Australian and New Zealand Intensive Care Society
Recommendations from the College of Intensive Care Medicine & the Australian and New Zealand Intensive Care Society on end-of-life care, invasive devices, anaemia, sedation & antibiotics. The Australian and New Zealand Intensive Care Society is the leading advocate on all intensive care related matters. ANZICS leads the world in intensive care research through its Clinical Trials Group and patient databases, including the Adult Patient Database, the Paediatric Intensive Care Registry and Critical Care Resources.
Undertake daily attempts to lighten sedation in ventilated patients unless specifically contraindicated and deeply sedate mechanically ventilated patients only if there is a specific indication.
Critically ill patients requiring mechanical ventilation are frequently treated with sedatives and analgesics, to treat pain, anxiety, dyspnoea and reduce tissue oxygen consumption. However prolonged or excessive sedation can be associated with delirium, critical illness weakness, prolonged ventilation and length of stay. Protocol-based approaches to limit deep sedation, by explicating titrating the sedation to a sedation goal, and daily interruptions of sedation, have been shown to improve patient outcomes, including a reduction in mortality. Exceptions to the daily sedation holiday are for patients requiring muscle paralysis, who should not be woken until the paralytic agent has worn off.
- Brook AD, Ahrens TS, Schai R, Prentice D, Sherman G, Shannon W, Kollef MH. Effect of a nursing-implemented sedation protocol on the duration of mechanical ventilation. Crit Care Med 1999;27:2609-15.
- Kress JP, Pohlman AS, Hall JB. Sedation and analgesia in the intensive care unit. American Journal of Respiratory and Critical Care Medicine 2002:166(8)1024-8.
- Marshall J, Finn C, Theodore A. Impact of a clinical pharmacist-enforced intensive care unit sedation protocol on duration of mechanical ventilation and hospital stay. Critical Care Medicine 2008;36(2):427-33.
- Girard TD, Kress JP, Fuchs BD, Thomason JW, Schweickert WD, Pun BT, Taichman DB, Dunn JG, Pohlman AS, Kinniry PA, Jackson JC, Canonico AE, Light RW, Shintani AK, Thompson JL, Gordon SM, Hall JB, Dittus RS, Bernard GR, Ely EW. Efficacy and safety of a paired sedation and ventilator weaning protocol for mechanically ventilated patients in intensive care (Awakening and Breathing Controlled trial): a randomized controlled trial. Lancet 2008;371(9607):126–34.
- Jacobi J, Fraser GL, et al. Clinical practice guidelines for the sustained use of sedatives and analgesics in the critically ill adult. Critical Care Medicine 2002;30(1):119-141.
- Kress JP, Pohlman AS, O’Connor MF, Hall JB. Daily interruption of sedative infusions in critically ill patients undergoing mechanical ventilation. N Eng J Med 2000;342:1471–7.
- Mehta S, Burry L, Cook D, Fergusson D, Steinberg M, Granton J, Herridge M, Ferguson N, Devlin J, Tanios M, Dodek P, Fowler R, Burns K, Jacka M, Olafson K, Skrobik Y, Hébert P, Sabri E, Meade M; SLEAP Investigators; Canadian Critical Care Trials Group. Daily sedation interruption in mechanically ventilated critically ill patients cared for with a sedation protocol: a randomized controlled trial. JAMA 2012;308(19):1985–92.
- Miller MA, Bosk EA, Iwashyna TJ, Krein SL. Implementation challenges in the intensive care unit: the why, who, and how of daily interruption of sedation. Journal of Critical Care 2012;27(2), 218-e1.
A working group of interested parties from both CICM and ANZICS was formed to develop a list of 12 items that they believe should be focused on to reduce the number of unnecessary tests and interventions performed in intensive care. All CICM Fellows and ANZICS members were surveyed to develop a consensus view of a final list of five items. There were 6 items clearly favoured and two of these were combined by the working group to develop the final 5 recommendations.
For patients with limited life expectancy (such as advanced cardiac, renal or respiratory failure, metastatic malignancy, third line chemotherapy) ensure patients have a ‘goals of care’ discussion at or prior to admission to ICU and for patients in ICU who are at high risk for death or severely impaired functional recovery, ensure that alternative care focused predominantly on comfort and dignity is offered to patients and their families.
- 2 Remove all invasive devices, such as intravascular lines and urinary catheters, as soon as possible.
- 3 Transfuse red cells for anaemia only if the haemoglobin concentration is less than 70gm/L or if the patient is haemodynamically unstable or has significant cardiovascular or respiratory comorbidity.
- 4 Undertake daily attempts to lighten sedation in ventilated patients unless specifically contraindicated and deeply sedate mechanically ventilated patients only if there is a specific indication.
- 5 Consider antibiotic de-escalation daily.