Actualización en sedación octubre 2014, WHAT´S NEW ON SEDATION IN ICU
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WHAT'S NEW IN SEDATION IN ICU ACTUALIZACIÓN EN SEDACIÓN
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Actualización en sedación octubre 2014, WHAT´S NEW ON SEDATION IN ICU
- 1. CICLO DE FORMACIÓN CONTINUA UNIDAD DE CUIDADOS INTENSIVOS ACTUALIZACIÓN EN SEDACIÓN Juan Pablo González V. Medicina de Urgencias USACH-HRR Tutor: Dra. Daniela Soto Medicina Interna UCI HRR
- 2. RINALDO BELLOMO ¿Cual es el futuro de los cuidados intensivos? “PRIMUN NON NOCERE”
- 3. PUNTOS A TRATAR • CONCEPTOS • DROGAS MÁS UTILIZADAS • EVIDENCIA • OTRA EXPERIENCIA • NUESTRO PROTOCOLO • CONCLUSIONES
- 4. CONCEPTOS SEDACIÓN EN CUIDADOS INTENSIVOS • ANSIEDAD – INCOMODIDAD • FACILITAR PROCEDIMIENTOS (ASPIRACIÓN - PUNCIONES) • DISMINUIR CONSUMO DE OXÍGENO • EVENTOS: EXTUBACIÓN ACCIDENTAL
- 5. DELIRIUM CONCEPTOS • EL DELIRIUM MATA (A) • EL DELIRIUM AUMENTA EL DETERIORO COGNITIVO (B) • EL DELIRIUM AUMENTA LOS DÍAS DE HOSPITALIZACIÓN (A) • EL DELIRIUM AUMENTA LOS COSTOS Barr J, Fraser G. Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit. Crit Care Med. 2013 Jan;41(1):263-306.
- 6. CONCEPTOS INTERRUPCIÓN DIARIA DE SEDACIÓN Y PROTOCOLOS MENOS DÍAS ESTADÍA MENOS DÍAS VM Kress JP et al. Daily interruption of sedative infusions in critically ill patients undergoing mechanical ventilation. N Engl J Med 2000, 342:1471-1477. Brook AD et al. Effect of a nursing implemented sedation protocol on the duration of mechanical ventilation. Crit Care Med 1999, 27:2609-2615
- 7. CONCEPTOS SOBRESEDACIÓN MAYOR MORTALIDAD Girard TD et al. Efficacy and safety of a paired sedation and ventilator weaning protocol for mechanically ventilated patients in intensive care (Awakening and Breathing Controlled trial: a randomised controlled trial. Lancet 2008;371:126–134. Shehabi Y, Bellomo R et al. Sedation Practice in Intensive Care Evaluation (SPICE) Study Investigators; ANZICS Clinical Trials Group. Early intensive care sedation predicts long term mortality in ventilated critically ill patients. Am J Respir Crit Care Med 2012;186:724–731 Shehabi Y, Chan L et al. Sedation Practice in Intensive Care Evaluation (SPICE) Study Group investigators. Sedation depth and long-term mortality in mechanically ventilated critically ill adults: a prospective longitudinal multicentre cohort study. Intensive Care Med 2013;39:910–918
- 8. MIDAZOLAM DROGAS • SINDROME DE DESCONTINUACIÓN • RECUPERACIÓN RETARDADA POR ACUMULACIÓN (FALLA RENAL) Hughes MA et al. Context-sensitive half-time in multicompartment pharmacokinetic models for intravenous anesthetic drugs. Anesthesiology 1992;76:334–341
- 9. LORAZEPAM – MIDAZOLAM DROGAS Factores de riesgo independientes para DELIRIUM Pandharipande PP, Pun BT, et al. Effect of sedation with dexmedetomidine vs lorazepam on acute brain dysfunction in mechanically ventilated patients: the MENDS randomized controlled trial. JAMA 2007;298:2644–2653. Pisani MA, Murphy TE, et al. Benzodiazepine and opioid use and the duration of intensive care unit delirium in an older population. Crit Care Med 2009;37:177–183 Pandharipande P et al. Lorazepam is an independent risk factor for transitioning to delirium in intensive care unit patients. Anesthesiology 2006;104:21–26.
