TY - JOUR
T1 - The ED-SED Study
T2 - A Multicenter, Prospective Cohort Study of Practice Patterns and Clinical Outcomes Associated With Emergency Department SEDation for Mechanically Ventilated Patients
AU - Fuller, Brian M.
AU - Roberts, Brian W.
AU - Mohr, Nicholas M.
AU - Knight, William A.
AU - Adeoye, Opeolu
AU - Pappal, Ryan D.
AU - Marshall, Stacy
AU - Alunday, Robert
AU - Dettmer, Matthew
AU - Goyal, Munish
AU - Gibson, Colin
AU - Levine, Brian J.
AU - Gardner-Gray, Jayna M.
AU - Mosier, Jarrod
AU - Dargin, James
AU - Mackay, Fraser
AU - Johnson, Nicholas J.
AU - Lokhandwala, Sharukh
AU - Hough, Catherine L.
AU - Tonna, Joseph E.
AU - Tsolinas, Rachel
AU - Lin, Frederick
AU - Qasim, Zaffer A.
AU - Harvey, Carrie E.
AU - Bassin, Benjamin
AU - Stephens, Robert J.
AU - Yan, Yan
AU - Carpenter, Christopher R.
AU - Kollef, Marin H.
AU - Avidan, Michael S.
N1 - Funding Information:
NHLBI T32 HL007287-39. Dr. Hough’s institution received fundingNIH (U01HL123008-02). Dr. Lokhandwala was supported by NIH/ The provision of sedation is almost universal in me-from the NIH (U01HL123008-02). Dr. Tonna was supported by a chanically ventilated patients and is a modifiable vari-career development award (K23HL141596) from the NHLBI of the able related to clinical outcomes during critical illness. statistics Center, with funding in part from the National Center forNIH, and, in part, by the University of Utah Study Design and Bio- Evidence demonstrates that efforts to decrease sedation in Research Resources and the National Center for Advancing Trans- the ICU improve outcome (1, 2). However, the majority of lational Sciences, NIH, through Grant 5UL1TR001067-02 (for- data come from randomized controlled trials which enrolled from NIH/NSF and Philips Healthcare. Dr. Carpenter disclosed hemerly 8UL1TR000105 and UL1RR025764); he received funding patients at 48–96 hours after intubation, or from observa- is a Member of American College of Emergency Physicians Clinical tional data from an entire ICU stay (3–6). Recently, prospec-Policy Committee, a Chair of Schwartz-Reisman Emergency Medi- tive, observational data showed that deep sedation during the for Best Evidence in Emergency Medicine (continuing medical edu-cine Research Institute International Advisory Board, and a Speaker first 48 hours of mechanical ventilation was associated with cation [CME] product) and for Emergency Medical Abstracts (CME worse short-and long-term outcomes (7, 8). A systematic product). Dr. Avidan received funding from UptoDate. Dr. Kollef re- review and meta-analysis also showed harm associated with maining authors have disclosed that they do not have any potentialceived funding from the Barnes-Jewish Hospital Foundation. The re- early deep sedation in the ICU (9). Despite this, up to 70% of conflicts of interest. ventilated patients arrive to the ICU deeply sedated, suggest-
Funding Information:
31Department of Anesthesiology, Washington University School of Medi-cine in St. Louis, St. Louis, MO. This work was performed at Washington University School of Medicine in St. Louis, University of Iowa, Cooper University Hospital, University of New Mexico, The Cleveland Clinic, MedStar Washington Hospital Center, Christiana Care Health System, University of Cincinnati, Henry Ford Health System, University of Arizona/Banner University Medical Center-Tucson, Lahey Hospital & Medical Center, University of Washington Harborview Medical Center, University of Utah Health, University of Pennsylvania, and Michigan Medicine. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (http://journals.lww.com/ ccmjournal). Dr. Roberts’ institution received funding from National Heart, Lung, and Blood Institute (NHLBI) K23HL126979. Drs. Roberts, Pappal, Lokhandwala, and Tonna received support for article research from the National Institutes of Health (NIH). Dr. Knight received funding from Bard Medical and Genentech (speaker bureau for both). Dr. Pappal’s institution received funding from National Center for Advancing Translational Sciences of the NIH under Award Number UL1 TR002345. Dr. Johnson’s institution received funding from NHLBI and Medic One Foundation; he received funding from the
Publisher Copyright:
Copyright © 2019 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.
