*Corresponding Author:
Huifang Yu
Critical Care Medicine Department Alpha, Renmin Hospital of Wuhan University (Hubei General Hospital), Wuhan, China
E-mail:
[email protected]

This article was originally published in a special issue, "Therapeutic Perspectives in Biomedical research and Pharmaceutical Sciences and their nursing methods"

Indian J Pharm Sci 2021:83(4)Spl issue “34-39”

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Abstract

To explore the effect of programmed sedation and analgesia combined with nursing intervention on weaning and extubation of patients with tracheal intubation. 128 patients who underwent tracheal intubation in our hospital from January 2020 to March 2021 were randomly divided into two groups. The control group received routine intensive care intervention, used and adjusted analgesic and sedative drugs according to the doctor’s instructions. The intervention group was evaluated and monitored for programmed sedation and analgesia based on the control group. The mechanical ventilation, with tube and intensive care unit hospitalization time, delirium, unplanned extubation, ventilator-associated pneumonia and deep vein thrombosis were compared between the two groups. The incidence of adverse events, nursing satisfaction and the dosage of analgesic and sedative drugs were evaluated. The mechanical ventilation, with tube and intensive care unit hospitalization time were significantly shorter in intervention group (p<0.05). The incidence of adverse events such as delirium, unplanned extubation, ventilator-associated pneumonia and deep vein thrombosis in the intervention group was significantly lower than that in the control group (p<0.05), nursing satisfaction has also increased significantly. Program analgesia and sedation combined care for intensive care unit patients with tracheal intubation can improve the clinical efficacy, shorten the time of weaning extubation and intensive care unit stay, reduce the amount of sedatives, reduce the incidence of related adverse reactions and improve nursing satisfaction.

Keywords

Programmed analgesia and sedation, ventilator-associated pneumonia, extubation, analgesia, sedation

Tracheal intubation is the main treatment measure for patients with respiratory failure or decreased airway protection in intensive care unit (ICU) [1,2]. An ICU survey study collected from all hospitals in Scotland showed that the incidence of ICU intubation was as high as 70 % [3]. Compared with the anesthesiology department, the rate of adverse consequences and serious defects of ICU airway management is much higher [4,5]. In addition, ICU patients with tracheal intubation are mostly critically ill patients. The torture of the disease, various restraints, and invasive operations can easily cause anxiety and psychological trauma to patients with mechanical ventilation (MV) [6,7]. Analgesia and sedation, as the basic treatment for mechanically ventilated patients in ICU, can improve patient comfort, reduce anxiety, promote nursing and adapt to assisted ventilation [8]. However, inappropriate analgesia and sedation can prolong the patient’s MV time, increase the incidence of ventilator-associated pneumonia (VAP), deep vein thrombosis, accidental extubation and the patient’s painful memories during ICU treatment reaction [9-11].

Programmed sedation and analgesia (PSA) is based on analgesia and systematically adjusts the amount of sedatives according to the goal of sedation, which is conducive to grasping the balance between insufficient sedation and excessive sedation [12]. However, in actual work, there are still many problems in the implementation of PSA, such as ignoring pain and pain assessment, uncertain frequency of sedation assessment, insufficient sedation concept and few people with moderate sedation [13,14]. Therefore, the effective implementation of PSA depends on the close cooperation of medical and nursing care to improve the prognosis of patients [15].

Therefore in our study, the combined care of programmed analgesia and sedation for ICU patients with tracheal intubation aims to explore the impact on patients with weaning extubation and related complications, to provide reference for clinical treatment and nursing.

Materials and Methods

General data:

128 cases of tracheal patients in ICU of our hospital from January 2020 to March 2021 were selected as the study population. The inclusion criteria: Age >18 y; Complete clinical data; Obtain patients or the patient’s technical informed consent was approved by the ethics department of our hospital. Exclusion criteria: suffer from severe neurological and muscle diseases; use drugs and long-term opioids to relieve pain and cause dependence; patients with severe mental illness; patients who require deep sedation. The main diagnoses of the patient include: cerebral hemorrhage, type 2 diabetic ketoacidosis, gastrointestinal hemorrhage, respiratory failure, acute severe pancreatitis, cervical spinal cord injury, septic shock, lung infection and other diseases. Use random number table method to divide into intervention group and control group.

