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Chemical and physical restraints are frequently used in the intensive care unit (ICU) to control agitated patients and to prevent self-harm and unplanned extubations. Published work relating to the numerous issues of the care and treatment strategies for these patients remains conflicting and unclear. Literature regarding sedation and chemical restraint reveals a trend towards management with lighter sedation, use of sedation assessment tools and sedation protocols. It remains unclear which treatment is best for agitated and delirious patients, and the evidence on the effect of sedation is conflicting. A large portion of the literature on the use of physical restraint is from general hospital wards and residential homes, and not from the ICU environment. The purpose of this paper is to provide a summary of the existing literature on the use of physical and chemical restraints in the ICU setting. In Part 1 of this two-part paper, the evidence on chemical and physical restraints is explored with specific focus on definition of terms, unplanned extubation, agitation, delirium and the impact of nurse-patient ratios in the ICU on these issues. Part 2 of the paper examines the evidence related to chemical and physical restraints from the perspective of the mechanically ventilated patient.

End-of-life care is a complicated topic, especially in a neurological intensive care unit. Death is a daily part of nursing care and should be treated with respect and a definite plan of care. Unfortunately, there are still hospitals that do not have protocols to deal with this outcome. The administration of opioids and appropriate sedation can be the difference between a calm serene death or one that is fraught with dyspnea, struggling, and unhappy families. Every hospital should have palliative care and hospice planning. This case study is about a dying patient that did not receive palliative care appropriately; however, through determination and personal knowledge of death and dying, a neurosurgical nurse was able to change the way a hospital dealt with do-not-resuscitate patients. Do not resuscitate does not mean no care; it means a different kind of care that can best be achieved through end-of-life protocols and education.

Objective: To determine whether the use of a nurse-implemented sedation protocol could reduce the incidence of ventilator-associated pneumonia in critically ill patients., Design: Two-phase (before-after), prospective, controlled study., Setting: University-affiliated, 11-bed medical intensive care unit., Patients: Patients requiring mechanical ventilation for >or=48 hrs and sedative infusion with midazolam or propofol alone., Interventions: During the control phase, sedatives were adjusted according to the physician's decision. During the protocol phase, sedatives were adjusted according to a protocol developed by a multidisciplinary team including nurses and physicians. The protocol was based on the Cambridge scale, and sedation level was adjusted every 3 hrs by the nurses. Standard practices, including weaning from the ventilator and diagnosis of VAP, were the same during both study phases., Measurements and Main Results: A total of 423 patients were enrolled (control group, n = 226; protocol group, n = 197). The incidence of VAP was significantly lower in the protocol group compared with the control group (6% and 15%, respectively, p = .005). By univariate analysis (log-rank test), only use of a nurse-implemented protocol was significantly associated with a decrease of incidence of VAP (p < .01). A nurse-implemented protocol was found to be independently associated with a lower incidence of VAP after adjustment on Simplified Acute Physiology Score II in the multivariate Cox proportional hazards model (hazard rate, 0.81; 95% confidence interval, 0.62-0.95; p = .03). The median duration of mechanical ventilation was significantly shorter in the protocol group (4.2 days; interquartile range, 2.1-9.5) compared with the control group (8 days; interquartile range, 2.2-22.0; p = .001), representing a 52% relative reduction. Extubation failure was more frequently observed in the control group compared with the protocol group (13% and 6%, respectively, p = .01). There was no significant difference in in-hospital mortality (38% vs. 45% in the protocol vs. control group, respectively, p = .22)., Conclusions: In patients receiving mechanical ventilation and requiring sedative infusions with midazolam or propofol, the use of a nurse-implemented sedation protocol decreases the rate of VAP and the duration of mechanical ventilation.

