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SPCI - Sociedade Portuguesa de Cuidados Intensivos

Revista Brasileira de Terapia Intensiva

AMIB - Associação de Medicina Intensiva Brasileira

OFFICIAL JOURNAL OF THE ASSOCIAÇÃO BRASILEIRA DE MEDICINA INTENSIVA AND THE SOCIEDADE PORTUGUESA DE CUIDADOS INTENSIVOS

ISSN: 0103-507X
Online ISSN: 1982-4335

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Veiga VC, Rojas SSO. Analgossedação e delirium em unidades de terapia intensiva brasileiras: como estamos na atualidade. Estudo ASDUTI. Rev Bras Ter Intensiva. 2018;30(2):246-248

 

 

2018;30(2):246-248
LETTERS TO THE EDITOR

10.5935/0103-507X.20180025

Analgosedation and delirium in intensive care units in Brazil: current status. ASDUTI study

Analgossedação e delirium em unidades de terapia intensiva brasileiras: como estamos na atualidade. Estudo ASDUTI

Viviane Cordeiro Veiga,, Salomón Soriano Ordinola Rojas

Neurological Intensive Care Unit, Hospital Beneficência Portuguesa de São Paulo - São Paulo (SP), Brazil; and Neurocritical Care Committee, Associação de Medicina Intensiva Brasileira (AMIB) - São Paulo (SP), Brazil.
Neurocritical Care Committee, Associação de Medicina Intensiva Brasileira (AMIB) - São Paulo (SP), Brazil.
Neurological Intensive Care Unit, Hospital Beneficência Portuguesa de São Paulo - São Paulo (SP), Brazil.

Conflicts of Interest: None.

Submitted on November 21, 2017
Accepted on December 03, 2017

Corresponding author: Viviane Cordeiro Veiga, Hospital BP - A Beneficência Portuguesa de São Paulo, Rua Martiniano de Carvalho, 864, conjunto 310 - Bela Vista, Zip code: 01321-000 - São Paulo (SP), Brasil, E-mail: dveiga@uol.com.br

 

To the Editor,

The adequate management of analgosedation and delirium is related to better outcomes in intensive care units.(1-3) The objective of this study is to evaluate the current status of the management of analgosedation and delirium in Brazil.

A questionnaire was developed on the SurveyMonkey® (Appendix 1) digital platform with 15 multiple-choice questions, among which some of the questions had only one option while others could have more than one option. The instrument was made available from November 2015 to February 2016. The method of selection of professionals for data collection included several multiprofessional categories.

A total of 410 professionals answered the questionnaire. Of these, 48.78% worked in public hospitals, 33.41% in private hospitals, and 17.80% in philanthropic hospitals. A total of 81.23% professionals worked in an intensive care unit (ICU) with a general profile.

The results indicated that 59.50% of the respondents used analgosedation protocols in their services, which is slightly higher than that found by Salluh et al.(4) but lower than that found by Patel et al.,(5) wherein 71% of the study participants used analgosedation protocols.

Among the study participants, 234 (59.24%) reported performing a systematic evaluation of pain in their ICU. Pain was evaluated up to twice a day for 35.48% of the sample, and the nurse and physician were responsible for these evaluations in most cases (51.34% and 42.78%, respectively). Sedation was evaluated up to twice a day in 49.35% of cases.

With respect to the management of sedation, validated tools (Richmond Agitation-Sedation Scale - RASS and Sedation-Agitation Scale - SAS) were used by 72.91% of the respondents, and the most commonly used sedation strategies were daily awakening (60.11%) and targeted sedation (23.94%). There was a high rate of use of validated tools (12%) compared with national data from 2009.(4)

The availability of analgosedation in services and its incorporation in protocols was evaluated. Midazolam, fentanyl, propofol, and morphine were the most available drugs in the analyzed institutions. The first three drugs, in addition to dexmedetomidine, were the most used in institutional protocols. The use of these drugs is common despite recommendations to avoid the use of benzodiazepines in the choice of sedative drugs.(2)

A total of 44.68% of the respondents evaluated delirium systematically. Of these, 56.72% used the Confusion Assessment Method for the ICU (CAM-ICU), and 37.37% did not use a validated tool. In the study by Patel et al., 59% of respondents systematically assessed delirium.(5)

Of the total sample, 29.62% evaluated delirium daily, and 23.10% performed evaluations twice a day. Physicians and nurses conducted these evaluations in 64.07% and 26.05% of cases, respectively. Haloperidol was the drug of choice for managing hyperactive delirium for 72.13% of participants. In addition, 12.30% of respondents used dexmedetomidine, and 11.20% used antipsychotics (Table 1).