Methods:

Before sedation and analgesia treatment, both groups of patients removed reversible factors such as the ward environment, avoided unnecessary iatrogenic stimulation, corrected shock, hypoglycemia and other adverse reactions and assessed the patient’s disease itself that requires sedation and analgesia and whether there are any problems. Comfortable, unable to cooperate with treatment, risk of accidental extubation, etc. The patient’s analgesic drugs were fentanyl (loading dose 0.7-1.5 μg/kg, maintenance dose 0.2-1.8 μg/kg.h) or sufentanil (loading dose 0.15-0.25 μg/kg, maintenance dose 0.1-0.3 μg/kg.h); sedative drugs are dexmedetomidine (loading dose 1 μg/kg, maintenance dose 0.2-0.7 μg/kg); propofol (loading dose 1-2.5 mg/ kg, maintenance dose 0.5-4.0 mg/kg.h), midazolam (loading dose 2-3 mg, maintenance dose 0.05 mg/ kg.h). The control group received routine intensive care intervention and used and adjusted analgesia and sedative drugs according to doctor’s instructions. The intervention group received programmed sedation and analgesia evaluation and monitoring on the basis of the control group. Basic pain assessment: Use the intensive care pain observation tool (COPT) for basic pain assessment and evaluate the analgesic effect every hour. If necessary, increase the dose of analgesic drugs appropriately until COPT ≤3 min and then change to a 4 h evaluation [16]. If the dose of sedative drugs is not reached appropriately, increase. Evaluation of delirium: If the patient has acute changes or fluctuations in the state of consciousness, characteristics of attention disorder and changes in the level of consciousness, confusion, etc, perform a confusion assessment method for the intensive care unit (CAM-ICU) delirium assessment in a timely manner and report to the doctor to take necessary measures in time. Daily wake-up strategy: In order to avoid drug accumulation and prolong the drug effect [19], stop the sedative on the patient at 7:00 every day and pay close attention to the change of the patient’s vital signs and recovery of consciousness. Weaning care: Decrease the daily dose of sedatives by 10 %-25 %. Observe whether the patient has any adverse reactions after weaning, such as delirium, restlessness, irritability, etc., once found, notify the doctor immediately and began to implement sedation assessment. Basic assessment of sedation: Richmond agitation-sedation scale (RASS) are scored every hour, so that patients are between 0 and -2 points during the day and between -1 and +3 at night [17]. If the dose of sedative drugs is not reached appropriately, increase. Evaluation of delirium: If the patient has acute changes or fluctuations in the state of consciousness, characteristics of attention disorder, changes in the level of consciousness, confusion, etc., perform a CAM-ICU delirium assessment in a timely manner and report to the doctor to take necessary measures in time [18]. Daily wake-up strategy: In order to avoid drug accumulation and prolong the drug effect [19], stop the sedative on the patient at 7:00 every day and pay close attention to the change of the patient’s vital signs and recovery of consciousness. Weaning care: Decrease the daily dose of sedatives by 10 %-25 %. Observe whether the patient has any adverse reactions after weaning, such as delirium, restlessness, irritability, etc., once found and notify the doctor immediately. Psychological intervention: When the patient is awake, provide psychological care to eliminate the fear of mechanical ventilation, inform the patient of the safety of the environment in which the patient is located and the good treatment effect and other beneficial psychological hints, so as to reduce the painful memory of the patient during the treatment.

Outcome indicators:

We compared the MV time between the two groups, the length of stay in the ICU, the incidence of delirium, the incidence of unplanned extubation, the incidence of VAP and the amount of analgesic and sedative drugs and the nursing satisfaction the degree was evaluated.

Statistical method:

All analyses were performed using the statistical software EmpowerStats. Count data is expressed as n/%, with χ2 test, measurement data is expressed with x±s and t test, with p<0.05 as the difference is statistically significant. The p value of p<0.05 is considered to be statistically significant.

