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      The Application of the Nurse-Led Sedation and Analgesia Management in ICU after Heart Surgeries


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          Traditional sedation management consists of doctors adjusting the dosage of sedative drugs or adding other drugs in combination according to the evaluation of nurses; the nurses then execute the orders. The nurses' passive execution in the process is not the ideal model for continuous evaluation and observation of sedation. This study aims to investigate the application and effects of nurse-provided procedural sedation and analgesia for patients in intensive care unit.


          The experimental group consisted of 354 heart surgery patients who received procedural sedation and analgesia from nurses from November 2020 to August 2021. The control group consisted of 301 patients who had had heart surgery and received the traditional sedation management program from January to October 2020. The differences in levels of the sedative effect, delirium, and unplanned extubation of patients between these two groups were compared.


          There were no significant differences in baseline characteristics between the two groups ( P > 0.05). It was found that both insufficient sedation and excessive sedation decreased in the experimental group when compared to the control group, while the appropriate proportion of sedation increased (72.41% versus 37.98%); the difference was statistically significant ( P < 0.05). The incidence of delirium was lower for patients in the experimental group than for patients in the control group (37.01% versus 66.45%); the difference was statistically significant ( P < 0.05). The incidence of unplanned extubation caused by patient factors was lower for the experimental group than for the control group, but the difference was not statistically significant ( P > 0.05).


          The programmed sedation scheme led by nurses can improve the sedation effect and reduce the incidence of delirium. Implications for Practice. The management team gives the sedative goal and establishes the standard flowchart. The sedation management led by the nurse according to the goal and flowchart is better than the traditional sedation management.

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          Most cited references23

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          Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit.

          To revise the "Clinical Practice Guidelines for the Sustained Use of Sedatives and Analgesics in the Critically Ill Adult" published in Critical Care Medicine in 2002. The American College of Critical Care Medicine assembled a 20-person, multidisciplinary, multi-institutional task force with expertise in guideline development, pain, agitation and sedation, delirium management, and associated outcomes in adult critically ill patients. The task force, divided into four subcommittees, collaborated over 6 yr in person, via teleconferences, and via electronic communication. Subcommittees were responsible for developing relevant clinical questions, using the Grading of Recommendations Assessment, Development and Evaluation method (http://www.gradeworkinggroup.org) to review, evaluate, and summarize the literature, and to develop clinical statements (descriptive) and recommendations (actionable). With the help of a professional librarian and Refworks database software, they developed a Web-based electronic database of over 19,000 references extracted from eight clinical search engines, related to pain and analgesia, agitation and sedation, delirium, and related clinical outcomes in adult ICU patients. The group also used psychometric analyses to evaluate and compare pain, agitation/sedation, and delirium assessment tools. All task force members were allowed to review the literature supporting each statement and recommendation and provided feedback to the subcommittees. Group consensus was achieved for all statements and recommendations using the nominal group technique and the modified Delphi method, with anonymous voting by all task force members using E-Survey (http://www.esurvey.com). All voting was completed in December 2010. Relevant studies published after this date and prior to publication of these guidelines were referenced in the text. The quality of evidence for each statement and recommendation was ranked as high (A), moderate (B), or low/very low (C). The strength of recommendations was ranked as strong (1) or weak (2), and either in favor of (+) or against (-) an intervention. A strong recommendation (either for or against) indicated that the intervention's desirable effects either clearly outweighed its undesirable effects (risks, burdens, and costs) or it did not. For all strong recommendations, the phrase "We recommend …" is used throughout. A weak recommendation, either for or against an intervention, indicated that the trade-off between desirable and undesirable effects was less clear. For all weak recommendations, the phrase "We suggest …" is used throughout. In the absence of sufficient evidence, or when group consensus could not be achieved, no recommendation (0) was made. Consensus based on expert opinion was not used as a substitute for a lack of evidence. A consistent method for addressing potential conflict of interest was followed if task force members were coauthors of related research. The development of this guideline was independent of any industry funding. These guidelines provide a roadmap for developing integrated, evidence-based, and patient-centered protocols for preventing and treating pain, agitation, and delirium in critically ill patients.
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            Effect of a nursing-implemented sedation protocol on the duration of mechanical ventilation.

