) of 1,381 assessments were Ramsay level 6 |
137 (10%) of 1,381 assessments were Ramsay level 1 |
926 (67%) of 1,381 |
Ramsay |
2-4 |
|
Sackey, et al., 2004 [51] |
RCT of sedation devices |
40 |
Isoflurane using AnaConDa |
46% of time; nursing staff estimate 11% of time |
44% of time |
2% of time |
54% of time; nursing staff estimate 89% of time |
Bloomsbury scale |
- 1 to +1 |
|
IV midazolam |
41%; nursing staff estimate 13% of time |
37% of time |
4% of time |
59% of time; nursing staff estimate 87% of time |
|||||
|
Walsh, et al., 2008 [52] |
Observational study of sedation devices |
30 |
All sedated patients |
137 (32.9%) of 416 assessments (Ramsay score 5-6) |
5 (1.2%) of 416 assessments (Ramsay score 1) |
Entropy Module/Modified Ramsay scale |
None stated. Refers to guidelines suggesting 2-3 is adequate and heavy/over-sedated is 5-6. |
||
|
Hernández-Gancedo, et al., 2006 [28] |
Observational study of sedation scales |
50 |
44% (66 cases) -- Ramsay level 6 |
25% (38 cases) |
Ramsay, Observer's Assessment of Alertness and Sedation |
Ramsay 3-4 |
|||
|
Roustan, et al., 2005 [27] |
Observational study of sedation scales |
40 |
All sedated patients -- treated with midazolam and morphine |
93 (61.6%) of 151 records |
19 (12.6%) of 151 records |
Ramsay, Comfort score, EEG |
Ramsay 3-4 |
||
|
McMurray, et al., 2004 [38] |
Observational study of sedation scales |
122 |
Propofol-containing regimens |
15.6% of time |
Mean 5.0% of time (SD 12.7) |
Mean 10.6% of time (SD 14.5) |
Mean 84.4% of time (SD 18.0) |
Modified Ramsay |
Individual to each patient |
|
Detriche, et al., 1999 [53] |
Before-after study of introduction of sedation protocol |
55 |
Before |
20 (30%) of 67 assessment days |
Brussels sedation scale |
3-4 |
|||
|
After protocol introduction |
9 (12%) of 77 assessment days |
||||||||
|
Costa, et al., 1994 [54] |
RCT of controlled and empirical sedation |
40 |
Controlled |
17% of time |
83% of time |
Ramsay, and Glasgow coma scale modified by Cook and Palma |
|||
|
Empirical |
65% of time |
35% of time |
|||||||
|
MacLaren, et al., 2000 [35] |
Before-after comparison of sedation protocol |
158 |
Before |
22.4% (experience of anxiety or pain) |
Modified Ramsay |
4 |
|||
|
After |
11.0% (P < 0.001) |
||||||||
|
Tallgren, et al., 2006 [3] |
Before-after comparison of sedation protocol |
53 |
Before reinforcement |
Median Ramsay level was 4 during the day and 5 at night, in contrast to the study's stated aim of Ramsay level 2-3 during the day and 3-4 at night |
Ramsay |
||||
|
After reinforcement |
Median Ramsay level was 4 during the day and 5 at night, in contrast to the study's stated aim of Ramsay level 2-3 during the day and 3-4 at night |
||||||||
|
Observational study |
250 |
50% of patients had MAAS 0-2 (although 2 was target for study, 0-1 could be viewed as over-sedated) |
0% |
39% of patients achieved MAAS 3 in ventilated period |
MAAS |
Stated 2-3 but results reported for patients achieving 3 |
|||
|
|
|||||||||
|
EEG, electroencephalogram; ICU, intensive care unit; IV, intravenous; MAAS, Motor Activity Assessment Scale; RASS, Richmond Agitation-Sedation Scale; RCT, randomised controlled trial; SAS, Riker Sedation-Agitation Scale; SD, standard deviation; SIMV, synchronised intermittent mandatory ventilation. |
|||||||||
|
Jackson et al. Critical Care 2009 13:R204 doi:10.1186/cc8212 |
|||||||||
