Most mechanically ventilated patients require analgesia and sedation. Adequate analgesia and sedation should ensure that the patient can receive intensive medical care without undue stress or pain 1. As with insufficient sedation, excessively deep sedation also may lead to increased morbidity, increased costs, and a prolonged stay in the intensive care unit (ICU) 234. Recent advances with drugs that are more controllable, better ventilation techniques and sedation strategies, and the use of scoring systems and sedation protocols enable optimization of sedation 156. However, the optimal sedation strategy remains a controversial issue at present. Despite controversies, a shift from deeper to lighter sedation, thereby maintaining the normal circadian rhythm, is emerging within the published literature 157.

Apart from sedation, emphasis should be placed on adequate monitoring of analgesia. Whipple and colleagues 8 have shown that 70% of patients admitted to an ICU recollected suffering pain. Regular review of pain scores followed by appropriate therapy leads to a reduction in morbidity and a reduction in duration of mechanical ventilation 9.

Soliman and colleagues 10 have shown that sedation practice and the use of differing scoring systems and guidelines are quite different between countries. In 2002, a national survey of analgesia and sedation practice in German ICUs was undertaken 11. The goal of the present study was to find out whether new trends or significant changes in ICU analgesia and sedation practice among mechanically ventilated patients in ICUs have emerged since the last survey 11 and the publication of national guidelines for analgesia and sedation practice in Germany in 2005 12. The major recommendations of the guidelines consist of the application of scores for analgesia and sedation, with a patient-oriented depth of sedation, implementation of written sedation protocols, application of short-acting drugs, and use of regional anesthesia techniques.

This study is a descriptive, comparative, multi-center follow-up study to the survey performed in 2002 11. The same address database was used as in the first study. In total, 254 general hospitals and 15 university hospitals were contacted. All ICUs were run by an anesthesiological department and include surgical and interdisciplinary adult ICUs. The survey was submitted to the chairmen of the departments up to four times in the period January to May 2006. The response rate was 82% and most of the forms were filled out by the head of the ICU. The questionnaire corresponded to the first questionnaire, although a few questions were added.

The response rate was 82% (214 out of 261). More than 90% of the ICUs that responded in 2002 also participated in this survey. At this rate of response, non-responder bias is insignificant 15. There was no significant difference to the 2002 survey response rate (82%). All data were entered into the analyses. In regard to general data (Table 1), there were significant differences in the number of ICU beds in university hospitals and in general hospitals (9 versus 10) and also in the number of patients treated annually (9,330 versus 1,000).

The goal of the present survey was to clarify whether a change has taken place in analgesia and sedation practice since the last survey in 2002 and after the publication of national practice guidelines on the subject 12. Underlying the same questionnaire as in 2002, we are able to compare and contrast our findings. The most striking results are the significantly increased use of sedation scales and written sedation protocols.

The RSS 16 was the scale most frequently used in the present survey, with only one institution employing the RASS 17. In recent reviews, Fraser and Rieker 1819 demonstrated that only the consistent use of a validated sedation scale led to a reduction in the duration of mechanical ventilation, as well as reduced length of ICU stay. Written sedation guidelines were used significantly more often in the present survey. Employment of sedation guidelines enables reductions in both duration of mechanical ventilation and use of intensive care time 20, with consequent savings in medical costs 21. However, as shown by Elliott and colleagues 22 and Andrews and colleagues 23, these positive changes are achieved only with sufficient training of the personnel involved and with adaptation of the guidelines to the local hospital environment. Meanwhile, a daily sedation break, as suggested by Kress and coworkers 2, is currently employed in one third of our surveyed hospitals. In addition, pain monitoring is increasingly performed. Chanques and colleagues 9 have pointed out that by monitoring and optimizing pain management, the number of nosocomial infections and the length of mechanical ventilation can be reduced. The use of analgesia and sedation scales, as well as the use of written guidelines, should result in avoidance of oversedation of patients, as described by Martin and colleagues 24.