            To compare a practice of protocol-directed sedation during mechanical ventilation implemented by nurses with traditional non-protocol-directed sedation administration. Randomized, controlled clinical trial. Medical intensive care unit (19 beds) in an urban teaching hospital. Patients requiring mechanical ventilation (n = 321). Patients were randomly assigned to receive either protocol-directed sedation (n = 162) or non-protocol-directed sedation (n = 159). The median duration of mechanical ventilation was 55.9 hrs (95% confidence interval, 41.0-90.0 hrs) for patients managed with protocol-directed sedation and 117.0 hrs (95% confidence interval, 96.0-155.6 hrs) for patients receiving non-protocol-directed sedation. Kaplan-Meier analysis demonstrated that patients in the protocol-directed sedation group had statistically shorter durations of mechanical ventilation than patients in the non-protocol-directed sedation group (chi-square = 7.00, p = .008, log rank test; chi-square = 8.54, p = .004, Wilcoxon's test; chi-square = 9.18, p = .003, -2 log test). Lengths of stay in the intensive care unit (5.7+/-5.9 days vs. 7.5+/-6.5 days; p = .013) and hospital (14.0+/-17.3 days vs. 19.9+/-24.2 days; p < .001) were also significantly shorter among patients in the protocol-directed sedation group. Among the 132 patients (41.1%) receiving continuous intravenous sedation, those in the protocol-directed sedation group (n = 66) had a significantly shorter duration of continuous intravenous sedation than those in the non-protocol-directed sedation group (n = 66) (3.5+/-4.0 days vs. 5.6+/-6.4 days; p = .003). Patients in the protocol-directed sedation group also had a significantly lower tracheostomy rate compared with patients in the non-protocol-directed sedation group (10 of 162 patients [6.2%] vs. 21 of 159 patients [13.2%], p = .038). The use of protocol-directed sedation can reduce the duration of mechanical ventilation, the intensive care unit and hospital lengths of stay, and the need for tracheostomy among critically ill patients with acute respiratory failure.
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              Early goal-directed sedation versus standard sedation in mechanically ventilated critically ill patients: a pilot study*.

              To assess the feasibility and safety of delivering early goal-directed sedation compared with standard sedation. Pilot prospective, multicenter, randomized, controlled trial. Six ICUs. Critically ill adults mechanically ventilated for greater than 24 hours. Patients randomized to early goal-directed sedation received a dexmedetomidine-based algorithm targeted to light sedation (Richmond Agitation Sedation Score of -2 to 1). Patients randomized to standard sedation received propofol and/or midazolam-based sedation as clinically appropriate. The main feasibility outcomes were time to randomization and proportion of Richmond Agitation Sedation Score assessments in the first 48 hours in the light and deep sedation range. Safety outcomes were delirium-free days, vasopressor and physical restraints use, and device removal. Randomization occurred within a median (interquartile range) of 1.1 hours (0.46-1.9) after intubation or ICU admission for out of ICU intubation. Patients in the early goal-directed sedation (n = 21) mean (SD) Acute Physiology and Chronic Health Evaluation II score was 20.2 (6.2) versus 18.6 (8.8; p = 0.53) in the standard sedation (n = 16). A significantly higher proportion of patients was lightly sedated on days 1, 2, and 3 (12/19 [63.2%], 19/21 [90.5%], and 18/20 [90%] vs 2/14 [14.3%], 8/15 [53.3%], and 9/15 [60%]; p = 0.005, 0.011, 0.036) and more Richmond Agitation Sedation Scale assessments between (-2 and 1), in the first 48 hours (203/307 [66%] versus (74/197 [38%]; p = 0.01) in the early goal-directed sedation versus standard sedation, respectively. Early goal-directed sedation patients received midazolam on 6 of 173 (3.5%) versus 4 of 114 (3.5%) standard sedation patient-days when dexmedetomidine was given. Propofol was given to 16 of 21 (76%) of early goal-directed sedation versus 16 of 16 (100%) of standard sedation patients (p = 0.04). Early goal-directed sedation patients had 101 of 175 (58%) versus 54 of 114 (47%; p = 0.27) delirium-free days and required significantly less physical restraints 1 (5%) versus 5 (31%; p = 0.03) than standard sedation patients. There were no differences in vasopressor use and self-extubation. Delivery of early goal-directed sedation was feasible, appeared safe, achieved early light sedation, minimized benzodiazepines and propofol, and decreased the need for physical restraints. The findings of this pilot study justify further investigation of early goal-directed sedation.

                Author and article information

                Evid Based Complement Alternat Med
                Evid Based Complement Alternat Med
                Evidence-based Complementary and Alternative Medicine : eCAM
                5 July 2022
                5 July 2022
                : 2022
                : 7706172
                1Department of SICU, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, Sichuan, China
                2Chinese Academy of Sciences Sichuan Translational Medicine Research Hospital, Chengdu, Sichuan, China
                3Department of Nursing, Sichuan Provincial People's Hospital and QiongLai Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, Sichuan, China
                4Department of Neurosurgery, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, Sichuan, China
                5Department of ICU, Deyang People's Hospital, Deyang, Sichuan, China
                6School of Nursing, North Sichuan Medical College, Nanchong, Sichuan, China
                7Department of Nursing, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, Sichuan, China
                8Department of NICU, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, Sichuan, China
                Author notes

                Academic Editor: Zhaoqi Dong

                Author information
                Copyright © 2022 Rong Lu et al.

                This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                : 30 March 2022
                : 25 April 2022
                : 28 April 2022
                Funded by: Nursing Association Sichuan Province
                Award ID: H19035
                Research Article

                Complementary & Alternative medicine
                Complementary & Alternative medicine


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