Table 1 - Characteristics of the assessment and management of analgosedation and delirium
  n (%)
Frequency of assessment of pain in the ICU  
    Once daily 52 (13.37)
    Twice daily 46 (11.83)
    Thrice daily 78 (20.05)
    Every 12 hours 40 (10.28)
    Every 2 hours 54 (13.88)
    Every hour 11 (2.83)
    None of the above 108 (27.76)
Professional performing pain assessment  
    Physician 160 (42.78)
    Nurse 192 (51.34)
    Physical therapist 3 (0.80)
    Another professional 19 (5.08)
Frequency of assessment of sedation in the ICU  
    Once daily 66 (17.14)
    Twice daily 82 (21.30)
    Thrice daily 69 (17.92)
    Every 12 hours 42 (10.91)
    Every 6 hours 33 (8.57)
    Every 2 hours 29 (7.53)
    Every hour 10 (2.60)
    None of the above 54 (14.03)
Tool used to assess sedation  
    RASS 269 (70.05)
    SAS 11 (2.86)
    Ramsay 78 (20.31)
    None 19 (4.95)
    Others 7 (1.82)
Strategy of sedation  
    Daily awakening 226 (60.11)
    Targeted sedation 90 (23.94)
    Intermittent sedation 25 (6.65)
    None 35 (9.31)
Tool used to assess delirium  
    CAM-ICU 211 (56.72)
    ICDSC 8 (2.15)
    Others 14 (3.76)
    None 139 (37.37)
Frequency of assessment of delirium  
    None 121 (32.88)
    Once daily 109 (29.62)
    Twice daily 85 (23.10)
    Thrice daily 31 (8.42)
    More than thrice daily 22 (5.98)
Professional assessing delirium  
    Physician 214 (64.07)
    Nurse 87 (26.05)
    Psychologist 21 (6.29)
    Another professional 12 (3.59)
Drug used to manage hyperactive delirium  
    Haloperidol 264 (72.13)
    Dexmedetomidine 45 (12.30)
    Antipsychotic drugs 41 (11.20)
    Others 7 (1.91)
    None 9 (2.46)

ICU - Intensive Care Unit; RASS - Richmond Agitation-Sedation Scale; SAS - Sedation-Agitation Scale; CAM-ICU - Confusion Assessment Method in an Intensive Care Unit; ICDSC - Intensive Care Delirium Screening Checklist.

Table 1 - Characteristics of the assessment and management of analgosedation and delirium

The limitations of the study were the lack of consideration of the geographical distribution of the ICUs of respondents, lack of differentiation of responses between public, private, and philanthropic hospitals, and lack of comparison of responses among multiprofessional teams.

In conclusion, this study reveals the need to advance the routines used in the management of analgosedation and delirium, despite consistent evidence for improved outcomes in the literature when the recommended protocols and strategies are used.

Viviane Cordeiro Veiga
Neurological Intensive Care Unit, Hospital Beneficência Portuguesa de São Paulo - São Paulo (SP), Brazil; and Neurocritical Care Committee, Associação de Medicina Intensiva Brasileira (AMIB) - São Paulo (SP), Brazil.
Salomón Soriano Ordinola Rojas
Neurological Intensive Care Unit, Hospital Beneficência Portuguesa de São Paulo - São Paulo (SP), Brazil.