- 10. BENZODIACEPINAS DROGAS PEORES RESULTADOS : SOBRESEDACIÓN, DELIRIUM, RETRASO DE EXTUBACIÓN, ESTADÍAS EN UCI PROLONGADAS Y COSTOSAS Breen D, Karabinis A. Decreased duration of mechanical ventilation when comparing analgesia-based sedation using remifentanil with standard hypnotic-based sedation for up to 10 days in intensive care unit patients: a randomised trial. Crit Care 2005. Pandharipande, et al. Effect of sedation with dexmedetomidine vs lorazepam on acute brain dysfunction in mechanically ventilated patients: the MENDS randomized controlled trial. JAMA 2007;298:2644–2653. Carson SS, et al. A randomized trial of intermittent lorazepam versus propofol with daily interruption in mechanically ventilated patients. Crit Care Med 2006; 34:1326–1332.
- 11. PROPOFOL DROGAS • EFECTOS DOSIS DEPENDIENTES • RECUPERACIÓN MÁS RAPIDA, SIN ACUMULACIÓN • HIPERTRIGLICERIDEMIA • DEPRESIÓN CARDIOVASCULAR • SD DE INFUSIÓN DE PROPOFOL • MAYOR COSTO
- 12. MODELO PK MULTICOMPARTAMENTAL DROGAS Hughes MA et al. Context-sensitive half-time in multicompartment pharmacokinetic models for intravenous anesthetic drugs. Anesthesiology 1992;76:334–341
- 13. DROGAS Sanders RD et al. Benzodiazepine augmented g-amino-butyric acid signaling increases mortality from pneumonia in mice. Crit Care Med 2013;41:1627–1636.
- 14. DROGAS BENZODIACEPINAS EFECTOS INMUNOMODULADORES ESTIMULACIÓN rGABA Producción citokinas Fagocitosis bacteriana Obiora E, Sanders RD et al. The impact of benzodiazepines on occurrence of pneumonia and mortality from pneumonia: a nested case-control and survival analysis in a population based cohort. Thorax 2013;68:163–170. Sanders RD et al. Benzodiazepine augmented g-amino-butyric acid signaling increases mortality from pneumonia in mice. Crit Care Med 2013;41:1627–1636.
- 15. Dexmedetomedina DROGAS • α2-AGONISTA • MECANISMO DE ACCIÓN UNICO • SEDANTE – ANALGESICO – SIMPATICOLÍTICO • HIPOTENSIÓN • BRADICARDIA Myatra et al. Dexmedetomidine: Toward a paradigm shift in ICU sedation. Indian J Crit Care Med. May 2014; 18(5): 271–272.
- 16. PUNTOS CLAVE • EXISTE UNA ACTIVA DISCUSIÓN SOBRE LA SEDACIÓN EN UCI – TEMA NO ACABADO • EL DELIRIUM DAÑA A LOS PACIENTES • HAY EVIDENCIA DE QUE LAS BENZODIACEPINAS POR DIVERSOS MECANISMOS PODRÍAN SER DELETÉREAS
- 17. EVIDENCIA American College of Critical Care Medicine Crit Care Med. 2013 Jan;41(1):263-306
- 18. EVIDENCIA EVIDENCIA “SE SUGIERE PREFERIR NO BENZODIAZEPINICOS PARA SEDACIÓN PARA MEJORAR RESULTADOS EN PACIENTES ADULTOS EN VENTILACIÓN MECANICA” (2B)
- 20. EVIDENCIA EVIDENCIA Lonardo NW et al. Propofol is associated with favorable outcomes compared to benzodiazepines in ventilated intensive care unit patients. Am J Respir Crit Care Med 2014;189: 1383–1394.
- 21. EVIDENCIA • BASE DE DATOS IMPACT • RETROSPECTIVO, COHORTE • PAREAMIENTO POR PROPENSIÓN Lonardo NW et al. Propofol is associated with favorable outcomes compared to benzodiazepines in ventilated intensive care unit patients. Am J Respir Crit Care Med 2014;189: 1383–1394.