Background: Propofol has been shown to be safe for nonanesthetist use during GI endoscopy. However, published studies involved propofol administration by an additional nurse or used specialized patient monitoring or were carried out in tertiary hospitals., Objective: Considering the downward pressure on reimbursement for endoscopic procedures, we asked how much staff and monitoring is necessary for safe use of propofol., Setting: Two private gastroenterology practices., Patients and Design: A total of 27,061 endoscopic procedures (14,856 EGDs and 12,205 colonoscopies) were prospectively assessed regarding patient characteristics, American Society of Anesthesiologists (ASA) status, dosage of propofol, fall of oxygen saturation below 90%, need to increase nasal oxygen administration above 2 L/min, and need for assisted ventilation., Intervention: Propofol was administered by the endoscopy nurse supervised by the endoscopist. Patient monitoring consisted of only pulse oximetry and clinical assessment., Results: The mean propofol dose for EGD was 161 mg (range 50-650 mg). During colonoscopy patients received a mean propofol dose of 116 mg (30-500 mg) in addition to 25 mg of meperidine. Oxygen saturation fell below 90% (lowest 74%) in 623 procedures (2.3%), normalizing within less than 30 seconds by stimulating the patient and increasing the nasal oxygen flow to 4 to 10 L/min. Six patients (ASA III) required mask ventilation for less than 30 seconds. No endotracheal intubation was necessary., Limitations: There was no further follow-up regarding adverse events after patient discharge from the endoscopy unit., Conclusions: An endoscopy team, consisting of 1 physician endoscopist and 1 endoscopy nurse, can safely administer propofol sedation for GI endoscopy in a practice setting without additional staff or specialized monitoring.

The prevention and treatment of pain, anxiety, and delirium in the ICU are important goals. But achieving a balance between sedation and analgesia, especially in critically ill patients on mechanical ventilation, can be challenging. Both under- and oversedation carry grave risks. Without having an agreed-upon end point for sedation, different providers will likely have disparate treatment goals, increasing the risk of iatrogenic complications and possibly impeding recovery. In 2002 the Society of Critical Care Medicine, along with the American Society of Health-System Pharmacists, updated recommendations in its clinical practice guidelines for the sustained use of sedatives and analgesics in adults. This two-part series examines those recommendations concerning sedation assessment and management, as well as the current literature. Last month, Part 1 reviewed pertinent recommendations concerning pain and delirium and discussed tools for assessing pain, delirium, and sedation. This month, Part 2 explores pharmacologic and nonpharmacologic management of anxiety and agitation in the ICU. The second in a two-part series focuses on the pharmacologic and nonpharmacologic management of anxiety and agitation in the ICU.

Purpose of Review: This review evaluates the past year's literature on the provision of pediatric procedural sedation outside of the operating room, especially as performed by non-anesthesiologist healthcare providers., Recent Findings: Research on pediatric procedural sedation practice continues to be limited by small case series and single institution study design. However, some exciting developments have occurred. Recent guideline revisions and safety initiatives are reported that impact positively on practice. Efforts to analyze the elements of sedation systems that result in greater safety, efficiency, and patient satisfaction are increasing, including evaluations of tiered systems utilizing the skills of various healthcare providers. Dexmedetomidine and etomidate are the subjects of investigation on their utility for procedural sedation. A multicentered study, adequately powered to provide meaningful evaluation of adverse events, has been completed and provides valuable insight on pediatric procedural sedation as practiced by a variety of healthcare providers., Summary: Pediatric procedural sedation practice as performed by non-anesthesiologists continues to grow. Ongoing efforts to understand the elements of sedation systems that lead to best practice, with the subsequent development of uniform practice approaches, are essential. A collaborative relationship between anesthesiologists and non-anesthesiologist providers of procedural sedation is essential for meeting common goals.

Purpose of Review: Most patients require sedation for gastrointestinal endoscopy. Moderate sedation for these procedures has traditionally been provided by the endoscopist with benzodiazepine and/or a narcotic. As endoscopy has increased in numbers and complexity, however, more effective sedation and analgesia is frequently required. Controversy has ensued over safe and efficient sedation practice. This review seeks to delineate what has been learned about this topic in the recent literature., Recent Findings: There has been an increase both in the number of endoscopic procedures performed and in the use of propofol for endoscopic sedation. Studies have focused on several basic issues: alternatives to anesthesiologist-supervised propofol, other sedation regimens, and complications related to sedation., Summary: Alternatives to anesthesiologist-supervised propofol include nurse-administered propofol sedation supervised by the endoscopist, and patient controlled sedation. While other sedative regimens continue to be examined, the use of propofol for gastrointestinal endoscopy will continue to increase. Structured nurse-administered propofol programs appear to be safe, but the occurrence of severe respiratory depression and the ability to rescue remain concerns. Further study into appropriate sedation training, patient selection, ability to rescue, complications and value of anesthesiologist-directed sedation is necessary.

The finite boundaries of the scope of nursing practice are constantly changing. One could expect that with new technology and advances in science, the interventions and assessments nurses perform will change over time. The practice of nursing is governed by nursing, however, it is often challenged by our partners in medicine, and frequently driven by time constraints or reimbursement issues. This article reviews a case example in which nurses were asked to expand their practice to assume responsibility for duties that were once traditionally performed by physicians. An evaluation of a practice problem using an evidence-based approach applying the PICO (population, intervention, comparison, outcome) method is explored. Proposed steps to minimize risk and staff moral distress are also described.

