VAP Getting Started Kit - Safer Healthcare Now!

Safer Healthcare Now! Prevent Ventilator Associated Pneumonia Getting Started Kit
detail, and supporting evidence is presented in this section. The daily evaluation of readiness for
extubation involves two central issues: minimization of unnecessary sedation, and testing the
patient’s ability to assume unassisted breathing while still intubated.
Minimization of unnecessary sedation
Sedation has traditionally been prescribed in mechanically ventilated patients in order to
maintain comfort, decrease pain and anxiety, improve patient-ventilator interaction, help
maintain major organ homeostasis, facilitate nursing care by avoiding self-injury and to allow
safe completion of daily activities and procedures. Unfortunately, over sedation may lead to
unintended consequences, such as longer duration of mechanical ventilation and ICU stay,
decreased communication with patient with consequent decreased ability to evaluate the
patient for – among other items - delirium, weaning and readiness for extubation, as well as
ventilator-related complications)such as neuromuscular weakness and pneumonia. 58
In 2000, Kress reported the results of a randomized controlled trial in which 128 adult
mechanically ventilated patients sedated by continuous IV infusion received either daily
interruption of sedation (irrespective of clinical state) or sedation interruption at the clinician’s
discretion. 59 Interruption was considered complete if the patient could perform 3 of 4 items on
command: open eyes, squeeze hands, lift head and protrude tongue. Daily sedation interruption
was associated with a marked and highly significant reduction in time on mechanical ventilation
from 7.3 days to 4.9 days (p=0.004). Schweickert et al performed a post-hoc analysis of the
Kress trial and found that patients undergoing spontaneous awakening trials via daily
interruption of sedative infusions experienced significantly less complications associated with
mechanical ventilation (VAP, upper gastrointestinal haemorrhage, bacteremia, barotrauma,
venous thromboembolic disease, cholestasis or sinusitis requiring surgical intervention) than in
those subjected to conventional sedation techniques (2.8% vs. 6.2%, p =.04). 60 In addition, these
patients had a reduced ICU length of stay and were not at risk for worse psychological outcomes
(anxiety, inability to cope with pain) after critical illness compared with conventional
therapies. 61
In an important proof-of-concept study by Strom et al showed that a no-sedation approach in
mechanically ventilated ICU patients is associated with an increase in days without ventilation. 62
In reality, as the intervention (no sedation) group was administered morphine as required, the
true concept demonstrated was rather that a conservative approach of less sedation does not
appear to cause harm in critically ill mechanically ventilated patients. Three caveats for this
study are 1) the intervention group (“no” sedation) had a greater incidence of delirium, 2) the
trial utilized more than usual resources, i.e. 1:1 patient: nurse ratios for all patients, 3) the trial
was a single center study. A multicentre study is required to ascertain the reproducibility of
these findings. In an observational study of 335 patients admitted to a mixed medical-surgical
ICU, Salgado observed that minimal use of continuous sedation (42% of patients received some
sedation, and only 10% of patients received sedation for >24 hours; 20% of ventilator hours were
accompanied by a continuous sedative infusion) was feasible without apparent adverse effects
(e.g. self-extubation requiring re-intubation). 63
Interventional studies assessing the effect of implementing an ICU sedation protocol alone have
provided inconsistent outcomes with respect to ventilator and ICU days, incidence of VAP and
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