- 22. EVIDENCIA • VENTILACIÓN MECANICA • Analisis pareado 1:1 Infusión contínua sedante único PROPOFOL VS MIDAZOLAM (2250 c/u) PROPOFOL VS LORAZEPAM (1054 c/u) Lonardo NW et al. Propofol is associated with favorable outcomes compared to benzodiazepines in ventilated intensive care unit patients. Am J Respir Crit Care Med 2014;189: 1383–1394.
- 23. MORTALIDAD EVIDENCIA MIDAZOLAM VS PROPOFOL Lonardo NW et al. Propofol is associated with favorable outcomes compared to benzodiazepines in ventilated intensive care unit patients. Am J Respir Crit Care Med 2014;189: 1383–1394.
- 24. MORTALIDAD – TRAQUEOSTOMÍA NEUMONIA EVIDENCIA LORAZEPAM VS PROPOFOL Lonardo NW et al. Propofol is associated with favorable outcomes compared to benzodiazepines in ventilated intensive care unit patients. Am J Respir Crit Care Med 2014;189: 1383–1394.
- 25. ALTA UCI MUERTE PROPOFOL MIDAZOLAM MIDAZOLAM PROPOFOL
- 26. ALTA UCI MUERTE PROPOFOL LORAZEPAM LORAZEPAM PROPOFOL
- 27. DEPENDENCIA DE VENTILACIÓN PROPOFOL MDZ P EVIDENCIA WEANING (+) (DIA 28) 84,4% 75.1% < 0,001 PROPOFOL LRZ P WEANING (+) (DIA 28) 84,3% 78,8% < 0,001 Lonardo NW et al. Propofol is associated with favorable outcomes compared to benzodiazepines in ventilated intensive care unit patients. Am J Respir Crit Care Med 2014;189: 1383–1394.
- 28. EVIDENCIA ESTADÍA ICU PROPOFOL MDZ P ALTA DE UCI (DIA 28) 78,9% 69,5% < 0,001 PROPOFOL MDZ P ALTA DE UCI (DIA 28) 78,9% 69,5% < 0,001 Lonardo NW et al. Propofol is associated with favorable outcomes compared to benzodiazepines in ventilated intensive care unit patients. Am J Respir Crit Care Med 2014;189: 1383–1394.
- 29. NEUMONIA PROPOFOL LRZP P EVIDENCIA NEUMONIA 7,9% 12,7% < 0,001 ASOCIADA VM Lonardo NW et al. Propofol is associated with favorable outcomes compared to benzodiazepines in ventilated intensive care unit patients. Am J Respir Crit Care Med 2014;189: 1383–1394.
- 30. PUNTOS CLAVE DEL ESTUDIO EVIDENCIA • EL USO DE BENZODIAZEPINAS PARA SEDACIÓN EN UCI PODRÍA GENERAR PEORES RESULTADOS COMPARADO CON PROPOFOL • EN MORTALIDAD, TIEMPO DE VM, TIEMPO DE ESTADÍA, NECESIDAD DE TRAUEOSTOMÍA Y NEUMONIA AVM Lonardo NW et al. Propofol is associated with favorable outcomes compared to benzodiazepines in ventilated intensive care unit patients. Am J Respir Crit Care Med 2014;189: 1383–1394.
