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Effect of early mobilization on sedation practices in the neurosciences intensive care unit: A preimplementation and postimplementation evaluation

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Abstract

Introduction

The use of sedation and analgesia protocols, daily interruption of sedation, and early mobilization (EM) have been shown to decrease duration of mechanical ventilation and hospital length of stay (LOS).

Methods

A retrospective chart review was conducted during a 6-month premobilization (pre-EM) and 6-month postmobilization (post-EM) period. Patients older than 18 years who were admitted to the neurosciences intensive care unit (ICU) and mechanically ventilated for at least 24 hours without documentation of withdrawal of life support or brain death were included.

Results

Thirty-one pre-EM and 37 post-EM patients were included. Baseline demographics were similar with the exception of more ischemic stroke patients in the pre-EM group (P < .05). In the pre-EM and post-EM groups, patients received similar cumulative doses of propofol, dexmedetomidine, and benzodiazepines but higher median (interquartile range) doses of opioids (50.0 [13.8-165.0] vs 173.3 [41.2-463.2] μg of fentanyl equivalents [P < .05]) in the post-EM group. Neurosciences ICU LOS was 10 (6-19) and 13 (8-18) days, respectively (P = .188).

Conclusions

After implementation of an EM program, an increase in opioid use and no significant change in other sedatives were observed. Despite an increase in the amount of physical therapy and occupational therapy provided to patients, there was no change in hospital and ICU LOS or duration of mechanical ventilation.

Introduction

Sedative and analgesic medications are used in critical care medicine spanning a wide range of indications. Sedation practices have evolved greatly from an era of heavy sedation to practices that aim to minimize sedation. Landmark trials have demonstrated that daily sedation interruptions, spontaneous breathing trials, and protocolized sedation have resulted in decreased duration of mechanical ventilation and length of hospital and intensive care unit (ICU) stay [1], [2], [3]. With more patients surviving acute illnesses, considerations for long-term implications after ICU stays and outcomes such as delayed rehabilitation, irreversible neurologic deficits, neurocognitive disability, and weakness become prudent [4], [5], [6], [7], [8].

A previous trial in a medical and surgical ICU population demonstrated that after the implementation of an early mobilization (EM) protocol, patients experienced a decreased duration of delirium and an increased number of ventilator-free days [9]. Patients' sedation was managed using goal-directed sedation guided by the Richmond Assessment for Sedation Scale and underwent daily interruption of sedative agents. In this population, investigators found no change in sedative and analgesic requirements. The only study to date to investigate the effectiveness of increased mobility in a neurocritically ill population was a prospective trial comparing a preintervention and postintervention period after the implementation of a comprehensive mobility initiative [10]. The initiative consisted of a progressive mobility algorithm in a series of planned movements in a sequential manner starting with the patient's current mobility status. The goal of the initiative was to rehabilitate the patient to his or her functional baseline. This program included activities of moving patients out of bed and into a chair in the ICU and contained components to allow for patient-activated progression through the algorithm, noting that there are many physically functional neurointensive care patients, such as subarachnoid hemorrhage patients. Patients included in this study most frequently had a primary neurologic diagnosis of subarachnoid hemorrhage followed by acute ischemic stroke, presence of an intracranial tumor, and intracerebral hemorrhage. Results of this investigation revealed that after the implementation of the initiative, the ICU and hospital length of stay (LOS) shortened significantly, as did the rates of hospital-acquired infection and ventilator-associated pneumonia. Investigators did not detect a difference in falls or inadvertent line disconnections between the 2 periods, and ultimately, the authors concluded that EM in neurologically injured patients was safe and effective in decreasing hospital LOS and hospital-acquired infections.

Currently, the impact of an EM program on analgesia and sedation patterns has not been evaluated in a neurocritically ill population.

Progressive practices including EM are not universally applied to neurocritically ill patients due to fear of serious or sentinel adverse events given some of the unique characteristics of this patient population. However, subpopulations in the neurosciences ICU (NICU) may benefit from practices of EM despite their neurologic injury. This study sought to examine the effect of an EM protocol on sedation practices of critically ill, mechanically ventilated patients in the NICU.

Section snippets

Patients and methods

We hypothesized that there would be a decrease in sedative and analgesic use as well as a decrease in duration of mechanical ventilation and a decrease in hospital and ICU LOS after the implementation of an EM program.

Results

A total of 180 patients were screened for inclusion, of which 112 were not included (55 mechanically ventilated < 24 hours or in NICU < 24 hours, 30 documentation of withdrawal of life support or brain death, 14 mechanically ventilated outside the NICU, and 13 intubated or received a tracheostomy outside the NICU), resulting in 68 patients included in this analysis: 31 in the pre-EM group and 37 in the post-EM group. Baseline demographics are listed in Table 1. The median age was 61 years; most

Discussion

In this evaluation, we found that benzodiazepine, propofol, or dexmedetomidine use was unchanged after the implementation of an EM program, a finding previously observed in a medical and surgical population; however, we found a statistically significant increase in opioid use, a novel finding in critically ill patients [8]. The baseline characteristics of the included population were statistically similar with the exception of more patients being managed for an acute ischemic stroke in the

Conclusion

Implementation of an EM program in a heterogeneous neurocritically ill population resulted in a significant increase in opioid use with no significant change in benzodiazepine, propofol, or dexmedetomidine use, potentially due to differences in disease states between populations. Despite an increase in the number of PT and OT sessions provided to patients, there was no statistical difference in duration of mechanical ventilation or hospital or ICU LOS.

Acknowledgments

The authors thank Christine Kubin, Jennifer Michaels, and Kevin McConeghy for their assistance with statistical analysis of these data.

References (16)

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Robert Witcher, Lauren Stoerger, Amy L. Dzierba, Amy Silverstein, Axel Rosengart, Daniel Brodie, and Karen Berger declare that they have no conflicts of interest.

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