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Effect of Protocolized Sedation on Clinical Outcomes in Mechanically Ventilated Intensive Care Unit Patients

A Systematic Review and Meta-analysis of Randomized Controlled Trials

      Abstract

      Objective

      To assess the effects of protocolized sedation (algorithm or daily interruption) compared with usual care without protocolized sedation on clinical outcomes in mechanically ventilated adult intensive care unit (ICU) patients via a systematic review and meta-analysis of randomized controlled trials (RCTs).

      Methods

      We searched Ovid MEDLINE, EMBASE, Cochrane CENTRAL, Web of Science, and ClinicalTrials.gov from their inception to February 28, 2013. A random-effects model was used to synthesize risk ratios (RRs) and weighted mean differences (WMDs).

      Results

      Of 4782 records screened, 6 RCTs including 1243 patients met the inclusion criteria. Protocolized sedation was associated with significant reductions in overall mortality (RR, 0.85; 95% CI, 0.74 to 0.97; P=.02; number needed to treat, 20; P=.11), ICU length of stay (WMD, −1.73 days; 95% CI, −3.32 to −0.14 days; P=.03), hospital length of stay (WMD, −3.55 days; 95% CI, −5.98 to −1.12 days; P=.004), and tracheostomy (RR, 0.69; 95% CI, 0.50 to 0.96; P=.03; number needed to treat, 16.6; P=.04; 5 RCTs) compared with usual care. Protocolized sedation produced no significant differences in duration of mechanical ventilation (WMD, −1.04 days; 95% CI, −2.54 to 0.47 days; P=.18), reintubation (RR, 0.78; 95% CI, 0.52 to 1.15; P=.21; 3 RCTs), and self-extubation (RR, 1.49; 95% CI, 0.46 to 4.82; P=.51; 4 RCTs) compared with usual care. Included studies did not report delirium incidence.

      Conclusion

      In mechanically ventilated adults in closed, nonspecialty ICUs, protocolized sedation seems to decrease overall mortality (15%), ICU and hospital lengths of stay (1.73 and 3.55 days, respectively), and tracheostomy (31%) compared with usual care without protocolized sedation.

      Abbreviations and Acronyms:

      APACHE II (Acute Physiology and Chronic Health Evaluation II), C (control), COPD (chronic obstructive pulmonary disease), I (intervention), ICU (intensive care unit), LOS (length of stay), NNT (number needed to treat), NR (not reported), PAD (pain, agitation/sedation, and delirium), RASS (Richmond Agitation Sedation Scale), RCT (randomized controlled trial), RR (risk ratio (relative risk)), SAS (Riker Sedation-Agitation Scale), WMD (weighted mean difference)
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