Frontline Medical News

Reporting from CCC47

SAN ANTONIO (FRONTLINE MEDICAL NEWS)Intermittent administration of sedation and analgesia significantly reduced mechanical ventilation time among surgical patients requiring ventilation, according to a preliminary analysis of a randomized trial.

Additionally, the researchers found that much lower amounts of sedation and analgesia were given to patients who underwent intermittent dosing, compared with patients who received a continuous infusion.

Lead investigator Nicholas Sich, MD, presented these findings of the SATIRE trial (Sedation Administration Timing: Intermittent Dosing Reduces Times to Extubation), at the Critical Care Congress sponsored by the Society for Critical Care Medicine. Dr. Sich’s study was a 2-year, single-blinded, randomized, controlled trial of surgical patients requiring ventilation.

Of the 95 patients in the trial, 39 were randomized to intermittent dosing and 56 to the control group of continuous infusion, with the drugs midazolam and fentanyl having been given to both groups.

Mean mechanical ventilation time was 65 hours in the intermittent dosing arm, versus 111 hours in the continuous infusion arm (P less than 0.03), noted Dr. Sich, a fourth-year general surgery resident at Abington Memorial Hospital, Abington, Pa., during his presentation.

Patients in the continuous infusions arm of the trial received a mean of 73.1 mg of midazolam, compared with 18 mg for the intermittent dosing arm, a difference that approached very closely to statistical significance (P = 0.06) and was thrown off in the latest iteration by an outlier, Dr. Sich explained. The relative difference between the mean fentanyl doses administered was even greater between the two groups, with 5,848 mcg given to patients in the control group, versus the 942 mcg given to participants in the intermittent dosing group (P less than 0.01).

“This is a new way to use an old drug, and it really might be beneficial, and can even be used as first-line therapy and a way to keep patients awake and off the ventilator,” said Dr. Sich, referring to the intermittent dosing. Continuous infusions leave patients oversedated and prolong ventilation time.

“What we propose, rather, is using a sliding-scale intermittent pain and sedation regimen,” he said. “We believe that it won’t compromise patient care and won’t compromise patient comfort, and it will lead to shorter mechanical ventilation times for surgical patients than continuous infusions.”

Dr. Sich also pointed out that there was no difference in time spent at target levels of sedation and analgesia between the two trial groups. Referring to this finding, he noted that “we wanted to make sure that in the intermittent arm we’re giving them less drug, but we don’t want them to be [less comfortable].”

One potential drawback to the intermittent dosing approach is that it is more nursing intensive, according to Dr. Sich, since it is based on a nursing treatment protocol to give medications every hour.

Intermittent dosing is “more hands-on” than a typical continuous infusion approach and so was more challenging for nurses who, per the treatment protocol, had to give medications every hour, he explained. However, “when they saw the data in the months and year as we’ve been going on, they’re actually quite proud of our work and their work.”

Gilman Baker Allen, MD , a pulmonologist and intensivist at the University of Vermont Medical Center, Burlington, said the study was “terrific work” and acknowledged the importance of gauging nurse satisfaction with the protocol.

“I think that when you feed this kind of data back to nursing staff, they may not be satisfied with the intensity of the work, but when they see the rewards at the end, it oftentimes is a very positive experience,” said Dr. Allen, who moderated the session.

Dr. Sich and his colleagues had no financial disclosures or conflicts of interest related to the study.

chestphysician@frontlinemedcom.com

SOURCE: Sich N et al. CCC47 , Abstract 18.

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