- 31. EVIDENCIA
- 32. EVIDENCIA • UN CENTRO, RANDOMIZADO, ABIERTO West China Hospital of Sichuan University Zhou et al. Midazolam and propofol used alone or sequentially for long-term sedation in critically ill, mechanically ventilated patients: a prospective, randomized study. Critical Care 2014, 18:R122
- 33. TRES GRUPOS FENTANILO Bolo 1 to 2 μg/kg BIC 1 to 2 μg/kg/hr INTERRUPCIONES DIARIAS TODOS + MIDAZOLAM (M) PROPOFOL (P) MIDAZOLAM-PROPOFOL (M-P) EVIDENCIA
- 34. EVIDENCIA 1. GRUPO MIDAZOLAM Bolo 0.03 - 0.30 mg/kg BIC 0.04 - 0.20 mg/kg/hr 2. GRUPO PROPOFOL Bolo 0.50 - 3mg/kg BIC 0.50 - 3 mg/kg/hr Zhou et al. Midazolam and propofol used alone or sequentially for long-term sedation in critically ill, mechanically ventilated patients: a prospective, randomized study. Critical Care 2014, 18:R122
- 35. EVIDENCIA EVIDENCIA GRUPO MIDAZOLAM - PROPOFOL PRIMERO Midazolam LUEGO: Propofol CRITERIOS DE CAMBIO: Pa O2 > 60 mmHg FiO2 < 50% PEEP < 10 ESTABILIDAD HEMODINAMICA: NO ISQUEMIA MIOCARDICA NI HIPOTENSIÓN Dobuta < 5 μg/kg/min Norepinefrina ≤2 μg/min Zhou et al. Midazolam and propofol used alone or sequentially for long-term sedation in critically ill, mechanically ventilated patients: a prospective, randomized study. Critical Care 2014, 18:R122
- 36. EVIDENCIA EVIDENCIA RESULTADOS Zhou et al. Midazolam and propofol used alone or sequentially for long-term sedation in critically ill, mechanically ventilated patients: a prospective, randomized study. Critical Care 2014, 18:R122
- 37. EVIDENCIA EVIDENCIA COSTOS Zhou et al. Midazolam and propofol used alone or sequentially for long-term sedation in critically ill, mechanically ventilated patients: a prospective, randomized study. Critical Care 2014, 18:R122
- 38. RECUERDOS EEVVIDIEDNECNIACIA Zhou et al. Midazolam and propofol used alone or sequentially for long-term sedation in critically ill, mechanically ventilated patients: a prospective, randomized study. Critical Care 2014, 18:R122
- 39. PUNTOS CLAVE DEL ESTUDIO EVIDENCIA • UN PROTOCOLO COMBINADO DE SEDACIÓN CON MIDAZOLAM – PROPOFOL PODRÍA TENER MEJORES RESULTADOS EN UCI • EN TIEMPO DE ESTADÍA, TIEMPO DE VENTILACIÓN MECÁNICA, COSTOS Y CANTIDAD DE RECUERDOS TRAUMÁTICOS Zhou et al. Midazolam and propofol used alone or sequentially for long-term sedation in critically ill, mechanically ventilated patients: a prospective, randomized study. Critical Care 2014, 18:R122
- 40. OTRA EXPERIENCIA
- 41. NUESTRO PROTOCOLO • Escasa adherencia ENCUESTA ¿Por qué no usa el protocolo de sedación? Los residentes no lo indican Se inicia y después es cambiado por el residente No se indica por escalón de sedación Porque no sirve – dosis muy bajas – respuesta inadecuada Nunca se a discutido ni actualizado Dosis se calculan por pero estimado y no real
- 42. CONCLUSIONES • LA MEJOR ESTRATEGIA DE SEDACIÓN EN UCI ES UN TEMA EN DISCUSIÓN • EXISTE EXTENSA EVIDENCIA EL USO DE BENZODIAZEPINAS PODRÍA SER DELETÉREO, INCLUSO CON EFECTO EN MORTALIDAD • PROPOFOL PARECE SER UNA BUENA ALTERNATIVA
- 43. CONCLUSIONES • EL USO DE UN PROTOCOLO COMBINADO PODRÍA MINIMIZAR EL RIESGO DE LAS BZD Y GENERAR MEJORES RESUTADOS CLÍNICOS Y ECONÓMICOS • HAY POCA ADHERENCIA A NUESTRO PROTOCOLO. ¿SERÁ MOMENTO DE ANALIZAR EL TEMA?