Central venous catheters have been established as a reliable source of vascular access since the 1970s. Peripherally inserted central catheters became a popular central catheter in the early 1990s for adults and children. The management of vascular access in children is an essential part of inpatient and outpatient care. Assessing and inserting the appropriate catheter for the pediatric patient is just a part of the component for central catheter care. Care providers also need to assess these children for sedation or distraction for the procedure. This article discusses factors for catheter choice and points for assessing children for sedation or distraction for vascular access insertion.

As professionals who care for the sickest children, we want to provide the best evidence-based care available. While there are questions still to be answered, it is clear that when propofol is administered to children, it should be done in a manner that is intentional, well planned, and consistent with national guidelines and regulatory groups. Haphazard administration of propofol will place children at risk.

Although literature on the subject is scant, in practice, pressure ulcers in the pediatric burn population remain a challenge. An interdisciplinary team at an urban pediatric burn institution treats a population (average age 8 years, range 1 month to 21 years) that includes children too young or unable to articulate pressure-related pain from dressings or positioning techniques. After pressure ulcer data collection procedures were instituted, it was observed that elastic bandages, wet operating room dressings, and positioning appeared to contribute to pressure ulcer occurrence. To better understand the patient's experience and educate staff, an informal study was conducted by an interdisciplinary committee of clinicians to assess the amount of pressure in mm Hg created on bony prominences by care procedures. Three staff members volunteered and were placed in elastic dressings and various commonly used positions for several minutes and three pressure measurements were obtained. Pressure readings of 40 and 56 mm Hg were common, causing pain and placing a person at risk for skin ulceration. The information was used to educate staff on how to maintain therapeutic efficacy without compromising skin integrity and causing pain. Lectures and hands-on demonstrations elucidated correct dressing application. The committee continues to provide education to all staff members on methods to prevent pressure ulcers from occurring in the high-risk burn patient population and ways to reduce the use of elastic wraps and improve patient positioning.

In January 2000, Primary Children's Medical Center (PCMC) nurses and physicians of specific disciplines including hematology/oncology, surgery, Emergency Department (ED), and anesthesia, identified a need to provide general anesthesia for children undergoing procedures outside of the operating room. This need was based upon two factors: (a) limited availability of the operating room, and (b) lack of proper monitoring of children receiving conscious sedation for painful procedures in PCMC clinics. In September 2000, the Rapid Treatment Unit (RTU) service was developed to provide cost-effective, efficient, patient/family-centered care for a variety of procedures. With limited literature on the subject of anesthesia services outside of the operating room, many hours of planning, education, and organizing occurred to develop this unique service. Parents have reported satisfaction with the service verbally and through an anonymous survey. Increasing numbers of patients seeking services from Utah, Idaho, Nevada, Wyoming, and Montana indicate a need for service expansion within the five-state region surrounding Salt Lake City. The RTU Anesthesia service is an important asset to PCMC and continues to expand to provide safe, efficient health care for children.

The goal of the study was to compare the reliability and validity of 3 Sedation Agitation Scale. Two nurses and a physician conducted 130 observations simultaneously. They found an excellent interrater reliability in the Richmond Agitation Sedation Scale (r>0.86), and high correlations between the Richmond Agitation Sedation Scale and the Sedation Agitation Scale and Visual Analog Scale scales (r=0.92, r=0.85). The research findings will help to assert Richmond Agitation Sedation Scale as a daily assessment tool in the intensive care unit, and it will pave the way for construction a sedation protocol according to the Richmond Agitation Sedation Scale level.

Aim: This article describes the current magnetic resonance imaging (MRI) sedation service, the role of the nurse sedationist, results of clinical audits, and future issues within MRI., Method: Data from 2004 until 2006 were analysed to describe the percentage of children who were successfully sedated, and any complications. The recovery profile was investigated by a questionnaire of 100 consecutive cases., Findings: Sedation was attempted in 455 cases with chloral hydrate, and 325 with temazepam and droperidol. The success rate was 97.4 and 92.6 per cent respectively. Top-up sedation was used in 10 and 29 per cent respectively. There were seven minor incidents but none required admission. Approximately 20 per cent of children were drowsy the following day., Conclusion: We believe that the success of the service depends upon three main factors: the deselection of children in whom sedation is unsafe or likely to be unsuccessful, the use of appropriate drugs in limited doses, and the training of experienced nurses.

