Critically ill patients in some cases can safely self-administer sedatives to manage their own anxiety during mechanical ventilation, according to research published in the July 2017 issue of American Journal of Critical Care.
The innovative approach to sedation is the latest effort to offer tailored care in the intensive care units (ICUs) while improving care results for patients.
“This study builds on 15 years of multi-disciplinary critical care research at the University of Minnesota to find new ways to relieve distressing symptoms such as anxiety for patients during life-threatening illnesses,” said Craig Weinert, MD, contributing author and professor within the University of Minnesota Medical School. “All current sedation practice starts with the assumption that only clinicians should decide how much sedation patients should receive—we show, that in certain situations, patients can safely and effectively make their own sedation decisions.”
Patients in intensive care units (ICUs) are often sedated to enhance their comfort with mechanical ventilator breaths and reduce anxiety. However, the prescribed sedatives are based on clinicians’ assessments of their patients’ discomfort or anxiety and may not meet their needs.
During a pilot randomized clinical trial in three Minnesota ICUs, 17 intubated patients were assigned to self-administer a FDA-approved sedative called dexmedetomidine. Twenty other patients received standard sedation care ordered by their ICU team. Only patients receiving mechanical ventilation who were willing and able to self-manage sedative therapy were eligible for the study.
Patients who self-administered the sedative were instructed to push a button on a standard hospital medication pump when they felt anxious or if they desired medication for relaxation. They were allowed up to three self-administered boluses of sedative per hour. Bedside nurses also adjusted the basal infusion rate, according to the number of patient bolus deliveries in the preceding two hours.
Overall, findings indicate that dexmedetomidine is safe using pre-defined criteria for patients during the later, more stable part of mechanical ventilation. Changes in heart rate and mild hypotension during the infusion were similar to those noted with clinician-administered sedatives. No self-extubations occurred in patients randomized to the experimental group.
A follow-up survey found that a majority of patients in the experimental group were satisfied with their ability to self-administer the sedative. Their anxiety scores were similar to patients who received clinician-administered medication.
Four patients in the control group experienced delirium after enrollment, but no patients in the experimental group experienced delirium after enrollment.
“This feasibility study showed that patients can manage their own sedation while mechanically ventilated. The next step is to conduct a larger trial that shows patient-controlled sedation actually decreases anxiety scores, duration of mechanical ventilation and delirium,” Weinert said. “Fortunately, the NIH is funding the University of Minnesota and Mayo Clinic to conduct a 200-subject trial to answer those questions and since March we’ve been enrolling subjects in the ICUs at the University of Minnesota Medical Center. If this current study shows benefit then this method could be widely adopted by ICUs across the country benefitting millions of patients.”
Weinert and Linda Chlan, RN, PhD, professor of nursing and associate dean for nursing research at Mayo Clinic, led the study.
The study also involved Debra Skaar, PharmD, FCCM, within the University of Minnesota College of Pharmacy; and Mary Fran Tracy, RN, PhD, CCNS, within the University of Minnesota School of Nursing and University of Minnesota Medical Center; and Kay Savik, MS, also within the school of nursing.
Sarah Hayes, PharmD, pharmacy resident at North Memorial Medical Center in Minneapolis, and Breanna Hetland, RN, PhD, CCRN-K, postdoctoral fellow at the Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland were also contributing authors.
The research was supported by the National Institute of Nursing Research, National Institutes of Health. Hospira Inc. supplied the study medication and laboratory testing.