Editor's Notes
- Kress JP, Pohlman AS, O’Connor MF, Hall JB: Daily interruption of sedative infusions in critically ill patients undergoing mechanical ventilation. N Engl J Med 2000, 342:1471-1477. 5. Brook AD, Ahrens TS, Schaiff R, Prentice D, Sherman G, Shannon W, Kollef MH: Eff ect of a nursing implemented sedation protocol on the duration of mechanical ventilation. Crit Care Med 1999, 27:2609-2615
- 10. Girard TD, Kress JP, Fuchs BD, Thomason JW, Schweickert WD, Pun BT, Taichman DB, Dunn JG, Pohlman AS, Kinniry PA, et al. Efficacy and safety of a paired sedation and ventilator weaning protocol for mechanically ventilated patients in intensive care (Awakening and Breathing Controlled trial): a randomised controlled trial. Lancet 2008;371:126–134. 11. Shehabi Y, Bellomo R, Reade MC, Bailey M, Bass F, Howe B, McArthur C, Seppelt IM, Webb S, Weisbrodt L; Sedation Practice in Intensive Care Evaluation (SPICE) Study Investigators; ANZICS Clinical Trials Group. Early intensive care sedation predicts long-term mortality in ventilated critically ill patients. Am J Respir Crit Care Med 2012;186:724–731. 12. Shehabi Y, Chan L, Kadiman S, Alias A, Ismail WN, Tan MA, Khoo TM, Ali SB, Saman MA, Shaltut A, et al.; Sedation Practice in Intensive Care Evaluation (SPICE) Study Group investigators. Sedation depth and long-term mortality in mechanically ventilated critically ill adults: a prospective longitudinal multicentre cohort study. Intensive Care Med 2013;39:910–918.
- Pandharipande PP, Pun BT, Herr DL, Maze M, Girard TD, Miller RR, Shintani AK, Thompson JL, Jackson JC, Deppen SA, et al. Effect of sedation with dexmedetomidine vs lorazepam on acute brain dysfunction in mechanically ventilated patients: the MENDS randomized controlled trial. JAMA 2007;298:2644–2653. Pisani MA, Murphy TE, Araujo KL, Slattum P, Van Ness PH, Inouye SK. Benzodiazepine and opioid use and the duration of intensive care unit delirium in an older population. Crit Care Med 2009;37:177–183. 14. Pandharipande P, Shintani A, Peterson J, Pun BT, Wilkinson GR, Dittus RS, Bernard GR, Ely EW. Lorazepam is an independent risk factor for transitioning to delirium in intensive care unit patients. Anesthesiology 2006;104:21–26. 15. Ely EW, Shintani A, Truman B, Speroff T, Gordon SM, Harrell FE Jr, Inouye SK, Bernard GR, Dittus RS. Delirium as a predictor of mortality in mechanically ventilated patients in the intensive care unit. JAMA 2004;291:1753–1762. 16. Shehabi Y, Riker RR, Bokesch PM, Wisemandle W, Shintani A, Ely EW; SEDCOM (Safety and Efficacy of Dexmedetomidine Compared With Midazolam) Study Group. Delirium duration and mortality in lightly sedated, mechanically ventilated intensive care patients. Crit Care Med 2010;38:2311–2318. 17. Pisani MA, Kong SY, Kasl SV, Murphy TE, Araujo KL, Van Ness PH. Days of delirium are associated with 1-year mortality in an older intensive care unit population. Am J Respir Crit Care Med 2009;180:1092–1097
- Carson SS, Kress JP, Rodgers JE, Vinayak A, Campbell-Bright S, Levitt J, Bourdet S, Ivanova A, Henderson AG, Pohlman A, et al. A randomized trial of intermittent lorazepam versus propofol with daily interruption in mechanically ventilated patients. Crit Care Med 2006; 34:1326–1332. 3. Pandharipande PP, Pun BT, Herr DL, Maze M, Girard TD, Miller RR, Shintani AK, Thompson JL, Jackson JC, Deppen SA, et al. Effect of sedation with dexmedetomidine vs lorazepam on acute brain dysfunction in mechanically ventilated patients: the MENDS randomized controlled trial. JAMA 2007;298:2644–2653. 4. Breen D, Karabinis A, Malbrain M, Morais R, Albrecht S, Jarnvig IL, Parkinson P, Kirkham AJ. Decreased duration of mechanical ventilation when comparing analgesia-based sedation using remifentanil with standard hypnotic-based sedation for up to 10 days in intensive care unit patients: a randomised trial [ISRCTN47583497]. Crit Care 2005;9:R200–R210. (ISRCTN47583497).
