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Evidence suggests prolonged sedation is associated with prolonged ventilation and mortality. Further evidence suggests that some sedatives and analgesics are more prone to cause oversedation than others, possibly due to disturbances in pharmacokinetic properties in the context of acute organ failure. Our aim was to describe current sedation and analgesic practice in UK ICUs, and to determine whether recent evidence has changed practice in recent years.
We performed a web-based survey using a tool developed via a systematic, step-wise process following recognised practice for questionnaire design. These steps included question development and questionnaire formatting and testing before being published on the Zoomerang™ website. The sampling frame was pharmacists who are members of the United Kingdom Clinical Pharmacy Association Critical Care Group (UKCPA CCG). Participants were invited to complete the 15-minute questionnaire. Email reminders were sent to all members every 2 weeks. After 6 months a reminder email was sent to pharmacists in institutions that had not responded. Questions were split into four categories: pharmacist and ICU-specific data; current sedation practice; sedative choice; and analgesic choice.
The response rate was 68%. Eighty-four per cent of respondents were senior pharmacists and 54% provided a service within a team. The median number of annual ICU admissions was 750 (IQR 635 to 865) and included a wide-ranging case mix. Forty-nine per cent of ICUs had a sedation policy, of which 76% included sedation holds and 87% used a sedation scoring system. Forty-three per cent assessed for delirium, but only 29% used a known delirium scoring system. Ninety-nine of the respondents used propofol (PPF) in the majority of patients, 56 midazolam (MDZ). Twenty-seven still used MDZ routinely in renal or hepatic failure, while 75 used MDZ where sedation was challenging.
Fifty-five used morphine, 37 fentanyl and 33 alfentanil as first-line opiate.
These data suggest that many ICUs do not routinely use sedation policies or assess patients for delirium. While PPF remains the first-line sedative for most ventilated patients, MDZ and morphine are still widely used despite evidence of prolonged effects in the presence of hepatic and renal failure.