From American Journal of Health-System Pharmacy

Daily Interruption of Sedation in Patients

Treated with Mechanical Ventilation
Abstract

Purpose. The evidence evaluating daily interruption of sedation (DIS) in mechanically ventilated
patients, the benefits of this intervention, and the barriers to its incorporation into clinical
practice are reviewed.
Summary. Recent epidemiologic studies have identified a high prevalence of oversedation in
the intensive care unit (ICU). The practice of DIS, which involves withholding all sedative and
analgesic medications until patients are awake on a daily basis, can limit excessive sedation. DIS
has been shown to reduce the duration of mechanical ventilation and length of ICU stay, lessen
the number of neurodiagnostic tests to assess for changes in mental status, decrease the
frequency of complications associated with critical illness, and reduce the total dose of
benzodiazepines and opiates administered. Although recent studies support the use of DIS, it
remains underutilized in clinical practice and additional trials may be needed before this
intervention will gain widespread acceptance. Barriers to the use of DIS include a lack of nursing
acceptance and concerns regarding patient removal of invasive devices, patient discomfort,
respiratory compromise, and withdrawal syndromes. Some clinicians are also concerned about
the possibility of long-term psychological sequelae and the risk of myocardial ischemia during
DIS in patients with coronary risk factors.
Conclusion. DIS limits oversedation in the ICU without compromising patient comfort or safety
and should be incorporated into the routine care of mechanically ventilated patients. Clinicians
should be aware of the numerous barriers that prevent the use of DIS and address these at
their institution to increase its use.
From Critical Care Medicine

Epidemiology of and Factors Associated with

End-of-life Decisions in a Surgical Intensive Care
Unit
Abstract

Objective: To investigate the epidemiology of and possible factors associated with end-of-life
decisions in a surgical intensive care unit.
Design: Analysis of prospectively collected data.
Setting: University hospital surgical intensive care unit.
Patients: All patients admitted to the surgical intensive care unit between September 2002 and
July 2006.
Measurements and main results: During the study period, 14,720 patients were admitted to the
surgical intensive care unit (61.8 male; mean age, 62 yrs). The prevalence of end-of-life
decisions was 2.7% (n = 398); 230 patients (1.6%) had a do-not-resuscitate order, 90 (0.6%) had
a decision to withhold therapy, and 78 (0.5%) had a decision to withdraw life-supportive therapy.
Patients with end-of-life decisions had higher severity scores on the day of intensive care unit
admission, were mostly unplanned admissions, were older, and were more commonly referred
from the emergency room or other hospitals compared to those who did not have an end-of-life
decision. The prevalence of end-of-life decisions increased significantly with the severity of
sepsis. An end-of-life decision was made for 29% of the patients who died in the intensive care
unit. Intensive care unit and hospital mortality rates were 6.1% and 10.3%, respectively, overall,
and 65.1% and 82.2%, respectively, in patients with an end-of-life decision. In multivariate
analysis, older age, admission from another hospital, cirrhosis, sepsis syndromes, simplified
acute physiology score II, and sequential organ failure assessment scores were independently
associated with end-of-life decisions.
Conclusions: Twenty-nine percent of patients who die in the surgical intensive care unit have an
end-of-life decision. Severe sepsis/septic shock was associated with a 16-fold increased
likelihood of having an end-of-life decision.
From The Pediatric Infectious Disease Journal®

Antibiotic Use in Neonatal Intensive Care Units

and Adherence with Centers for Disease
Control and Prevention 12 Step Campaign to
Prevent Antimicrobial Resistance
Abstract and Introduction