The care of the mechanically ventilated patient is at the core of a nurse's clinical practice in the Intensive Care Unit (ICU). Published work relating to the numerous nursing issues of the care of the mechanically ventilated patient in the ICU is growing significantly. Literature focuses on patient assessment and management strategies for patient stressors, pain and sedation. Yet this literature is fragmentary by nature. The purpose of this paper is to provide a single comprehensive examination of the evidence related to the care of the mechanically ventilated patient. In part one of this two-part paper, the evidence on nursing care of the mechanically ventilated patient is explored with specific focus on patient safety: particularly patient and equipment assessment. Part two of the paper examines the evidence related to the mechanically ventilated patient's comfort, the patient/family unit, patient position, hygiene, management of stressors, pain management and sedation.

Objective: Describe the pharmacoepidemiology of sedative medications and nurse-rated patients' behavior and sedation adequacy., Design: Cohort study, 2001-2003., Patients: Patients ventilated for >36 hrs in a medical or surgical intensive care unit at a university-affiliated hospital. Proxies for 312 eligible subjects were approached for consent, 277 subjects enrolled, and data from 274 subjects were analyzed., Interventions: None., Measurements and Main Results: Distribution of Arousal and Motor Activity levels, proportion of inadequate sedation and factors associated with inadequate sedation, variation of sedative therapy intensity, and behavior over time were measured. Sedatives were administered in 85% of 18,050 four-hour intervals during mechanical ventilation. Sedation was judged as adequate in 83% of 12,414 sedation assessments; patients were judged to be undersedated in 13.9% and oversedated in 2.6% of the assessments. Patients were unarousable or minimally arousable 32% of the time and had no spontaneous motor activity (during a 10-min observation period) 21.5% of the time. There was little variation in level of consciousness or motor activity or drug dose over 24 hrs, but daytime caregivers were more likely to judge patients as oversedated (3.7%) compared with nighttime caregivers (1.6%, p<.001). Inadequate sedation was associated with sedative drug intensity and patient behavior as measured by a two-domain sedation scale. Sedative drug intensity and behavior varied during the course of respiratory failure, and survivors received 13% more sedation per 4-hr interval of mechanical ventilation than nonsurvivors (p<.001)., Conclusions: Although patients were minimally arousable or nonarousable in 32% and motionless in 21% of the sedation assessments, surprisingly, an oversedation rating occurred in <3%. This discrepancy, along with findings that time of day influences the interpretation of sedation adequacy and that patients' behavior change over time suggests that collaborative research is needed to define adequate sedation.

Coronary artery bypass grafting is performed on the beating heart and thus requires the use of cardiopulmonary bypass. To avoid the complications associated with cardiopulmonary bypass, off-pump bypass (OPB) is viewed as a desirable alternative. Technological advancements have made OPB a viable option in an expanding population of patients. As a result, the number of OPB surgeries performed annually in the United States has increased. Critical care nurses are increasingly likely to provide care for patients after off-pump surgery. The differences between on-pump and OPB surgeries affect the postoperative nursing care requirements. While there are many common aspects of postoperative cardiac care for these 2 groups of surgical patients, there is a need to focus on the unique aspects of care for OPB patients. Despite promising short-term results in OPB patients, questions surrounding this procedure remain. Studies are under way to determine long-term graft patency.

Introduction: The Ramsay scale which is internationally one of the most frequently cited sedation assessment tools has not had adequate psychometric evaluation. The objective of this study was to test the inter-rater reliability of the Ramsay scale., Methods: This study was based on a prospective, single-blinded randomized design targeted to provide a psychometric analysis of the Ramsay scale. Following informed consent nurses were provided with written instructions on use of the Ramsay scale. A total of 241 critical care nurses were recruited from seven specialty critical care units in a major teaching institution; 237 nurses completed the study. After reviewing the written instructions, nurses viewed one out of six randomly selected videos of a sedation assessment and then scored that video using the Ramsay scale. Each nurse viewed and independently scored only one video using the Ramsay scale., Results: Across the 237 nurses, who scored one out of six videos using the Ramsay scale a Kappa of 0.28 was obtained., Conclusions: Based on these findings, there is insufficient evidence to support the reliability of the Ramsay scale as a measure of sedation assessment.