As with the Danish follow-up questionnaire on sedation and analgesia in the ICU 25, a trend is being observed in Germany toward the application of analgesics and sedatives that are more controllable. For sedation periods of less than 72 hours, midazolam is used significantly less frequently than in 2002. Carson and colleagues 26 have shown the more favorable pharmacokinetics of propofol versus benzodiazepines. In terms of analgesics, the same development emerges. Fentanyl is used less frequently in all stages of sedation, but sufentanil is increasingly used. Remifentanil was applied more often for sedation periods of up to 24 hours, sedation for less than 72 hours, and during weaning. Breen and colleagues 27 and Muellejans and colleagues 28 have shown that using remifentanil in that way leads to a significantly shortened ventilation time compared with a control group. Ketamine (S) was more frequently used in the phases up to 24 hours and from 24 to 72 hours than in 2002. However, as has been shown by Ostermann and colleagues 29, there has been very little investigation of long-term use of ketamine sedation. Nevertheless, an important reason favoring the use of ketamine is the absence of a significant effect on bowel motility 30.

Epidural analgesia was performed more frequently in the phases of greater than 72 hours and during weaning than in the survey of 2002. As has been shown by Brodner and colleagues 31 and in the meta-analysis by Rodgers and colleagues 32, the perioperative use of epidural analgesia leads to both shortening of intensive care stay as well as lowering the incidence of cardiac and pulmonary complications. Thus, this approach of epidural analgesia is recommended in the German guidelines on analgesia and sedation in the ICU 12.

In total, two thirds (67%) of those taking part in the present survey reported changes in analgesia and sedation management since the last inquiry. Changes were induced by recent literature, scientific lectures, publication of national guidelines in 2005 12, and a change in departmental leadership. Nevertheless, this current survey merely demonstrates that knowledge regarding analgesia and sedation policy has changed. Whether a real change in practice has occurred at the patient's bedside cannot be stated with certainty. In the implementation of guidelines in health care, large barriers to change exist 33, and so all parties of interest must be involved and motivated in order to effect changes in the daily treatment routine 34. To evaluate actual analgesia and sedation practice, patient-centered investigations similar to those of Martin and colleagues 24 and Payen and colleagues 35 are needed.

These results show that changes in analgesia and sedation practice among intensive care patients have taken place by the time of this survey, which was conducted 4 years after the initial investigation and 1 year after the appearance of national guidelines. In summary, the increased use of scoring systems for pain severity and sedation depth, a daily sedation break, the implementation of protocols, and the use of more short-acting medications for analgesia and sedation conform to the guidelines on patient-oriented analgesia and sedation. Although we see some areas of improvement, further efforts are necessary to reach widespread implementation of the analgesia and sedation guidelines into practice. Further patient-centered studies are needed to determine the extent to which these changes translate into performance at the patient's bedside. As wide variations in sedation practice exist internationally 10, further national investigations are needed to improve national sedation and analgesia policies, and, in the long run, to yield international consensus.

• According to our 2006 follow-up survey of German intensive care units, the following changes have occurred since 2002:

∘ Increased use of scoring systems for pain severity and sedation depth.

∘ Use of more short-acting medications for analgesia and sedation.

∘ A trend toward conformity with the national guidelines on patient-oriented analgesia and sedation.

• Also according to our follow-up survey, a daily sedation break is currently employed in only 34% of the hospitals.

ICU = intensive care unit; RASS = Richmond agitation sedation scale; RSS = Ramsay sedation scale.

JM has been employed by GlaxoSmithKline (Uxbridge, Middlesex, UK) and B. Braun Melsungen AG (Melsungen, Germany) to present educational talks on therapy for analgesia and sedation and economics. The other authors declare that they have no competing or financial interests.

JM made substantial contributions to the conception, design, analysis and interpretation of data. MF was involved in drafting the article and revising it critically for important intellectual content. SS performed the acquisition, analysis and interpretation of data. MW participated in the design and coordination and helped to draft the manuscript. CS made substantial contributions to the conception, design, analysis and interpretation of data.

All authors read and approved the final manuscript.