Abstract

Background: The Centers for Disease Control and Prevention (CDC) 12-Step Campaign to
Prevent Antimicrobial Resistance was launched to educate clinicians about antimicrobial
resistance and provide strategies to improve clinical practice, including antimicrobial utilization.
Methods: A multicenter retrospective observational study of antibiotic use was performed in 4
tertiary care NICUs to assess adherence to the guidelines defined by the CDC 12-Step Campaign
using predetermined criteria. Fifty infants per NICU were identified who received intravenous
antibiotics at greater than 72 hours of age. Antibiotic regimens, clinical and microbiologic data,
and indications for initiation and continuation of antibiotics (after 72 hours of use) were
recorded. Inappropriate utilization was characterized at initiation, continuation, by agent, and by
CDC 12-Step.
Results: Two hundred neonates received 323 antibiotic courses totaling 3344 antibiotic-days.
Ninety (28%) courses and 806 (24%) days were judged to be nonadherent to a CDC 12-Step.
Inappropriate use was more common with continuation of antibiotics (39%) than with initiation
(4%) of therapy. Vancomycin was the most commonly used drug (n = 895 antibiotic-days) of
which 284 (32%) days were considered inappropriate. Carbapenems were used less frequently (n
= 310 antibiotic-days), and 132 (43%) of these days were inappropriate. Common reasons for
nonadherence at the time of continuation included failure to narrow antibiotic coverage after
microbiologic results were known and prolonged antibiotic prophylaxis after surgery with chest
tube placement.
Conclusions: The CDC 12-Step Campaign can be modified for neonatal populations.
Inappropriate antibiotic prescribing was common in the study NICUs. Improvement efforts
should target antibiotic use 72 hours after initiation, particularly focusing on narrowing therapy
and instituting protocols to limit prophylaxis.
From Medscape Critical Care > Viewpoints

Selective Decontamination for the Prevention

of Nosocomial Respiratory Infection in ICU
Patients
Critically ill patients often require prolonged hospital care, which may be complicated by nosocomial
infections. Some data have suggested that nosocomial respiratory infections may be reduced with the use
of prophylactic antibiotic regimens, such as selective digestive tract decontamination (SDD) and selective
oropharyngeal decontamination (SOD). The study authors sought to determine whether SDD or SOD
would improve clinical outcomes in intensive care unit (ICU) patients, and thus evaluated these 2
regimens in 13 ICUs in The Netherlands. SDD consisted of 4 days of intravenous cefotaxime and topical
application of tobramycin, colistin, and amphotericin B in the oropharynx and stomach. SOD consisted of
only oropharyngeal application of these antibiotics. Patients with an expected duration of intubation of
more than 48 hours or an expected ICU stay of more than 72 hours were eligible for inclusion; each ICU
was randomized to 1 of 3 regimens (SDD, SOD, or standard care) over 6 months. The primary endpoint
of the study was 28-day mortality. Five thousand nine hundred thirty-nine patients were enrolled (N =
1990 for standard care, N = 1904 for SOD, and N = 2045 for SDD), and crude mortality at 28 days was
not different between the groups (27.5%, 26.6%, and 26.9%, respectively). In a regression model
adjusting for age, sex, severity of illness (Acute Physiology and Chronic Health Evaluation [APACHE] II
score), intubation status, and medical specialty, the odds ratios for death at day 28 in the SOD and SDD
groups, as compared with the standard care group, were 0.86 (95% confidence interval [CI] = 0.74-0.99)
and 0.83 (95% CI = 0.72-0.97), respectively. On the basis of the adjusted analyses, the study authors
concluded that mortality was reduced by approximately 3.5% with SDD and by 2.9% with SOD.

Viewpoint

This study suggested that in severely ill ICU patients with an overall mortality of nearly 30%,
decontamination strategies may improve survival. Unfortunately, several limitations of the study preclude
direct application of these results to patient care. First, the effect on mortality was only evident after
complex statistical modeling to adjust for factors that may also have contributed to differences in
survival. Second, there was no clear reduction in nosocomial infections as expected, which raises the
question of how survival may have been improved if not through prevention of infectious complications.
(Crude incidences of bacteremia were reduced for Staphylococcus aureus, Pseudomonas aeruginosa, and
Enterobacteriaceae, but respiratory infections were not prevented as expected). Third, although
surveillance was undertaken to assess changes in resistance or the emergence of resistant pathogens, the
time period for this assessment was short and likely insufficient to exclude these occurrences, particularly
for nosocomial infections, such as Clostridium difficile colitis. In addition, unlike most ICUs in North
America, no methicillin-resistant S aureus (MRSA) infections were identified in any group, and SDD has
been associated with increased prevalence of MRSA infections. Finally, there was no discrete clinical
benefit that may explain the improvement in survival because there were no differences in the duration of
mechanical ventilation, ICU, or hospital length of stay. Although provocative, the data from this study do
not demonstrate a clear clinical benefit of either SDD or SOD, nor does it help us to understand the
mechanisms by which improvements may accrue.