- Hughes MA, Glass PS, Jacobs JR. Context-sensitive half-time in multicompartment pharmacokinetic models for intravenous anesthetic drugs. Anesthesiology 1992;76:334–341. Midazolam, for example, has a significantly longer context-sensitive half-time than propofol (9).
- recent studies suggest that benzodiazepines have immunomodulatory effects that may be deleterious to patients with life-threatening infections. Animal research, for example, revealed critical impairments in immune function, including cytokine production and bacterial phagocytosis and killing, in mice treated with a benzodiazepine (19). These changes resulted from benzodiazepine stimulation of GABAA receptors expressed on immune cells and led to increased mortality and bacterial load from pneumococcal pneumonia. Additionally, observational and randomized studies of humans have noted worse infection-related outcomes in patients who received benzodiazepines 3. Pandharipande PP, Pun BT, Herr DL, Maze M, Girard TD, Miller RR, Shintani AK, Thompson JL, Jackson JC, Deppen SA, et al. Effect of sedation with dexmedetomidine vs lorazepam on acute brain dysfunction in mechanically ventilated patients: the MENDS randomized controlled trial. JAMA 2007;298:2644–2653. 19. Sanders RD, Godlee A, Fujimori T, Goulding J, Xin G, Salek-Ardakani S, Snelgrove RJ, Ma D, Maze M, Hussell T. Benzodiazepine augmented g-amino-butyric acid signaling increases mortality from pneumonia in mice. Crit Care Med 2013;41:1627–1636. 20. Obiora E, Hubbard R, Sanders RD, Myles PR. The impact of benzodiazepines on occurrence of pneumonia and mortality from pneumonia: a nested case-control and survival analysis in a population-based cohort. Thorax 2013;68:163–170. 21. Pandharipande PP, Sanders RD, Girard TD, McGrane S, Thompson JL, Shintani AK, Herr DL, Maze M, Ely EW; MENDS investigators. Effect of dexmedetomidine versus lorazepam on outcome in patients with sepsis: an a priori-designed analysis of the MENDS randomized controlled trial. Crit Care 2010;14:R38.
- recent studies suggest that benzodiazepines have immunomodulatory effects that may be deleterious to patients with life-threatening infections. Animal research, for example, revealed critical impairments in immune function, including cytokine production and bacterial phagocytosis and killing, in mice treated with a benzodiazepine (19). These changes resulted from benzodiazepine stimulation of GABAA receptors expressed on immune cells and led to increased mortality and bacterial load from pneumococcal pneumonia. Additionally, observational and randomized studies of humans have noted worse infection-related outcomes in patients who received benzodiazepines 3. Pandharipande PP, Pun BT, Herr DL, Maze M, Girard TD, Miller RR, Shintani AK, Thompson JL, Jackson JC, Deppen SA, et al. Effect of sedation with dexmedetomidine vs lorazepam on acute brain dysfunction in mechanically ventilated patients: the MENDS randomized controlled trial. JAMA 2007;298:2644–2653. 19. Sanders RD, Godlee A, Fujimori T, Goulding J, Xin G, Salek-Ardakani S, Snelgrove RJ, Ma D, Maze M, Hussell T. Benzodiazepine augmented g-amino-butyric acid signaling increases mortality from pneumonia in mice. Crit Care Med 2013;41:1627–1636. 20. Obiora E, Hubbard R, Sanders RD, Myles PR. The impact of benzodiazepines on occurrence of pneumonia and mortality from pneumonia: a nested case-control and survival analysis in a population-based cohort. Thorax 2013;68:163–170. 21. Pandharipande PP, Sanders RD, Girard TD, McGrane S, Thompson JL, Shintani AK, Herr DL, Maze M, Ely EW; MENDS investigators. Effect of dexmedetomidine versus lorazepam on outcome in patients with sepsis: an a priori-designed analysis of the MENDS randomized controlled trial. Crit Care 2010;14:R38.