PY - 2019/11/1
Y1 - 2019/11/1
N2 - Objectives: To characterize emergency department sedation practices in mechanically ventilated patients, and test the hypothesis that deep sedation in the emergency department is associated with worse outcomes. Design: Multicenter, prospective cohort study. Setting: The emergency department and ICUs of 15 medical centers. Patients: Mechanically ventilated adult emergency department patients. Interventions: None. Measurements and Main Results: All data involving sedation (medications, monitoring) were recorded. Deep sedation was defined as Richmond Agitation-Sedation Scale of –3 to –5 or Sedation-Agitation Scale of 2 or 1. A total of 324 patients were studied. Emergency department deep sedation was observed in 171 patients (52.8%), and was associated with a higher frequency of deep sedation in the ICU on day 1 (53.8% vs 20.3%; p < 0.001) and day 2 (33.3% vs 16.9%; p = 0.001), when compared to light sedation. Mean (sd) ventilator-free days were 18.1 (10.8) in the emergency department deep sedation group compared to 20.0 (9.8) in the light sedation group (mean difference, 1.9; 95% CI, –0.40 to 4.13). Similar results according to emergency department sedation depth existed for ICU-free days (mean difference, 1.6; 95% CI, –0.54 to 3.83) and hospital-free days (mean difference, 2.3; 95% CI, 0.26–4.32). Mortality was 21.1% in the deep sedation group and 17.0% in the light sedation group (between-group difference, 4.1%; odds ratio, 1.30; 0.74–2.28). The occurrence rate of acute brain dysfunction (delirium and coma) was 68.4% in the deep sedation group and 55.6% in the light sedation group (between-group difference, 12.8%; odds ratio, 1.73; 1.10–2.73). Conclusions: Early deep sedation in the emergency department is common, carries over into the ICU, and may be associated with worse outcomes. Sedation practice in the emergency department and its association with clinical outcomes is in need of further investigation.
AB - Objectives: To characterize emergency department sedation practices in mechanically ventilated patients, and test the hypothesis that deep sedation in the emergency department is associated with worse outcomes. Design: Multicenter, prospective cohort study. Setting: The emergency department and ICUs of 15 medical centers. Patients: Mechanically ventilated adult emergency department patients. Interventions: None. Measurements and Main Results: All data involving sedation (medications, monitoring) were recorded. Deep sedation was defined as Richmond Agitation-Sedation Scale of –3 to –5 or Sedation-Agitation Scale of 2 or 1. A total of 324 patients were studied. Emergency department deep sedation was observed in 171 patients (52.8%), and was associated with a higher frequency of deep sedation in the ICU on day 1 (53.8% vs 20.3%; p < 0.001) and day 2 (33.3% vs 16.9%; p = 0.001), when compared to light sedation. Mean (sd) ventilator-free days were 18.1 (10.8) in the emergency department deep sedation group compared to 20.0 (9.8) in the light sedation group (mean difference, 1.9; 95% CI, –0.40 to 4.13). Similar results according to emergency department sedation depth existed for ICU-free days (mean difference, 1.6; 95% CI, –0.54 to 3.83) and hospital-free days (mean difference, 2.3; 95% CI, 0.26–4.32). Mortality was 21.1% in the deep sedation group and 17.0% in the light sedation group (between-group difference, 4.1%; odds ratio, 1.30; 0.74–2.28). The occurrence rate of acute brain dysfunction (delirium and coma) was 68.4% in the deep sedation group and 55.6% in the light sedation group (between-group difference, 12.8%; odds ratio, 1.73; 1.10–2.73). Conclusions: Early deep sedation in the emergency department is common, carries over into the ICU, and may be associated with worse outcomes. Sedation practice in the emergency department and its association with clinical outcomes is in need of further investigation.
KW - Emergency department
KW - Mechanical ventilation
KW - Sedation
UR - http://www.scopus.com/inward/record.url?scp=85073184735&partnerID=8YFLogxK
U2 - 10.1097/CCM.0000000000003928
DO - 10.1097/CCM.0000000000003928
M3 - Article
C2 - 31393323
AN - SCOPUS:85073184735
SN - 0090-3493
VL - 47
SP - 1539
EP - 1548
JO - Critical care medicine
JF - Critical care medicine
IS - 11
ER -