Analgosedation and delirium in intensive care units in Brazil: current status. ASDUTI study

To the Editor,

The adequate management of analgosedation and delirium is related to better outcomes in intensive care units.^(1-3) The objective of this study is to evaluate the current status of the management of analgosedation and delirium in Brazil.

A questionnaire was developed on the SurveyMonkey^® (^{Appendix 1}) digital platform with 15 multiple-choice questions, among which some of the questions had only one option while others could have more than one option. The instrument was made available from November 2015 to February 2016. The method of selection of professionals for data collection included several multiprofessional categories.

A total of 410 professionals answered the questionnaire. Of these, 48.78% worked in public hospitals, 33.41% in private hospitals, and 17.80% in philanthropic hospitals. A total of 81.23% professionals worked in an intensive care unit (ICU) with a general profile.

The results indicated that 59.50% of the respondents used analgosedation protocols in their services, which is slightly higher than that found by Salluh et al.⁽⁴⁾ but lower than that found by Patel et al.,⁽⁵⁾ wherein 71% of the study participants used analgosedation protocols.

Among the study participants, 234 (59.24%) reported performing a systematic evaluation of pain in their ICU. Pain was evaluated up to twice a day for 35.48% of the sample, and the nurse and physician were responsible for these evaluations in most cases (51.34% and 42.78%, respectively). Sedation was evaluated up to twice a day in 49.35% of cases.

With respect to the management of sedation, validated tools (Richmond Agitation-Sedation Scale - RASS and Sedation-Agitation Scale - SAS) were used by 72.91% of the respondents, and the most commonly used sedation strategies were daily awakening (60.11%) and targeted sedation (23.94%). There was a high rate of use of validated tools (12%) compared with national data from 2009.⁽⁴⁾

The availability of analgosedation in services and its incorporation in protocols was evaluated. Midazolam, fentanyl, propofol, and morphine were the most available drugs in the analyzed institutions. The first three drugs, in addition to dexmedetomidine, were the most used in institutional protocols. The use of these drugs is common despite recommendations to avoid the use of benzodiazepines in the choice of sedative drugs.⁽²⁾

A total of 44.68% of the respondents evaluated delirium systematically. Of these, 56.72% used the Confusion Assessment Method for the ICU (CAM-ICU), and 37.37% did not use a validated tool. In the study by Patel et al., 59% of respondents systematically assessed delirium.⁽⁵⁾

Of the total sample, 29.62% evaluated delirium daily, and 23.10% performed evaluations twice a day. Physicians and nurses conducted these evaluations in 64.07% and 26.05% of cases, respectively. Haloperidol was the drug of choice for managing hyperactive delirium for 72.13% of participants. In addition, 12.30% of respondents used dexmedetomidine, and 11.20% used antipsychotics (Table 1).

Table 1
Characteristics of the assessment and management of analgosedation and delirium

	n (%)
Frequency of assessment of pain in the ICU
Once daily	52 (13.37)
Twice daily	46 (11.83)
Thrice daily	78 (20.05)
Every 12 hours	40 (10.28)
Every 2 hours	54 (13.88)
Every hour	11 (2.83)
None of the above	108 (27.76)
Professional performing pain assessment
Physician	160 (42.78)
Nurse	192 (51.34)
Physical therapist	3 (0.80)
Another professional	19 (5.08)
Frequency of assessment of sedation in the ICU
Once daily	66 (17.14)
Twice daily	82 (21.30)
Thrice daily	69 (17.92)
Every 12 hours	42 (10.91)
Every 6 hours	33 (8.57)
Every 2 hours	29 (7.53)
Every hour	10 (2.60)
None of the above	54 (14.03)
Tool used to assess sedation
RASS	269 (70.05)
SAS	11 (2.86)
Ramsay	78 (20.31)
None	19 (4.95)
Others	7 (1.82)
Strategy of sedation
Daily awakening	226 (60.11)
Targeted sedation	90 (23.94)
Intermittent sedation	25 (6.65)
None	35 (9.31)
Tool used to assess delirium
CAM-ICU	211 (56.72)
ICDSC	8 (2.15)
Others	14 (3.76)
None	139 (37.37)
Frequency of assessment of delirium
None	121 (32.88)
Once daily	109 (29.62)
Twice daily	85 (23.10)
Thrice daily	31 (8.42)
More than thrice daily	22 (5.98)
Professional assessing delirium
Physician	214 (64.07)
Nurse	87 (26.05)
Psychologist	21 (6.29)
Another professional	12 (3.59)
Drug used to manage hyperactive delirium
Haloperidol	264 (72.13)
Dexmedetomidine	45 (12.30)
Antipsychotic drugs	41 (11.20)
Others	7 (1.91)
None	9 (2.46)

• ICU - Intensive Care Unit; RASS - Richmond Agitation-Sedation Scale; SAS - Sedation-Agitation Scale; CAM-ICU - Confusion Assessment Method in an Intensive Care Unit; ICDSC - Intensive Care Delirium Screening Checklist.

The limitations of the study were the lack of consideration of the geographical distribution of the ICUs of respondents, lack of differentiation of responses between public, private, and philanthropic hospitals, and lack of comparison of responses among multiprofessional teams.

