From: The incidence of sub-optimal sedation in the ICU: a systematic review
Study | Study design and comparisons made | Number | Treatment arms (if relevant) | Incidence of sub-optimal sedation | Incidence of over-sedation | Incidence of under-sedation | Incidence of optimal sedation | Sedation scale/monitoring system used | Definition of optimal sedation |
---|---|---|---|---|---|---|---|---|---|
Weinert, et al., 2007 [44] | Cohort study | 274 |  |  | 326 (2.6%) of 12,414 assessments. 111 patients (40%) had ≥ 1 rating of over-sedation. Patients were unarousable/minimally arousable 32% of the time. | 1,731 (13.9%) of 12,414 assessments. 211 (76.2%) had ≥ 1 rating of under-sedation. | 10,357 (83%) of 12,414 | Minnesota Sedation Assessment Tool -- nurse assessment | Arousal level 3-5 (of 6-point scale) |
Martin, et al., 2006 [30] | Cohort study | 305 (from 220 ICUs) | Â | Â | 42.6% of 49 patients sedated 24-72 hours, 39.5% of 157 patients sedated >72 hours, and 43.9% of 57 patients under weaning had significantly deeper sedation than desired level | 5.2% of 157 patients sedated >72 hours and 3.5% of 57 patients under weaning had significantly lower sedation than desired level | In patients sedated >72 hours, the desired Ramsay score was 0-4 in 44% of cases -- this was achieved in 28%; in 55% of patients, the desired value was 4-5, which was achieved in 68%; in 1% of patients, the desired score was 6, which was achieved in 6%. | Ramsay scale | Individual to each patient |
Payen, et al., 2007 [43] | Cohort study | 1,381 | Â | Â | 258 (57%) of 451 patients on sedation day 2; 169 (48%) of 355 patients on day 4; 109 (41%) of 266 patients on day 6 | Â | Â | Multiple: most commonly Ramsay, RASS, Sedation-Agitation scale | Over-sedation defined as Ramsay 5-6, RASS -5 or --4, Sedation-Agitation scale 1-2 |
Sandiumenge, et al., 2000 [36] | RCT/observational study of sedative drugs | 63 | Midazolam | 19 (7%) of 266 hours | Â | Â | 247 (93%) of 266 hours | Modified Ramsay scale | Equivalent of Ramsay 5-6 (for deep sedation) |
 |  |  | 2% propofol | 14 (9%) of 156 hours |  |  | 142 (91%) of 156 hours |  |  |
Carrasco, et al., 1993 [26] | RCT (with economic study) of sedative drugs | 88 | Midazolam | 18% of time (hours) | Â | Â | 82% of time (hours) | Ramsay scale; Glasgow coma scale (modified by Cook and Palma) | Ramsay scale 2-5, Glasgow coma scale 8-13 |
 |  |  | Propofol | 7% of time (hours) |  |  | 93% of time (hours) |  |  |
McCollam, et al., 1999 [23] | RCT of sedative drugs | 30 | Lorazepam | 32% of assessments | 14% of assessments | 18% of assessments | 68% of assessments | Ramsay scale | Ramsay scale 2-4 |
 |  |  | Midazolam | 21% of assessments | 6% of assessments | 16% of assessments | 79% of assessments |  |  |
 |  |  | Propofol | 38% of assessments | 7% of assessments | 31% of assessments | 62% of assessments |  |  |
Chinachoti, et al., 2002 [40] | RCT of sedative drugs | 152 | Remifentanil | 28% of patients; 17.3% of time (hours) | 13% of time (hours) | 4% of time (hours) | 78% of patients (without midazolam), 83% of time (hours) (maintenance phase) | SAS | SAS 4 with no or mild pain |
 |  |  | Morphine | 27% of patients; 16% of time (hours) | 13% of time (hours) | 3% of time (hours) | 73% of patients (without midazolam), 84% of time (hours) (maintenance phase) |  |  |
Harper, et al., 1991 [25] | RCT of sedative drugs | 37 | Alfentanil low, moderate and high doses -- results reported together | Â | 4 patients had >10% of time at sedation level 6 | 3 patients had >10% of time at sedation level 1 | Â | Ramsay (assessed hourly) | 2-5 |
Manley, et al., 1997 [46] | RCT (and economic study) of sedative drugs | 26 | Morphine + midazolam | 56.8% of time | Â | Â | 43.2% of time | North Staffordshire ICU (modification of Ramsay/Addenbrooke's scores) | 3-4 |
 |  |  | Alfentanil + propofol | 57.8% of time |  |  | 42.2% of time |  |  |
Millane, 1992 [21] | RCT of sedative drugs | 24 | Isoflurane for 24 hours followed by propofol | 3.4% | Â | Â | Â | Ramsay plus subjective nurse assessment | 2-3 (plus subjective nurse assessment) |
 |  |  | Propofol for 24 hours followed by isoflurane | 3.6% |  |  |  |  |  |
