Elsevier

Journal of Critical Care

Volume 24, Issue 4, December 2009, Pages 556-562
Journal of Critical Care

Sedation
Delirium recognition and sedation practices in critically ill patients: A survey on the attitudes of 1015 Brazilian critical care physicians

https://doi.org/10.1016/j.jcrc.2009.04.004Get rights and content

Abstract

Purpose

The aim of the study was to characterize the practices of Brazilian ICU physicians toward sedation and delirium.

Materials and Methods

A cross-sectional survey was conducted among a convenience sample of critical care physicians between April and June 2008.

Results

One thousand fifteen critical care physicians responded. Sedation scoring systems were used by 893 (88.3%) of the respondents. The Ramsay and Richmond Agitation-Sedation Scale were used by 81.9% and 6.8% of the respondents, respectively. Most respondents did not discuss sedation targets (62.8%) or practice daily sedative interruption (68.3%) in most patients. More than half of the respondents (52.7%) used a sedation protocol, and the most used sedatives were midazolam (97.8%), fentanyl (91.5%), and propofol (55%). A significant rate of the respondents (42.7%) estimated that more than 25% of patients under mechanical ventilation have delirium, but 53.5% occasionally assessed patients for delirium. Thirteen percent used specific delirium scales, with the Confusion Assessment Method for intensive care unit (ICU) being the most applied. Delirium was often treated with haloperidol (88.1%); however, atypical antipsychotics (36.3%) and benzodiazepines (42.3%) were also used.

Conclusions

Despite the recent advances in knowledge of sedation and delirium, most of them are still not translated into clinical practice. Significant variation in practice is observed among ICU physicians and represents a potential target for future research and educational interventions.

Introduction

Critically ill patients frequently need invasive procedures and require several forms of advanced life support, especially mechanical ventilation (MV). Sedatives and analgesics are often used in mechanically ventilated patients to improve patient ventilator synchrony and to relieve anxiety and physical distress. However, in recent years, there is increasing evidence that excessive sedation is associated with longer duration of mechanical ventilation [1] and longer intensive care unit (ICU) length of stay [2]. Oversedation is associated with slower awakenings, more neurologic investigations for coma [2], and long-term neuropsychiatric dysfunction [3], [4], [5]. Delirium is a form of acute brain dysfunction that occurs in up to 80% of mechanically ventilated patients and is a strong predictor of adverse outcomes in critically ill patients [6]. Moreover, several neurologic events that occur in ICU patients maybe ascribed to specific sedation regimens [2], [7]. The use of benzodiazepines has been recently associated with the occurrence of transitioning delirium [8], [9] and the use of drug-regimens that are based on avoidance of benzodiazepines [8] or on the use of α-2 agonists [7] may result in increased delirium-free days. The Society of Critical Care Medicine (SCCM) guidelines for sedation and analgesia [1] recommends the use of sedation scales, daily sedative interruptions, and delirium monitoring for optimal patient care. However, it remains unclear how these recommendations have translated into clinical practice. In view of this increasing knowledge in the field, we conducted a national survey of Brazilian ICU physicians to determine the perceived use of sedation scoring systems; daily interruption and goal-directed sedation; and delirium assessment, monitoring, and treatment.

Section snippets

Survey development and administration

We conducted a Medline search of the literature on “sedation,” “delirium,” “mechanical ventilation,” and “ICU” to identify the most important aspects in the field that could facilitate the development of the questionnaire's items. We also surveyed the members of the Brazilian Research in Intensive Care Network steering committee to identify other potential domains of interest.

This resulted in a 3-part questionnaire that evaluated the respondents and related ICU profile (10 questions), sedation

Demographics

A total of 1015 critical care physicians responded to the survey. The main respondents' demographics and ICU characteristics are depicted in Table 1. We had responders from all geographic regions of the country, and every state was represented in our sample. Among all physicians who browsed the survey, 76% provided complete responses and had their results analyzed. Among the respondents, 539 (49.4%) were board-certified critical care physicians, whereas the remaining 552 (50.6%) had profession

Discussion

We conducted a national survey aiming to characterize the perceived attitudes of Brazilian ICU physicians toward diagnosis, monitoring, and pharmacologic interventions for delirium and sedation.

More than 5 years ago, the 2002 practice parameters for sedations and analgesia of the SCCM already highlighted the importance of sedation monitoring using specific scales and also regarding the choice of sedatives [1]. Moreover in recent years, several studies demonstrated that delirium is frequent in

Conclusion

In conclusion, this survey provides valuable data on the perceived attitudes of Brazilian ICU physicians regarding sedation and delirium. Although delirium is acknowledged by most respondents as a severe medical condition, few systematic tools are used in clinical practice for the evaluation and treatment of delirium. Moreover, although daily interruption of sedation is a well-known concept and sedation scales are often used by the respondents, insufficient effort is put into frequent

Acknowledgments

We thank Dr E. Wesley Ely and Dr Rina Patel for the helpful information for the construction of the survey. We also thank Dr Pratik Pandharipande for the critical reading of the manuscript.

Authors' contributions: JIFS, FP, and MS contributed to the study conception and design, carried out and participated in data analysis, and drafted the manuscript. FAB, GF, SML, ES, JMT, and PVM conceived the study, participated in its design and coordination, and helped to draft the manuscript. All authors

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