In intensive care units (ICU), patients in life-threatening situations are hospitalized. While the health status of these patients is often severely compromised, therapeutic interventions include endo-tracheal intubation with artificial ventilation, sedation, and analgesia which restrict their ability to communicate. These patients become additional vulnerable since their pains may not been adequately identified. Uncontrolled pain in sedated and artificial ventilated patients lead to increased number of respiration days and increased length of stay in hospital, which, may result in increased morbidity. This situation appears precarious since pain assessment of these patients in daily clinical practice seems often based on subjective criteria by the health care staff in charge. The purpose of this study was to describe pain-assessment instruments for sedated and artificial ventilated ICU-patients in view of validity, reliability and clinical application. With a systematic literature review, a total of 61 articles were identified in the databases of PUB-MED (National Library of Medicine) and CINAHL (Cumulative Index to Nursing and Allied Health Literature ) and additional bibliographic sources. Indicators for pain in sedated and artificial ventilated ICU-patients were physiological and behavior-related, without biochemical parameters. In most of the instruments, the validity was tested only superficially and no detailed reports regarding the application in everyday practice were given. However, the studied instruments includes algorithm as a significant component which enable decision making of the health care providers in order to execute stepwise pain management interventions. In conclusion, a need for further research to disclose pain indicators in sedated and artificial ventilated ICU-patients, continuous development of instruments and their validation in clinical practice is obvious.

Most patients who are admitted to intensive care in need of ventilator support may also require sedation. It is a part of the nurses' role to manage sedation therapy according to patients' needs, avoiding complications of over and under sedation. The purpose of the study was to explore nurses' perceptions of their role in sedation management. A convenience sample of 107 registered nurses in the intensive care unit of a large teaching hospital was accessed and a response rate of 86% (n=92) obtained. Results showed that the nurse has a major role in sedation management in the critically ill patient. Sedation scoring is used in the assessment of the patient's sedation level and sedation is then titrated by the nurse in collaboration with medical staff to an agreed target level. However, the impact of this role depends on the experience and confidence of the nurse as knowledge and skills are required in order to provide effective sedation for patients. Recommendations from this study are to incorporate a team approach within a locally devised sedation protocol. This should be supported by an education programme aiming to improve decision-making about sedation management at the bedside.

Patients with obstructive sleep apnea are at risk of mortality and morbidity related to the administration of sedatives, anesthetics, and opioids. Commonly employed sedatives and analgesics promote pharyngeal collapse and alter normal respiratory responses to obstruction and apnea. Literature concerning patients with obstructive sleep apnea undergoing moderate and deep sedation in the endoscopy suite is lacking. The purpose of this article is to provide the reader with a review of normal airway patency, the effects of obstructive sleep apnea on airway patency, and the impact that analgesics and sedatives may impart on the airway of patients with obstructive sleep apnea. The goal of this article is to increase awareness, stimulate discussions within the gastroenterological community, and encourage research regarding sedation in this at-risk population.

Background and Aims: Bispectral (BIS) monitoring provides an objective, non-invasive measure of the level of consciousness in sedated patients. BIS has been shown to lag behind the level of sedation during induction and emergence of sedation with propofol. In this study, we sought to determine whether BIS is a useful adjunctive maneuver to registered nurse-administered propofol sedation (NAPS) as measured by reductions in recovery time and doses of propofol administered., Methods: A randomized controlled trial of 102 outpatients presenting for colonoscopy was performed. BIS values were recorded continuously in all subjects. Patients were randomized to receive NAPS with BIS visible to nurse and endoscopist versus BIS invisible to nurse and endoscopist. In phase 1 (47 patients), the nurse and endoscopist team were instructed to consider BIS (when visible) as only adjunctive information with regard to titrating sedation. In phase 2 (55 patients), the nurse endoscopist team was instructed to use BIS as the primary endpoint for titration of sedation, and to target BIS to greater than 60 (60-70 is deep sedation)., Results: In phase 1, the mean (SD) BIS value from scope-in (SI) to scope-out (SO) for BIS was 59.3 (9.9) and was not different from controls at 59.9 (10.1; p= 0.82). The mean (SD) propofol dose (mg/min) was 15.8 (5.6) and 17.2 (6.2) for BIS and controls, respectively (p= 0.45). The mean (SD) recovery time with BIS visible in phase 1 was 20.6 min (5.5) versus 19.2 min (4.5) in controls (p= 0.34). In phase 2, the mean (SD) BIS from SI to SO in those randomized to have BIS visible was 64.1 (5.4) versus 63.1 (8.5) in controls (p= 0.58). The mean (SD) dose of propofol (mg/min) was 16.1 (11.2) and 16.4 (12.3) for BIS and control groups, respectively (p= 0.92). The mean (SD) recovery time in phase 2 with BIS visible was 18.7 (3.5) versus 20.1 (5.6) in controls (p= 0.27)., Conclusions: BIS did not lead to reductions in mean propofol dose or recovery time when used as an adjunct to NAPS for colonoscopy, or when used as the primary target for sedation. No clinically important role for BIS monitoring as an adjunct to NAPS has yet been established.