Muellejans, et al., 2004 [41] | RCT of sedative drugs | 152 | Remifentanil | 11.7% of time (hours) | Â | Â | 88.3% of time (hours) | SAS | 4 |
 |  |  | Fentanyl | 10.7% of time (hours) |  |  | 89.3% of time (hours) |  |  |
Muellejans, et al., 2006 [47] | RCT of sedative drugs | 80 | Remifentanil -- propofol | 41% of time | 28% of time | 13% of time | 59% of time | 3 level sedation score specific to study | Level 2 |
 |  |  | Midazolam -- fentanyl | 30% of time | 19% of time | 11% of time | 70% of time |  |  |
Chamorro, et al., 1996 [45] | RCT of sedative drugs | 98 | Propofol | 332 assessments -- 3% (after first hour) | Â | Â | 332 assessments -- 76.5% effective, 20.5% acceptable | Study-specific (modified Glasgow coma scale). Patients monitored at 1 and 6 hours and then every 12 hours. | 4 = effective, 3 = acceptable less than 3 = ineffective |
 |  |  | Midazolam | 355 assessments -- 7.6% |  |  | 355 assessments -- 66.2% effective, 26.2% acceptable |  |  |
Barr, et al., 2001 [34] | RCT of sedative drugs | 24 | Lorazepam | 51% of time | 47% of time | Â | 49% of time | Modified Ramsay | 3-4 (5-6 = over-sedation) |
 |  |  | Midazolam | 31% of time | 22% of time |  | 69% of time |  |  |
Finfer, et al., 1999 [33] | RCT of sedative drugs | 40 | Diazepam (intermittent) | 9 (64.3%) of 14 patients; 15.0% of time (hours) | 2.8% of time (hours) | 21.1% of time (hours) | 5 (35.7%) of 14 patients; 85.0% of time (hours) | Modified Ramsay | 1-4 |
 |  |  | Midazolam (continuous) | 6 (35.3%) of 17 patients; 40.8% of time (hours) | 14.8% of time (hours) | 0% of time (hours) | 11 (64.7%) of 17 patients; 59.2% of time (hours) |  |  |
Richman, et al., 2006 [37] | RCT of sedative drugs | 30 | Midazolam | Mean 9.1 hours/day (SD 4.9) | Â | Â | Â | Modified Ramsay | Individual to each patient |
 |  |  | Midazolam and fentanyl | Mean 4.2 hours/day (SD 2.4) |  |  |  |  |  |
Karabinis, et al., 2004 [39] | RCT of sedative drugs | 161 | Remifentanil | 4.4% of time | Â | Â | 95.6% of time (median) | SAS | 1-3 |
 |  |  | Fentanyl | 1.9% of time |  |  | 98.1% of time (median) |  |  |
 |  |  | Morphine | 1.0% of time |  |  | 99.0% of time (median) |  |  |
Pandharipande, et al., 2007 [48], Pandharipande, et al., 2006 [59] | RCT of sedative drugs | 106 | Dexmedetomidine | 20% of patients according to nurse goals; 33% according to physician goals | 15% of patients | Â | 80% of patients within 1 point of nurse goal; 67% within 1 point of physician goal | RASS, confusion-assessment method for the ICU (CAM-ICU) | Individual to each patient |
 |  |  | Lorazepam | 33% of patients according to nurse goals; 45% according to physician goals | 33% of patients |  | 67% within 1 point of nurse goal; 55% within 1 point of physician goal |  |  |
Swart, et al., 1999 [50] | RCT of sedative drugs | 64 | Lorazepam | 13% of time | Â | Â | 87.0% of time (SD 10.5) | Addenbrooke's Hospital's ICU sedation scale | Individual to each patient |
 |  |  | Midazolam | 34% of time |  |  | 66.2% of time (SD 23.1) |  |  |
Carson, et al., 2006 [22] | RCT of sedative drugs | 132 | Intermittent lorazepam | 42.8% (ventilator hours) | 37.9% (ventilator hours) | 15.1% (ventilator hours) | Â | Ramsay | 2-3 |
 |  |  | Continuous propofol | 49.9% (ventilator hours) | 38.6% (ventilator hours) | 11.5% (ventilator hours) |  |  |  |
RCT of sedative drugs | 156 | Propofol | 39.8% of time | 12.0% of time | 11.2% of time | 60.2% of time | Ramsay | Individual to each patient | |
 |  |  | Midazolam | 56.0% of time | 18.4% of time | 8.1% of time | 44.0% of time |  |  |
Park, et al., 2007 [49] | RCT of sedative drugs | 134 (111 analysed) | Analgesia-based sedation | 50% of time | Â | Â | 50% of time on SIMV (median) | Assessor judgement | Adequate judged as awake or easily rousable |
 |  |  | Hypnotic-based sedation | 81% of time |  |  | 19% of time on SIMV (median) |  |  |
Cigada, et al., 2005 [32] | Observational study of sedative drugs | 42 | Propofol or midazolam with enteral hydroxyzine with or without supplemental lorazepam. IV drugs were tapered after 48 hours. | 36.9% of assessments as judged by Ramsay score; 17% by nurse assessment | 421 (24.6%) of 1,711 assessments (Ramsay score) 42 (7.3%) of 577 assessments (nurse judgement) | 211 (12.3%) of 1,711 assessments (Ramsay score) 56 (9.8%) of 577 assessments (nurse judgement) | 1,079 (63.1%) of 1,711 assessments (Ramsay score) 479 (83%) of 577 assessments (nurse judgement) | Ramsay score plus nurse assessment | Adequate sedation defined as the achievement of the planned Ramsay score or nurse judgement as adequate |
