The Administration of Moderate Sedation and the Role of the Radiology Nurse

BackgroundModerate sedation administration is an assumed role of the nurse in interventional radiology. There remains limited documentation to define this practice and its relationship to the radiology nurse. The use of moderate sedation is common for patients receiving interventional radiology procedures, and therefore, defining the administrative parameters for this variable will allow for the future study of outcomes for this patient population. The primary aim of this article is to describe moderate sedation parameters in interventional radiology in hospitals offering adult interventional radiology services. Parameters included total case volumes, presence of provider type during interventional radiology cases using moderate sedation, existence of moderate sedation privileges, and the total percentage of moderate sedation administration by provider type. The results of this study are part of a larger nationwide survey that described administratively mediated variables in interventional radiology.MethodsA 26-question survey was developed and sent to a sample of radiologic administrators (n = 510) across the United States. The survey was developed using the Minnick and Roberts Outcomes Production Model, which identifies the relationship among essential health services concepts and their influence on patient outcomes. Recipients could answer via paper survey or by electronic link. Completion of the survey constituted consent.ResultsA total of 82 individuals responded to the survey (response rate = 16.8%). Respondents reported a median value of 2656.5 (n = 74, IQR: 1175.0, 5833.0) interventional radiology cases completed in the last year and a median value of 1500 patients receiving moderate sedation (n = 82, IQR: 600.0, 2725.0). Respondents reported that the registered nurse was responsible for a median of 90.0% of the sedation administered for adult patients (IQR: 80.0, 98.0).ConclusionsBased on the results of the survey, it is determined that moderate sedation is primarily administered by the registered nurse in interventional radiology. Future studies can include relational designs that focus on aspects of the registered nurse as a highly influential factor in moderate sedation patient outcomes.     

ICU机械通气患者应用镇静治疗的安全护理分析

目的探讨ICU机械通气患者应用镇静治疗的安全护理效果。方法选取我院ICU 2013年1月~12月进行机械通气的患者100例作为研究对象,随机分为对照组和实验组,各50例。对照组采用地西泮注射液和鲁米那注射液进行镇静。实验组采用咪达唑仑注射液和丙泊酚注射液进行镇静。观察两组不良反应发生率及治疗满意率,并进行比较。结果实验组不良反应发生率(8%)明显低于对照组(32%),实验组治疗总满意率(94%)明显高于对照组(62%),两组比较有显著性差异(P0.05)。结论咪达唑仑、丙泊酚注射液镇静效果优于地西泮、鲁米那注射液,有效减少人机对抗,减少非计划性拔管的发生,保证患者安全,增加患者及家属的满意度。     

静脉麻醉镇痛法在患者胃镜检查中的应用效果观察及护理

目的观察静脉麻醉镇痛法在患者胃镜检查中的应用效果,以便提高患者胃镜检查的依从性。方法对845例需胃镜检查的患者实施静脉镇痛麻醉,观察胃镜检查过程中患者镇静程度、遗忘程度及对麻醉镇痛效果的满意程度。结果845例患者顺利完成胃镜检查,均未出现并发症,且在检查完毕后10min内恢复清醒。镇静程度2级718例,占85.0%（为最理想镇痛效果）;术后722例（85.4%）完全遗忘;794例（94.0%）患者表示对镇痛效果满意。结论静脉麻醉镇痛实施胃镜检查可减轻患者的痛苦,提高其检查依从性,从而确保了检查顺利进行,提高了诊断检查的成功率。     

机械通气患儿应用咪唑安定镇静的护理

总结了28例机械通气患儿应用咪唑安定镇静治疗的护理经验,包括：观察镇静效果,预防药物引起的低血压．对于长期使用咪唑安定的患儿,注意观察其耐药性。PICU机械通气患儿使用咪唑安定镇静,结合适当护理,能达到满意的镇静效果．     

Pediatric Sedation: Using Secondary Data to Describe Registered Nurse Practice in Radiology

Children often require sedation for procedures because of their developmental level and difficulty complying with positioning. There are few studies that describe nurse sedation practices or adverse events. Studies of pediatric sedation care have small sample sizes that are inadequate to detect adverse events. This study reports practices and outcomes of sedation delivered to children from infancy up to 14 years of age, who were monitored only by registered nurses during diagnostic radiology procedures drawn from a sample of 12,584 cases from the Pediatric Sedation Research Consortium database. There were 727 adverse events (5.78%). However, no deaths, cardiac arrests, intubations, or aspirations were reported in this sample. The most common adverse event was inadequate sedation/agitation/delirium 196 (155.8/10,000) and desaturation below baseline for more than 30 s 173 (138/10,000). Further research comparing sedation practices and outcomes by type of providers, including nurses, is necessary to improve practice.     