Funding agency: AMIBNet; Associação de Medicina Intensiva Brasileira

REFERENCES

Jackson DL, Proudfoot CW, Cann KF, Walsh T. A systematic review of the impact of sedation practice in the ICU on resource use, costs and patient safety. Crit Care. 2010;14(2):R59. Link DOILink PubMed
Shehabi Y, Bellomo R, Mehta S, Riker R, Takala J. Intensive care sedation: the past, presente and the future. Crit Care. 2013;17(3):322. Link DOILink PubMed
Shinotsuka CR, Salluh JI. Percepções e práticas sobre delirium, sedação e analgesia em pacientes críticos: uma visão narrativa. Rev Bras Ter Intensiva. 2013;25(2):155-61. Link DOILink PubMed
Salluh JI, Dal-Pizzol F, Mello PV, Friedman G, Silva E, Teles JM, Lobo SM, Bozza FA, Soares M; Brazilian Research in Intensive Care Network. Delirium recognition and sedation practices in critically ill patients: a survey on the attitudes of 1015 Brazilian critical care physicians. J Crit Care. 2009;24(4):556-62. Link DOILink PubMed
Patel RP, Gambrell M, Speroff T, Scott TA, Pun BT, Okahashi J, et al. Delirium and sedation in the intensive care unit: survey of behaviors and attitudes of 1384 healthcare professionals. Crit Care Med. 2009;37(3):825-32. Link DOILink PubMed

Appendices

Appendix 1 - ASDUTI study questionnaire. Evaluation of analgosedation and delirium in intensive care units.
Institutional data:
Hospital profile:   (  ) public   (  ) private   (  ) philanthropic
Unit profile:   (  ) general   (  ) trauma   (  ) cardiologic   (  ) neurological   (  ) other
 
1. At your service, is there a protocol for analgesia and sedation?
(  ) Yes
(  ) No
 
2. Is there systematic pain assessment in your ICU?
(  ) Yes
(  ) No
 
3. How often is pain assessed at your ICU?
(  ) Once daily
(  ) Twice daily
(  ) Thrice daily
(  ) Every 12 hours
(  ) Every 2 hours
(  ) Every hour
(  ) None of the above
 
4. Which professional assesses pain in your unit?
(  ) Physician   (  ) Nurse   (  ) Physical therapist   (  ) Other professional
 
5. Is there systematic assessment of sedation in your ICU?
(  ) Yes
(  ) No
 
6. How many times is sedation assessed in your ICU?
(  ) Once daily
(  ) Twice daily
(  ) Thrice daily
(  ) Once every 12 hours
(  ) Once every 6 hours
(  ) Once every 2 hours
(  ) Once every hour
(  ) None of the above
 
7. Which tool is used to evaluate sedation in your unit?
(  ) Richmond Agitation-Sedation Scale (RASS)
(  ) Sedation-Agitation Scale (SAS)
(  ) Ramsay
(  ) None
(  ) Others
 
8. Which of these medications are AVAILABLE for use in your hospital? Check all that apply.
(  ) Midazolam   (  ) Morphine   (  ) Fentanyl   (  ) Remifentanil
(  ) Sufentanil   (  ) Alfentanil   (  ) Dexmedetomidine   (  ) Clonidine
(  ) Ketamine   (  ) Propofol
 
9. Which of these drugs are INCLUDED in your analgosedation PROTOCOL? Check all that apply.
(  ) Midazolam   (  ) Morphine   (  ) Fentanyl   (  ) Remifentanil   (  ) Sufentanil 
(  ) Alfentanil   (  ) Dexmedetomidine   (  ) Clonidine   (  ) Ketamine   (  ) Propofol
 
10. Which sedation strategy do you apply in your unit?
(  ) Intermittent sedation
(  ) Daily awakening
(  ) Targeted sedation
(  ) None of the above
 
11. Does your unit evaluate delirium systematically?
(  ) Yes
(  ) No
 
12. Which tool do you use to assess delirium?
(  ) Confusion Assessment Method in an Intensive Care Unit (CAM-ICU)
(  ) Intensive Care Delirium Screening Checklist (ICDSC)
(  ) Others
(  ) None
 
13. How many times a day is delirium evaluated in your unit?
(  ) None
(  ) Once daily
(  ) Twice daily
(  ) Thrice daily
(  ) More than thrice daily
 
14. Which professional assesses delirium in your ICU?
(  ) Physician   (  ) Nurse   (  ) Psychologist   (  ) Other professionals
 
15. Which drugs do you use for managing hyperactive delirium?
(  ) Haloperidol   (  ) Antipsychotics   (  ) Dexmedetomidine
(  ) Others   (  ) None
Appendix 1 - ASDUTI study questionnaire. Evaluation of analgosedation and delirium in intensive care units.

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