Results and Discussion

64 patients in the intervention group, aged from 29 to 80 y old, with an average age of 59 y old, 34 females. Acute Physiology and Chronic Health Score (APACEII) 34 points; 64 patients in the control group, aged between 31 and 82 y old, with an average age of 57 y, 35 female cases, APACEII score 32 points. The baseline information was similar in two groups. See for details Table 1. The MV, with tube and ICU stay time were significantly shorter in the intervention group (p<0.05). See Table 2 and fig. 1 for details.

  Intervention group (n=64) Control group (n=64) t/χ2 P
Age 59.1±19.1 57.3±18.6 0.53 0.59
Gender: (Female) 34 (53.1 %) 35 (54.7 %) 0.03 0.85
Type of disease        
Cerebral hemorrhage 10 (15.6 %) 11 (17.2 %) 0.06 0.81
Diabetic ketoacidosis 2 (3.1 %) 1 (1.6 %) 0.34 0.55
Gastrointestinal bleeding 8 (12.5 %) 6 (9.4 %) 0.32 0.57
Acute severe pancreatitis 3 (4.7 %) 2 (3.1 %) 0.21 0.64
Cervical spinal cord injury 2(3.1 %) 3 (4.7 %) 0.41 0.60
Septic shock 20 (31.2 %) 19 (29.7 %) 0.04 0.84
Lung infection 19 (29.7 %) 22 (34.4 %) 0.32 0.50
APACHEII 32.1±15.4 34.1±16.6 -0.70 0.48

Table 1: Baseline Data of the Two Groups

IJPS-tube

Figure 1: Comparison of MV with tube and ICU stay time between the two groups,equation Intervention group;equation Control group

The incidence of delirium in the intervention group was 3.1 % and the incidence of VAP was 12.5 %, which were significantly lower than those in the control group (p<0.05); the incidence of deep vein thrombosis and unplanned extubation was not significant and difference between two groups (p>0.05), see Table 3, fig. 2 for details.

  Intervention group (n=64) Control group (n=64) t P
MV (d) 3.5±1.7 4.2±2.0 -2.13 0.03
With tube time (d) 3.8±1.8 4.5±2.0 -2.03 0.03
ICU stay (d) 6.0±3.2 7.5±3.3 -2.61 0.01

Table 2: Comparison of MV with Tube and ICU Stay Time Between the Two Groups

  Intervention group (n=64) Control group (n=64) χ2 P
Delirium 2 (3.1 %) 8 (12.5 %) 3.91 0.04
VAP 5 (7.8 %) 13 (20.3 %) 4.14 0.04
Thrombosis 3 (4.7 %) 6 (9.4 %) 1.08 0.29
Unplanned extubation 3 (4.7 %) 4 (6.2 %) 0.69 0.15

Table 3: Comparison of the Incidence of Adverse Events Between the Two Groups

IJPS-incidence

Figure 2: Comparison of the incidence of adverse events between the two groups (%),equation Intervention group;equation Control group

The sedative drugs were significantly lower in the intervention group, whether it was propofol or dexmedetomidine, while the analgesic drugs used more than the control group (p< 0.05), see Table 4, fig. 3 for details. The nursing satisfaction rate was significantly higher in the intervention group (p <0.05), see Table 5, fig. 4 for details.

  Intervention group (n=64) Control group (n=64) t P
Fentanyl (mg) 1.5±0.7 1.2±0.5 2.73 0.05
Sufentanil (mg) 0.34±0.16 0.28±0.12 2.94 0.04
Propofol (g) 2.6±1.0 3.1±1.5 -2.21 0.02
Dexmedetomidine (mg) 0.5±0.24 0.6±0.28 -2.16 0.04
Midazolam (mg) 71±21.6 82±31.2 -2.52 0.01

Table 4: The Average Dosage of Analgesic and Sedative Drugs in the Two Groups Per Day