- recent clinical practice guidelines (5) to recommend “nonbenzodiazepine sedatives (either propofol or dexmedetomidine)” for sedation in the ICU instead of benzodiazepines—
- Lonardo, Mone, Nirula, et al.: Propofol vs. Benzodiazepines in Ventilated ICU Patients 1383
- Lonardo NW, Mone MC, Nirula R, Kimball EJ, Ludwig K, Zhou X, Sauer BC, Nechodom K, Teng C, Barton RG. Propofol is associated with favorable outcomes compared to benzodiazepines in ventilated intensive care unit patients. Am J Respir Crit Care Med 2014;189: 1383–1394. This type of study model is especially well suited to examine the outcomes of sedatives used in the ICU because of the well-known variability of their use (29–31) that may not be apparent in a controlled study environment. A limitation of randomized, controlled sedation studies is that they often exclude patients, such as those with renal and/or liver dysfunction and hemodynamic instability. These critically ill patients are especially vulnerable to the adverse effects of continuous-infusion benzodiazepines because of potentially reduced hepatic clearance, renal insufficiency, and accumulation of active metabolites (24). In a natural ICU practice setting, continuous-infusion sedatives are commonly used in patients with organ dysfunction. By comparison, in the metaanalysis by Ho and Ng (25), patients with renal or liver dysfunction were excluded in half of the randomized trials
- Figure 4. Cumulative incidence of intensive care unit (ICU) discharge over 28 days in the presence of competing risk event (mortality) for matched midazolam- and lorazepam-treated patients compared with propofol-treated patients.
- Girard TD, Kress JP, Fuchs BD, et al. Efficacy and safety of a paired sedation and ventilator weaning protocol for mechanically ventilated patients in intensive care (Awakening and Breathing Controlled trial): a randomised controlled trial. Lancet 2008; 371: 126-134
- Data are expressed as median (interquartile range) for non-normally distributed data or number (%) for nominal data. Kruskal–Wallis analysis of variance was used for non-normally distributed data comparisons, and the nominal data comparisons were based on either the chi-squared test or Fisher's exact test. In the presence of a significant difference in the three groups (P < 0.05), the parameters between any two groups were further compared with the value of α adjusted to 0.017. AKI, acute kidney injury; CRRT, continuous renal replacement therapy. aMedazolam sedation times of group M and group M-P were analyzed byindependent two-sample t test. bTime from the stopping of sedation until awake: missing assessments for the patients withdrawing from treatment or suffering from therapeutic failure (four patients in group M, six patients in group P, and three patients in group M-P). cTime from the stopping of sedation until extubation: exposure calculation was based on patients completing treatment (including 37 patients in group M, 35 patients in group P, and 32 patients in group M-P), patients withdrawing treatment and suffering therapeutic failure, and those who underwent tracheostomy without determining the extubation.
- Data expressed as median (interquartile range). Kruskal–Wallis analysis of variance was used for data comparison. In the presence of significant difference in the three groups (P < 0.05), the parameters between any two groups were further compared with the value of α adjusted to 0.017.
- Data expressed as number (percentage). Data comparisons were based on the chi-squared test. In the presence of significant difference in the three groups (P < 0.05), the parameters between any two groups were further compared with the value of α adjusted to 0.017.
- Their analysis of a large, heterogeneous population not only improved statistical power but also enhances the generalizability of their findings. Just as important, by using 1:1 propensity matching based on 15 Pretreatment covariates that were considered predictive of propofol use, the authors attempted to account for potential selection bias by creating comparator groups that were similar with regard to these measured covariates. Propensity score matching is a powerful technique used to reduce bias in observational studies in critical care and many other areas of research
- 25. Ho KM, Ng JY. The use of propofol for medium and long-term sedation in critically ill adult patients: a meta-analysis. Intensive Care Med 2008;34:1969–1979.