This article highlights a highly controversial practice issue referred to as nurse-administered propofol sedation, which affects registered nurses as well as advanced practice nurses in many different practice settings across the United States. Amid varied advice from professional organizations and state licensing boards, a thorough and systematic review of the current evidence provides insight into the question of safety associated with the practice. The evidence examined includes position statements from professional organizations and state boards, information from the United States Food and Drug Administration and the Joint Commission on Accreditation of Healthcare Organizations, and published research since 1999. The body of evidence demonstrates diverse positions; however, the empirical evidence in the author's opinion unanimously supports nurse-administered propofol sedation as a safe practice in nonintubated adult patients. Under research conditions, participants had a low incidence of untoward events and were adequately rescued with no intubations required and no deaths reported.

The prevention of ventilator-associated pneumonia (VAP) has been a quality effort that many organizations across the country have undertaken. Through a multidisciplinary approach, the best practices to prevent VAP for our organization were established. Through the interventions of securing the patient resuscitation bag in one location, maintaining the patient's head-of-bed elevation to more than 30 degrees if not contraindicated, Yankauer suction tip care, and the use of chlorhexidine mouth rinse, the incidence of VAP decreased by 43% within a 6-month time frame. Additional ventilator-associated prevention efforts such as sedation and weaning protocols have been established to further enhance preventive efforts.

Background and Study Aims: Recent studies have documented the safety of propofol sedation for endoscopic procedures, but many endoscopists are reluctant to use propofol for high-risk patients because of adverse effects. The aim of this study was to demonstrate the safety and efficacy of nurse-administered propofol sedation during emergency upper endoscopy for patients with gastrointestinal bleeding., Patients and Methods: Over a period of 18 months, 120 patients suffering from acute upper gastrointestinal bleeding received propofol sedation administered by a registered nurse. Among these, 15 patients were classified into American Society of Anesthesiologists (ASA) class IV, 84 were ASA class III, and 21 were ASA class II. Patients without gastrointestinal bleeding, who also received propofol during the same period and were matched for age, gender, and ASA class, served as controls., Results: Endoscopic hemostasis was achieved in 98.3 % of patients, and 97.5 % were satisfied with the procedure. In patients with gastrointestinal bleeding, the rates of hypotension (systolic blood pressure < 90 mmHg) and hypoxemia (peripheral oxygen saturation < 90 %) were 8.3 % and 6.7 % respectively, values higher than those in the control group. However, neither mask ventilation nor endotracheal intubation was necessary. Although two patients with gastrointestinal bleeding developed pneumonia, most likely due to aspiration during the procedure, they recovered within 5 days of treatment. There were no sedation-associated severe complications or mortalities., Conclusion: Using a strict protocol designed to protect the patient's airway and cardiovascular function, nurse-administered propofol sedation during emergency upper gastrointestinal endoscopy is safe and appropriate in cases of acute gastrointestinal bleeding.

In situations in which clinical assessment of sedation level is compromised, such as deep sedation/analgesia with and without neuromuscular blockade (NMB), electroencephalogram-based monitoring may potentially assist in achieving balance between inadequate and excessive levels of sedation. To validate the bispectral index (BIS) for use in clinical practice, correlation and possible differences in outcome using clinical assessment versus clinical assessment augmented by electroencephalogram-based monitoring were determined. BIS monitoring was decisive in ICU care in 9 of 15 patients in this series. The most significant potential benefit was obtained in the subset of patients receiving NMB.

The quality of sedation management in mechanically ventilated patients has been a source of concern in recent years. This paper summarises the literature on the principles of optimal sedation, discusses the consequences of over and undersedation, highlighting the importance of appropriate pain management, and presents a case study using the results of an audit of 48 mechanically ventilated adults. As a result of the review and audit, we are implementing changes to practice. The most important recommendations from the literature are the use of a sedation scale, setting of a goal sedation score, appropriate pain management and implementation of a nurse initiated sedation algorithm. Other recommendations include use of bolus rather than continuous sedative infusions and recommencing regular medications for anxiety, depression and other phychiatric disorders as soon as possible. A recommendation arising from our audit was the need to identify patients at high risk of oversedation and undersedation and adopt a proactive rather than reactive approach to management. The practice goal is to provide adequate and appropriate analgesia and anxiolysis for patients. This will improve patient comfort while reducing length of mechanical ventilation and minimising risk of complications.