In conclusion, this study reveals the need to advance the routines used in the management of analgosedation and delirium, despite consistent evidence for improved outcomes in the literature when the recommended protocols and strategies are used.

Viviane Cordeiro Veiga
Neurological Intensive Care Unit, Hospital Beneficência Portuguesa de São Paulo - São Paulo (SP), Brazil; and Neurocritical Care Committee, Associação de Medicina Intensiva Brasileira (AMIB) - São Paulo (SP), Brazil.
Salomón Soriano Ordinola Rojas
Neurological Intensive Care Unit, Hospital Beneficência Portuguesa de São Paulo - São Paulo (SP), Brazil.

Appendix

Appendix 1
ASDUTI study questionnaire. Evaluation of analgosedation and delirium in intensive care units.

Institutional data:

Hospital profile: ( ) public ( ) private ( ) philanthropic

Unit profile: ( ) general ( ) trauma ( ) cardiologic ( ) neurological ( ) other

1. At your service, is there a protocol for analgesia and sedation?

( ) Yes

( ) No

2. Is there systematic pain assessment in your ICU?

( ) Yes

( ) No

3. How often is pain assessed at your ICU?

( ) Once daily

( ) Twice daily

( ) Thrice daily

( ) Every 12 hours

( ) Every 2 hours

( ) Every hour

( ) None of the above

4. Which professional assesses pain in your unit?

( ) Physician ( ) Nurse ( ) Physical therapist ( ) Other professional

5. Is there systematic assessment of sedation in your ICU?

( ) Yes

( ) No

6. How many times is sedation assessed in your ICU?

( ) Once daily

( ) Twice daily

( ) Thrice daily

( ) Once every 12 hours

( ) Once every 6 hours

( ) Once every 2 hours

( ) Once every hour

( ) None of the above

7. Which tool is used to evaluate sedation in your unit?

( ) Richmond Agitation-Sedation Scale (RASS)

( ) Sedation-Agitation Scale (SAS)

( ) Ramsay

( ) None

( ) Others

8. Which of these medications are AVAILABLE for use in your hospital? Check all that apply.

( ) Midazolam ( ) Morphine ( ) Fentanyl ( ) Remifentanil

( ) Sufentanil ( ) Alfentanil ( ) Dexmedetomidine ( ) Clonidine

( ) Ketamine ( ) Propofol

9. Which of these drugs are INCLUDED in your analgosedation PROTOCOL? Check all that apply.

( ) Midazolam ( ) Morphine ( ) Fentanyl ( ) Remifentanil ( ) Sufentanil

( ) Alfentanil ( ) Dexmedetomidine ( ) Clonidine ( ) Ketamine ( ) Propofol

10. Which sedation strategy do you apply in your unit?

( ) Intermittent sedation

( ) Daily awakening

( ) Targeted sedation

( ) None of the above

11. Does your unit evaluate delirium systematically?

( ) Yes

( ) No

12. Which tool do you use to assess delirium?

( ) Confusion Assessment Method in an Intensive Care Unit (CAM-ICU)

( ) Intensive Care Delirium Screening Checklist (ICDSC)

( ) Others

( ) None

13. How many times a day is delirium evaluated in your unit?

( ) None

( ) Once daily

( ) Twice daily

( ) Thrice daily

( ) More than thrice daily

14. Which professional assesses delirium in your ICU?

( ) Physician ( ) Nurse ( ) Psychologist ( ) Other professionals

15. Which drugs do you use for managing hyperactive delirium?

( ) Haloperidol ( ) Antipsychotics ( ) Dexmedetomidine

( ) Others ( ) None

REFERÊNCIAS

• ¹
  Jackson DL, Proudfoot CW, Cann KF, Walsh T. A systematic review of the impact of sedation practice in the ICU on resource use, costs and patient safety. Crit Care. 2010;14(2):R59.
• ²
  Shehabi Y, Bellomo R, Mehta S, Riker R, Takala J. Intensive care sedation: the past, presente and the future. Crit Care. 2013;17(3):322.
• ³
  Shinotsuka CR, Salluh JI. Percepções e práticas sobre delirium, sedação e analgesia em pacientes críticos: uma visão narrativa. Rev Bras Ter Intensiva. 2013;25(2):155-61.
• ⁴
  Salluh JI, Dal-Pizzol F, Mello PV, Friedman G, Silva E, Teles JM, Lobo SM, Bozza FA, Soares M; Brazilian Research in Intensive Care Network. Delirium recognition and sedation practices in critically ill patients: a survey on the attitudes of 1015 Brazilian critical care physicians. J Crit Care. 2009;24(4):556-62.
• ⁵
  Patel RP, Gambrell M, Speroff T, Scott TA, Pun BT, Okahashi J, et al. Delirium and sedation in the intensive care unit: survey of behaviors and attitudes of 1384 healthcare professionals. Crit Care Med. 2009;37(3):825-32.

• Funding agency: AMIBNet; Associação de Medicina Intensiva Brasileira

Publication Dates

• Publication in this collection
  Apr-Jun 2018
• Date of issue
  June 2018

History

• Received
  21 Nov 2017
• Accepted
  03 Dec 2017