Barrientos-Vega, et al., 2001 [29] | Observational study of sedative drugs | 51 | 2% propofol (compared with historical cohort on 1% propofol -- not reported here) | 8 (15.6%) of 51 patients judged therapeutic failure on 2% propofol (inadequate level of sedation) | Â | Â | Â | Ramsay score | 4-5 |
MacLaren, et al., 2007 [42] | Observational study of sedative drugs | 40 | Dexmedetomidine as adjunct to lorazepam/midazolam/propofol | 35% of patients with dexmedetomidine; 52% without | 12 (30%) patients with dexmedetomidine; 9 (23%) without | 4 (10%) patients with dexmedetomidine; 12 (30%) without | 65% of patients with dexmedetomidine; 48% without | SAS | 3-4 |
Shehabi, et al., 2004 [24] | Observational study of sedative drugs | 20 | Dexmedetomidine with supplemental midazolam if required | 455 (33%) of 1,381 assessments | 97 (7%) of 1,381 assessments were Ramsay level 6 | 137 (10%) of 1,381 assessments were Ramsay level 1 | 926 (67%) of 1,381 | Ramsay | 2-4 |
Sackey, et al., 2004 [51] | RCT of sedation devices | 40 | Isoflurane using AnaConDa | 46% of time; nursing staff estimate 11% of time | 44% of time | 2% of time | 54% of time; nursing staff estimate 89% of time | Bloomsbury scale | - 1 to +1 |
 |  |  | IV midazolam | 41%; nursing staff estimate 13% of time | 37% of time | 4% of time | 59% of time; nursing staff estimate 87% of time |  |  |
Walsh, et al., 2008 [52] | Observational study of sedation devices | 30 | All sedated patients | Â | 137 (32.9%) of 416 assessments (Ramsay score 5-6) | 5 (1.2%) of 416 assessments (Ramsay score 1) | Â | Entropy Module/Modified Ramsay scale | None stated. Refers to guidelines suggesting 2-3 is adequate and heavy/over-sedated is 5-6. |
Hernández-Gancedo, et al., 2006 [28] | Observational study of sedation scales | 50 |  |  | 44% (66 cases) -- Ramsay level 6 |  | 25% (38 cases) | Ramsay, Observer's Assessment of Alertness and Sedation | Ramsay 3-4 |
Roustan, et al., 2005 [27] | Observational study of sedation scales | 40 | All sedated patients -- treated with midazolam and morphine | Â | 93 (61.6%) of 151 records | 19 (12.6%) of 151 records | Â | Ramsay, Comfort score, EEG | Ramsay 3-4 |
McMurray, et al., 2004 [38] | Observational study of sedation scales | 122 | Propofol-containing regimens | 15.6% of time | Mean 5.0% of time (SD 12.7) | Mean 10.6% of time (SD 14.5) | Mean 84.4% of time (SD 18.0) | Modified Ramsay | Individual to each patient |
Detriche, et al., 1999 [53] | Before-after study of introduction of sedation protocol | 55 | Before | Â | Â | 20 (30%) of 67 assessment days | Â | Brussels sedation scale | 3-4 |
 |  |  | After protocol introduction |  |  | 9 (12%) of 77 assessment days |  |  |  |
Costa, et al., 1994 [54] | RCT of controlled and empirical sedation | 40 | Controlled | 17% of time | Â | Â | 83% of time | Ramsay, and Glasgow coma scale modified by Cook and Palma | Â |
 |  |  | Empirical | 65% of time |  |  | 35% of time |  |  |
MacLaren, et al., 2000 [35] | Before-after comparison of sedation protocol | 158 | Before | Â | Â | 22.4% (experience of anxiety or pain) | Â | Modified Ramsay | 4 |
 |  |  | After |  |  | 11.0% (P < 0.001) |  |  |  |
Tallgren, et al., 2006 [3] | Before-after comparison of sedation protocol | 53 | Before reinforcement | Â | Â | Median Ramsay level was 4 during the day and 5 at night, in contrast to the study's stated aim of Ramsay level 2-3 during the day and 3-4 at night | Â | Â | Ramsay |
 |  |  | After reinforcement |  |  | Median Ramsay level was 4 during the day and 5 at night, in contrast to the study's stated aim of Ramsay level 2-3 during the day and 3-4 at night |  |  |  |
Observational study | 250 | Â | Â | 50% of patients had MAAS 0-2 (although 2 was target for study, 0-1 could be viewed as over-sedated) | 0% | 39% of patients achieved MAAS 3 in ventilated period | MAAS | Stated 2-3 but results reported for patients achieving 3 |