This observation study examined the behaviors of 20 sedated, mechanically ventilated children, ages 1 month to 14 years. Observations were made using the Comfort Scale at the beginning and end of the two-hour observation period and of body and facial movements, behavior state, and environmental activity occurring during the 2-hour period. Mean Comfort scores at both measurement points were 16, below the target sedation level. In addition, while most children were in sleep states, they exhibited many body movements, particularly of the upper extremities. Body movements were related to behavior state but not to Comfort scores. Environmental activity was not significantly related to child activity, behavior state, or Comfort scores. Sedation scales in children may be best used in conjunction with behavior observations although further research is needed to determine the predictive capabilities of either scales or behavior on actual ventilation outcomes.

Perianesthesia nurses care for patients who receive anesthesia, sedation, and analgesia. Anesthesia, sedation, and analgesia can adversely affect the patient with obstructive sleep apnea syndrome (OSAS). Increased patient morbidity and mortality have been associated with the perianesthesia management of the patient with OSAS and can potentially impact every phase of the perianesthesia experience. Negative outcomes have been associated with respiratory arrest after the administration of opioid or sedative medications, difficult intubation or failure to intubate, and respiratory obstruction after extubation. It is important for the perianesthesia nurse to identify the implications of OSAS and respond with appropriate patient management strategies. The purpose of this article is to identify perianesthesia implications associated with the patient with formally diagnosed OSAS, patient characteristics that may imply undiagnosed OSAS, and considerations for the management of the patient with OSAS for each phase of the perianesthesia experience. The new ASA practice guidelines developed to assist the practitioner in the decision-making process for the management of this patient population have been incorporated.

Background and Study Aims: Propofol has several attractive properties, including a rapid onset of action and rapid recovery. However, the administration of propofol sedation in the absence of anesthesiologists remains controversial. This report describes the safety profile of propofol sedation for endoscopy when administered by registered nurses under the supervision of endoscopists., Patients and Methods: The study was conducted in the endoscopic center of a Japanese private hospital. With assistance from an anesthesiologist, a protocol for administration of propofol by registered nurses was developed. Over the past 6 years, 27,500 patients received nurse-administered propofol sedation. The safety and patient satisfaction with this sedation procedure were evaluated., Results: Among the participating patients, 6.7% developed hypoxemia (Sp(O2) < 90%); 6.2% required oxygen administration via a nasal cannula. Severe hypoxemia (Sp(O2) < 85%) occurred in 121 patients (0.62%) during upper gastrointestinal endoscopy and 20 patients (0.25%) during colonoscopy, but neither mask ventilation nor endotracheal intubation was necessary. A decline in blood pressure (systolic blood pressure < 90 mm Hg) was seen in 3.5% of the colonoscopy patients and 1.2% of the upper endoscopy patients. However, hypotension was corrected immediately using an intravenous saline solution. Patients who received propofol sedation expressed overall satisfaction on a 10-point visual analogue scale (with an average of 9.4 points). Among patients who had previously received a combination of midazolam and pethidine for colonoscopy, 85% preferred propofol sedation. The mean time from the end of the procedure to full recovery was 14.6 min., Conclusions: Administration of propofol by registered nurses under the supervision of endoscopists was safe, and resulted in high rates of patient satisfaction.

Objectives: An agreement among physician, nurse, and family on the issue and a solution developed by all will improve the quality of work. The aims of this study were to determine health care professionals' (physicians and nurses) attitude toward parental presence during invasive procedures and toward parental participation in this decision and to investigate the difference between the approach of physicians and nurses., Methods: This study was performed on the physicians and nurses of the Medical Faculty of the Department of Pediatrics of Ege University between December 2003 and March 2004. The questionnaire delivered was completed by 49 (94%) of 52 nurses and 51 (89%) of 57 physicians., Results: Parental presence during blood sampling, simple wound repair/suture, lumbar puncture, and bone marrow aspiration/biopsy was approved by 72.5%, 27.5%, 66.7%, and 82.4% of the physicians and 53.1%, 57.1%, 81.6%, and 85.7% of the nurses, respectively. None of the health care professionals preferred parents to attend during any kind of resuscitation. Attitudes of the nurses and physicians were found to be similar between the 2 groups except for simple wound repair. Major determinants of the decision about the agreement for parental presence were procedural invasiveness for physicians (reported by 82.5%) and level of sedation for nurses (reported by 75.5%). The mean ages of both groups of health care professionals who did not approve parental presence during invasive procedures were lower than that of the ones who approved for all procedures., Conclusion: The physicians and nurses in the study population tended to prefer parents not to be present during procedures as the level of invasiveness increased. An agreement between the attitudes of physicians and nurses toward parental presence during invasive procedures is essential for improving quality of service, especially in the dynamic environment of the emergency department.

