Pain, Agitation/Sedation, Delirium, Immobility, Sleep Disruption, and Neuromuscular Blockade

SBT: If a patient tolerates the SBT for 30 to 120 minutes, consider extubation.

SBT failure:

Respiratory rate greater than 35 breaths/minute (for more than 5 minutes) or less than 8 breaths/

minute

Oxygen saturation less than 88% for more than 5 minutes

ICP greater than 20 mm Hg, mental status change

Respiratory distress (use of accessory muscles, abdominal paradox, diaphoresis, and dyspnea)

If SBT fails: Place the patient on prior ventilator settings. Repeat bundle in 12–24 hours or according

to hospital protocol.

protocol with daily pairing of a SAT with SBT have shown decreased days on mechanical ventilation, days

in the ICU, and decreased rates of delirium when the SAT is paired with the SBT.

The ABC trial included 336 mechanically ventilated patients from four tertiary care hospitals. Patients

were randomized to patient-targeted sedation protocol plus the SBT (“usual care” control group) or to

daily SAT paired with the SBT (intervention group). Both groups were deeply sedated on enrollment

(RASS -4), and both groups had been admitted for 2.2 days before enrollment. In the intervention group,

patients who passed the safety screen underwent an SAT: sedatives and analgesics used for sedation

were discontinued, and analgesics used for active pain were continued. Patients “passed” their SAT if

they opened their eyes to command or tolerated being off sedation for at least 4 hours without meeting

failure criteria. The mean ventilator-free days was 11.6 days in the usual care control group versus 14.7

days in the SAT plus SBT group (p=0.02). The time to discharge was 12.9 days in the control group

versus 9.1 days in the intervention group (p=0.01). Self-extubations were higher in the intervention

group, but there was no difference in self-extubations requiring reintubation between groups. Rates of

delirium assessed by the confusion assessment method for the intensive care unit (CAM-ICU) were no

different between groups (74% vs. 71%).

Management, and Early Mobility) Bundle compared clinical outcomes in patients before (n=146) and

after (n=150) bundle-protocol implementation; 187 patients were on mechanical ventilation. The bundle

protocol consisted of a daily-paired SAT/SBT, delirium screening with the CAM-ICU every 8 hours,

and an early mobility protocol. The “before” bundle patients were enrolled from February to October

2011; the “after” bundle patients were enrolled from October 2011 to April 2012. There were some

differences in patient type on admission, including more elective admissions in the post-bundle group

(39 vs. 30), more cardiothoracic surgery patients in the post-bundle group (20 vs. 6), more surgical

patients in the pre-bundle group (21 vs. 11), and more patients coming from an outside hospital in the

pre-bundle group (9 vs. 1). The post-bundle group had more median ventilator-free days (24 vs. 21

days, p=0.04), less delirium at any time (49 vs. 62%, p=0.03), and shorter percentage of ICU days with

The SLEAP investigators from the Canadian Critical Care Trials Group studied the outcomes of

patients receiving a daily sedation protocol alone versus patients receiving a daily sedation protocol

care medical and surgical ICUs. Only opiate and benzodiazepine infusions were allowed in the study.

According to the sedation-alone protocol, the RASS goal was -3 to 0, and the Sedation-Agitation Scale

(SAS) goal was 3 or 4. Nurses assessed sedation levels on an hourly basis and titrated medications

every 15–30 minutes to achieve sedation goals. If patients were oversedated in either group (SAS 1 or

2; RASS −4 or −5), infusions were discontinued. According to the sedation protocol with daily sedation