The Feasibility of Implementing Targeted SEDation in Mechanically Ventilated Emergency Department Patients: The ED-SED Pilot Trial.
The Feasibility of Implementing Targeted SEDation in Mechanically Ventilated Emergency Department Patients: The ED-SED Pilot Trial.
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DOI：
10.1097/ccm.0000000000005558
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发表时间：
2022-08-01
影响因子：
8.8
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中科院分区：
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深度镇静在急诊科（艾德）是常见的，增加深度镇静在重症监护室（ICU），并与结果呈负相关。因此，限制艾德深度镇静可能是改善结局的高产干预措施。然而，进行充分的ED临床镇静试验的可行性尚不清楚。我们的目的是评估试验的可行性：1）招募; 2）方案实施和实践变更; 3）安全性。以患者为中心的临床结果进行了评估，以更好地规划未来的大规模临床试验。实用、多中心（n= 3）、前瞻性前后先导性和可行性试验。三个医疗中心的艾德和ICU连续性成人机械通气艾德患者。一项旨在可靠的艾德镇静深度记录和减少深度镇静患者比例的教育计划（主要结局）。记录艾德和ICU前48小时的镇静相关数据。深度镇静定义为里士满躁动-镇静量表为−3至−5或镇静-躁动量表为1-3。筛选了1300例五十六患者;最终人群为415例。干预组达到较轻的艾德镇静，深度镇静患者比例从60.2%降至38.8%，p < 0.01。不良事件无相关趋势（即意外拔管、器械取出、意识瘫痪）。干预组死亡率为10.0%，干预前组为20.4%，p <0.01。与干预前相比，干预组经历了更多的无呼吸机天数[22.0（9.0）vs. 19.9（10.6）]和无ICU天数[20.8（8.7）vs. 18.1（10.4）]，两者p <0.05。该初步试验证实了以艾德为目标以改善镇静实践和减少深度镇静的可行性。这些发现证明了一个适当的把握度的临床试验，ED为基础的镇静，以改善临床结果。
Deep sedation in the emergency department (ED) is common, increases deep sedation in the intensive care unit (ICU), and is negatively associated with outcome. Limiting ED deep sedation may therefore be a high-yield intervention to improve outcome. However, the feasibility of conducting an adequately powered ED-based clinical sedation trial is unknown. Our objectives were to assess trial feasibility in terms of: 1) recruitment; 2) protocol implementation and practice change; and 3) safety. Patient-centered clinical outcomes were assessed to better plan for a future large-scale clinical trial. Pragmatic, multicenter (n= 3), prospective before-after pilot and feasibility trial. The ED and ICUs at three medical centers Consecutive, adult mechanically ventilation ED patients. An educational initiative aimed at reliable ED sedation depth documentation and reducing the proportion of deeply sedated patients (primary outcome). Sedation-related data in the ED and first 48 ICU hours were recorded. Deep sedation was defined as Richmond Agitation-Sedation Scale of −3 to −5 or Sedation-Agitation Scale of 1–3. One thousand, three hundred fifty-six patients were screened; 415 comprised the final population. Lighter ED sedation was achieved in the intervention group, and the proportion of deeply sedated patients was reduced from 60.2% to 38.8%, p < 0.01. There were no concerning trends in adverse events (i.e. inadvertent extubation, device removal, awareness with paralysis). Mortality was 10.0% in the intervention group and 20.4% in the pre-intervention group, p <0.01. Compared to pre-intervention, the intervention group experienced more ventilator-free days [22.0 (9.0) vs. 19.9 (10.6)] and ICU-free days [20.8 (8.7) vs. 18.1 (10.4)], p <0.05 for both. This pilot trial confirmed the feasibility of targeting the ED in order to improve sedation practices and reduce deep sedation. These findings justify an appropriately powered clinical trial regarding ED-based sedation to improve clinical outcomes.