  Very dissatisfied Dissatisfied Fair Satisfied Very satisfied Total satisfaction rate
Intervention group 0 (0 %) 1 (1.5 %) 1 (1.5 %) 30 (45 %) 32 (50 %) 62 (96.9 %)
Control group 1 (1.5 %) 2 (3.0 %) 6 (9.0 %) 29 (40.6 %) 26 (71.8 %) 55 (85.9 %)
χ2           4.87
p           0.02

Table 5: Comparison of Nursing Service Satisfaction Between the Two Groups [n (%)]

IJPS-dosage

Figure 3: Average dosage of analgesic and sedative drugs in the two groups per dayequation Intervention group;equation Control group

IJPS-nursing

Figure 4: Comparison of nursing service satisfaction between the two groups,equation Intervention group;equation Control group

Analgesia and sedation are part of the treatment of ICU patients with tracheal intubation. Excessive sedation and insufficient sedation can bring hidden dangers to the life safety of patients and increase unnecessary medical expenditures. In the past, in order to facilitate the management of ICU, the traditional sedation was mostly based on deep sedation [20]. With the development of medical technology and the advancement of mechanical ventilation, the disadvantages of deep sedation have become increasingly apparent [21]. A multicenter prospective cohort study conducted in 45 ICUs from Brazil showed that early deep sedation was associated with adverse outcomes and was an independent predictor of hospital mortality in mechanically ventilated patients [22]. In a multicenter prospective longitudinal cohort study of 11 hospitals in Malaysia, regardless of the sedative used, early deep sedation was independently associated with delayed extubation and high mortality [23]. Excessive sedation can also increase the length of stay in the ICU [24,25]. However, insufficient analgesia and sedation will not only increase the work intensity of the staff, but also increase the pain of the patient, increase the patient’s anxiety, restlessness and even endanger the patient’s life [26,27]. Studies have shown that most ICU survivors have pain and anxiety in their memories of ICU [28].

Therefore, to reduce individual differences in critically ill patients, it is necessary to implement PSA for ICU patients [29]. As one of the important personnel in the management of ICU patients, nurses are important assessors of analgesia and sedation status, as well as important implementers of sedation measures and play an important role in the implementation of PSA [24,30]. PSA joint care is a patient-centered nursing intervention model that requires planned and targeted completion of various nursing tasks, provides patients with individualized solutions and uses the smallest sedatives and maximum humane care to enable patients To achieve the optimal state of analgesia and sedation, while avoiding the related complications caused by insufficient and excessive analgesia and sedation and reducing the incidence of adverse events [31]. Our results also confirm the above view: PSA combined nursing intervention can significantly reduce the time of mechanical ventilation, ICU stay, the incidence of delirium, the incidence of VAP and avoid large-dose infusion of sedative drugs, which improves nursing satisfaction.

The PSA combined nursing intervention model can significantly improve the prognosis of patients and should become a template for the care of patients with ICU tracheal intubation for analgesia and sedation. However, since most of its studies are from nonrandomized controlled trials and the sample size is not large enough, the level of evidence is biased low [32]. A study showed that the implementation rate of the PSA program was only 43.7 % and there was a significant difference in the compliance rate between different hospitals [33]. A sample survey of medical staff in 101 ICUs across Belgium found that the effective rate was only 60 % and increasing the autonomy of nurses and assisting in the detection and management of sedatives can help optimize the goal of analgesia [34]. Most nurses encounter different challenges when using analgesia and sedation strategies. Therefore, it is necessary for nurses to make analgesia and analgesia strategies suitable for them.

This study has some limitations. Since our research population is mainly for Chinese people, it is necessary to be cautious to interpret this result to other populations; secondly, our research sample size is too small and it is not ruled out that some errors may be brought about in the research results [35-37].

The combined care of programmed analgesia and sedation for ICU patients with tracheal intubation can improve the clinical efficacy, shorten the event of weaning extubation and ICU admission, reduce the amount of sedatives and reduce the incidence of related adverse reactions, improve nursing satisfaction.

Conflicts of interest:

The authors declared no conflict of interest.

References