Critical care nurses' decision making: sedation assessment and management in intensive care

Aims. This study was designed to examine the decision making processes that nurses use when assessing and managing sedation for a critically ill patient, specifically the attributes and concepts used to determine sedation needs and the influence of a sedation guideline on the decision making processes. Background. Sedation management forms an integral component of the care of critical care patients. Despite this, there is little understanding of how nurses make decisions regarding assessment and management of intensive care patients’ sedation requirements. Appropriate nursing assessment and management of sedation therapy is essential to quality patient care. Design. Observational study. Methods. Nurses providing sedation management for a critically ill patient were observed and asked to think aloud during two separate occasions for two hours of care. Follow‐up interviews were conducted to collect data from five expert critical care nurses pre‐ and postimplementation of a sedation guideline. Data from all sources were integrated, with data analysis identifying the type and number of attributes and concepts used to form decisions. Results. Attributes and concepts most frequently used related to sedation and sedatives, anxiety and agitation, pain and comfort and neurological status. On average each participant raised 48 attributes related to sedation assessment and management in the preintervention phase and 57 attributes postintervention. These attributes related to assessment (pre, 58%; post, 65%), physiology (pre, 10%; post, 9%) and treatment (pre, 31%; post, 26%) aspects of care. Conclusions. Decision making in this setting is highly complex, incorporating a wide range of attributes that concentrate primarily on assessment aspects of care. Relevance to clinical practice. Clinical guidelines should provide support for strategies known to positively influence practice. Further, the education of nurses to use such guidelines optimally must take into account the highly complex iterative process and wide range of data sources used to make decisions.     

Comparison of the effect of protocol-directed sedation with propofol vs. midazolam by nurses in intensive care: efficacy, haemodynamic stability and patient satisfaction

Aim. The aim of this study was to compare the effect of protocol‐directed sedation propofol vs. midazolam by nurses in intensive care on efficacy, haemodynamic stability and patient satisfaction. Background. Protocols represent one method potentially to reduce treatment delays and ensure that medical care is administered in a standardised manner. Propofol and midazolam are often used for sedation in intensive care units. Method. A randomised, prospective cohort study and data were collected in 2003. The subjects were randomised either into propofol (n = 32) or into midazolam (n = 28) group. Efficacy of sedation, haemodynamic stability, pulse oximetry saturation, Acute Physiology and Chronic Health Evaluation II (APACHE II score), weaning time from mechanical ventilation, duration of mechanical ventilation, length of stay at intensive care unit, sedative drugs cost and patient satisfaction were measured. Results. The nursing staff were able to maintain patients at Ramsay sedation scale (RSS) 3–4 during the sedative period. The efficacy of sedation was 74·2% and 66·9% of time in propofol and midazolam group respectively. Both sedatives reduced the arterial blood pressure and heart rate, but did not alter haemodynamic stability. The mean score of satisfactory sedation was not significantly different between the two groups (propofol: 11·4 SEM 0·2 vs. midazolam: 11·5 SEM 0·7). Conclusion. Protocol‐directed sedation with propofol vs. midazolam by nurses were similar in quality during the sedative period. Relevance to clinical practice. This sedation practice for titration of propofol and midazolam by nurses was of similar quality and able to achieve an appropriate depth of sedation during the sedative period. Furthermore, they should provide care for patients’ needs during the sedative period.     

Implementation of standard sedation management in paediatric intensive care: effective and feasible?

Objective. To study the effects of the introduction of a sedation treatment protocol for children in intensive care, including nurses’ compliance. Background. While several sedation guidelines for adults and children have been developed and implemented, there is little evidence on use of sedation protocols in critically ill infants. Design. Pretest–posttest intervention study. Methods. Administered sedatives and analgesics over the first seven days of admission were documented for convenience samples, before (n = 27) and after (n = 29) implementation of standard sedation assessments and a sedation protocol. Sedation was assessed with the COMFORT behaviour scale, Nurse Interpretation of Sedation Score and the Visual Analogue Scale for three‐month periods, both pretest and posttest. Starting 21 months after the posttest, nurses’ compliance with the sedation protocol, as well as administered sedatives and analgesics were evaluated for 12 months. Results. Infants in the posttest period received significantly more midazolam and morphine. The proportion of patients adequately sedated on the grounds of COMFORT scores had increased from 63% pretest to 72% posttest and to 75% in the long run. Adequate sedation as judged from the sedation protocol cutoffs was found in 71% of the assessments. In 45% of assessments indicating undersedation, the infusion rate had been increased on the guidance of the protocol. A survey among staff revealed that most considered the sedation protocol comprehensible and useful. Conclusion. This study showed that regular sedation assessment in critically ill children was feasible and had become standard practice two years after the first posttest. There is insufficient evidence to conclude whether implementation of a sedation treatment protocol indeed improves sedation treatment. Relevance to clinical practice. This sedation protocol provides decision trees for increasing or weaning of sedatives in both haemodynamically stable and unstable patients. It standardises sedation management and allows nurses to adapt medication themselves.     