Unlabelled: Current empirical evidence supports claims that pain in sedated, unconscious Intensive Care Unit (ICU) patients is underrated and under-treated. Given the severity of ICU patients' illness pain management, whilst important, may not be considered a priority and therefore can be easily overlooked. The aim of this study was to validate the Behavioural Pain Scale (BPS) for the assessment of pain in critically ill patients by evaluating facial expressions, upper limb movements and compliance with mechanical ventilation., Methods: A prospective, descriptive repeated measures study design was used to assess the validity and reliability of the BPS for assessing pain in critically ill patients undergoing routine painful (repositioning) and non-painful (eye care) procedures., Results: An average of 73% of BPS scores increased (indicating pain) after patients were repositioned, as opposed to 14% after eye care. This increase was statistically significant for repositioning (p < 0.003) but not for eye care (p > 0.3). The odds of an increase in BPS between pre- and post-procedure assessments was more than 25 times higher for repositioning compared with eye care (p < 0.0001), after controlling for analgesics and sedatives., Conclusion: The BPS was found to be a valid and reliable tool in the assessment of pain in the unconscious sedated patient. Results also highlighted that traditional pain indicators, such as fluctuations in haemodynamic parameters, are not always an accurate measure for the assessment of pain in unconscious patients and as such more objective pain assessment measures are essential. Finally, further validation of the BPS and identification of other painful routine procedures is needed to enhance pain management delivery for unconscious patients.

Objective: The aim of the study was to describe and compare physicians' and nurses' estimated use of sedatives and analgesics in patients requiring mechanical ventilation in Danish Intensive Care Units (ICUs) in 2003., Design: Questionnaires were mailed in January 2003 to all Danish ICUs providing mechanical ventilation (n = 48). One physician and one nurse at each site were included in the study., Results: Thirty-nine questionnaires were returned by physicians (response rate 81%) and 43 by the nurses (response rate 90%). Physicians and nurses agreed that sedation related decisions are predominately made during rounds and that most decisions are made by physicians and nurses collaboratively. Only 9% of the nurses and 23% of the physicians reported using a written protocol for sedation, while 30% of the nurses and 44% of the physicians reported the use of sedation scoring systems. The study generally supported the hypothesis, that nurses' and physicians' would respond similarly, but there were, however, significant variations, regarding formal sedation practices., Conclusions: Sedation decisions are made collaboratively by nurses and physicians, while sedation protocols and scoring systems are still not systematically implemented in Danish ICUs. The most common drugs for sedation of the mechanically ventilated patient are propofol and fentanyl by continuous infusion. It is recommended that the ICUs collaborate on developing evidence-based standards for sedation and that clinical databases are introduced, which may be used to assess the efficacy of such standards.

Introduction: Among the intensive care specialized nursing staff, knowing the sedation level of the patient under their responsibility is of crucial importance. The present study evaluated the knowledge that nurses specialized in intensive care (NSIC) have on the Ramsay Scale (RS) and the way in which they apply it., Material and Methods: Those personnel who were developing their activity in the intensive care units (ICU) of four public hospitals of the cities of Merida, Yucatan, Mexico were enrolled during May 2003. The information was obtained by applying an expressly designed questionnaire that contained both demographic endpoints (age, years of experience as NSIC and type of ICU) and those related with the RS (clinical components that it evaluates, operative definitions, frequency of use per week or day). 95% (95% CI) confidence intervals were applied and odds ratio (OR) was used to determined the likelihood of the event., Results: Of the 60 nurses interviewed, 75% did not know the RS. Age was a significant factor associated with its knowledge, since 11 of 23 with an age equal to or less than 38 years (47.8%) and 4 of 37 over 38 years (10.8%) knew what it evaluated (OR of 4 for the group of lower age, 95% CI 1.5 to 12.3, p = 0.002). Of 15 NSIC who knew what it evaluated, 9 (60%) also knew its operative definitions, and stated that they applied it adequately per day., Conclusions: In this sample, there is an elevated percentage of NSIC who did not know the RS. Age was the factor associated with lack of knowledge.