ABCDE集束化镇痛镇静策略在ICU机械通气患者中应用效果的Meta分析

目的系统评估ABCDE集束化镇痛镇静策略在ICU机械通气患者中的应用效果。方法计算机检索中国期刊全文数据库、万方数据库、中国生物医学文献服务系统、Cochrane图书馆、MEDLINE、Web of SCIENCE、EMbase中关于ABCDE集束化镇痛镇静策略的RCT文献,采用RevMan5.2软件进行统计处理。结果共纳入3篇中文RCT文献,Meta分析结果显示:集束化干预策略能够缩短ICU患者的机械通气时间(Z=7.13,P0.01)、ICU治疗时间(Z=6.85,P0.01),降低谵妄的发生率(Z=4.40,P0.01)。结论 ABCDE集束化镇痛镇静策略对ICU机械通气患者是安全有效的,建议应用于每日的治疗护理中。     

Adoption of a sedation scoring system and sedation guideline in an intensive care unit

AIM: The paper presents a study assessing the rate of adoption of a sedation scoring system and sedation guideline. BACKGROUND: Clinical practice guidelines including sedation guidelines have been shown to improve patient outcomes by standardizing care. In particular sedation guidelines have been shown to be beneficial for intensive care patients by reducing the duration of ventilation. Despite the acceptance that clinical practice guidelines are beneficial, adoption rates are rarely measured. Adoption data may reveal other factors which contribute to improved outcomes. Therefore, the usefulness of the guideline may be more appropriately assessed by collecting adoption data. METHOD: A quasi-experimental pre-intervention and postintervention quality improvement design was used. Adoption was operationalized as documentation of sedation score every 4 hours and use of the sedation and analgesic medications suggested in the guideline. Adoption data were collected from patients' charts on a random day of the month; all patients in the intensive care unit on that day were assigned an adoption category. Sedation scoring system adoption data were collected before implementation of a sedation guideline, which was implemented using an intensive information-giving strategy, and guideline adoption data were fed back to bedside nurses. After implementation of the guideline, adoption data were collected for both the sedation scoring system and the guideline. The data were collected in the years 2002-2004. FINDINGS: The sedation scoring system was not used extensively in the pre-intervention phase of the study; however, this improved in the postintervention phase. The findings suggest that the sedation guideline was gradually adopted following implementation in the postintervention phase of the study. Field notes taken during the implementation of the sedation scoring system and the guideline reveal widespread acceptance of both. CONCLUSION: Measurement of adoption is a complex process. Appropriate operationalization contributes to greater accuracy. Further investigation is warranted to establish the intensity and extent of implementation required to positively affect patient outcomes.     

Paediatric sedation in emergency departments: What is our practice?

Objectives: The aim of the present study was to document the use of sedation in paediatric patients in emergency departments within Australia and New Zealand. Methods: A questionnaire was sent to 54 emergency departments throughout Australia and New Zealand. Results: A total of 45 departments (83%) responded to the survey. Because the adult departments (n = 5) reported few paediatric attendances, they were not included in the analysis. Thirty‐nine of 40 departments (97.5%) reported using sedation in children. Midazolam was used most frequently (77%) for sedation. There was marked variation in the route of delivery and the dose of midazolam used. Ketamine was reported as the most efficacious agent used, but it was used only in 12% of cases. Formal guidelines existed in all paediatric departments but only in 58% of mixed departments, and formal discharge criteria were used in only 52% of all departments. The use of topical anaesthesia in wound closure was reported in only 30% of departments. Conclusions: There exists wide variation in practice regarding the use of sedation in children in emergency departments throughout Australia and New Zealand. Thus, the development of adequate guidelines, including discharge instructions and the use of topical agents, will improve sedation for children.