Critical care nurses today are less likely than 10 years ago to believe patients on mechanical ventilation need sedation.
But 66% of nurses still believe mechanical ventilation sedation is necessary for patient comfort, according to a survey published July 2019 in the American Journal of Critical Care. The data was collected in a survey of the 177 members of the American Association of Critical-Care Nurses (AACN). Reasons to lessen sedation use, according to one researcher, are compelling. [caption id="attachment_56315" align="alignleft" width="300"]
Jill Guttormson, PhD, RN[/caption] "Since the late 1990s, there has been quite a bit of research out about the negative consequences of having patients sedated," said study coauthor Jill Guttormson, PhD, RN, associate professor at the College of Nursing, Marquette University, Milwaukee. According to Guttormson, those negative patient consequences include:
- Increased time on the ventilator
- Increased time in the ICU
- Increased rate of delirium
"And all those things have long-term consequences for our patients as they recover from critical illness," Guttormson said. "It's not just about their ICU stay. If we can decrease sedation, we may be able to help people have a more complete recovery -- or a quicker recovery -- after they leave the ICU." The 2016 survey results suggest critical care nurses are making strides to decrease sedation use but have a long way to go.
"We saw that more nurses feel an awake, alert patient is appropriate," Guttormson said. "Fewer nurses feel sedation is necessary for all patients. But nurses' attitudes still influence how we sedate patients. Our attitudes about what it's like to be on a ventilator, what we would like if we were on the ventilator and the comfort of patients still influence how nurses manage sedation."
In a 2005 survey of AACN members, 81% of nurses felt mechanical ventilation sedation was necessary to minimize patient discomfort, versus more than 65% in the most recent survey. Among additional 2016 study findings were:
- More than a third of nurses indicated they think limiting patient recall is a good thing resulting from sedation.
- More than 30% of nurses indicated they intend to sedate all mechanical ventilation patients, versus 47.7% of nurses who disagree with making sedation a blanket practice.
- More than 40% of nurses surveyed said patients' families influenced their sedation practices.
- Eighty-seven percent of nurses said physicians considered their nursing assessments when writing sedation orders.
- Nurses might need more training when caring for alert and interactive patients on mechanical ventilation given more than half of those surveyed agreed that tachypnea and spontaneous trunk and leg movement indicated undersedation. Only half agreed that not following commands indicated oversedation.
- While 94% of nurses said their units had sedation assessment tools and 86% indicated they had sedation protocols, adherence to protocols has been reported to be as low as 25%. This survey didn't assess adherence to protocols.
- About a third of nurses reported staffing ratios of 1:1 or 1:2 impacted their sedation practices, but 45% said they administered sedatives to complete nursing functions.
- Nurses who were older, more experienced, or had critical care nurse certification (CCRN) were less likely to administer sedative medications and positively evaluate sedatives' ability to minimize distress.
- Nurses employed at Magnet hospitals tended to less positively evaluate the effectiveness of sedative medications and were less inclined to agree they would sedate all patients receiving mechanical ventilation.
Patient discomfort creates real concern
The most recent study results suggest nurses remain concerned about their options for alleviating patient discomfort and distress, especially when it comes to mechanical ventilation sedation, Guttormson said.
"We ask people to limit sedation, and we don't have other options for what to use to help minimize discomfort or anxiety," she said. "So, we're asking nurses to do a really hard thing. I think nurses still agree sedation might be needed because of that concern about patient comfort while they're in the ICU."
Guidelines published since 2002 have called for limiting sedative administration to maintain "light levels" of these medications during mechanical ventilation unless clinically contraindicated. But that might not be realistic yet. "Ideally a patient is calm and comfortable and arouses to voice and can interact with you and answer questions and let you know their needs," Guttormson said. "I don't think we're there yet in practice consistently with our ventilated patients, and certainly some patients are so sick that it's not reasonable to have them awake and interactive. But for many, many of our ventilated patients, that would be the better route. We have to get more comfortable doing that, and we have to have alternatives to sedation." Another potential problem with implementing better sedation practices is the challenge of communicating with a patient who can't verbalize, Guttormson said.
How to limit mechanical ventilation sedation
Hospitals and other employers should consider their environments for helping nurses and physicians use less sedation, and nurses should be supported and involved, she said. Key employer considerations include staffing and giving nurses a voice in sedation protocols from day one because nurses know best how to get change to happen in the ICU, according to Guttormson. It's also important that nurses have easy access to tools to help them better communicate with non-vocal, very weak patients. Then it's a matter of looking into the tools that are complementary treatments that could be implemented in the care of patients, she said.
It's vitally important to think about other ways to manage anxiety that don't involve the use of these powerful medications. Things such as music at the bedside and family, according to Guttormson, can help keep patients calm and manage their anxiety.
According to Guttormson, is research looking at music to decrease anxiety, which was published in 2013 in the Journal of the American Medical Association. In addition, a study about the use of patient-controlled sedation during mechanical ventilation published in 2017 in the American Journal of Critical Care could be helpful. There's also the SPEACS-2 Communication Training Program, a training tool to help nurses better communicate with these patients. "Like anything, practice change takes a lot of time," Guttormson said. "I do see that more nurses are aware sedation should be limited, and I do think there is a trend toward decreasing sedation. But I don't think we've gone far enough yet for the long-term health and long-term recovery of our patients."
Take these courses related to mechanical ventilation sedation:
Mechanical Ventilation and Weaning (1 contact hr) Caring for mechanically ventilated patients is one of the most commonly used technologies and challenging part of nursing care in the ICU. Promoting patient safety is paramount in caring for mechanically ventilated patients. Patients who require mechanical ventilation for more than three days are at an increased risk to develop complications, prolonged length of stay in the ICU, ventilator dependence and death. The nurse and other healthcare professionals must understand current modes and settings of ventilation, exercise-appropriate assessment, ventilation management skills, and safe and successful weaning techniques. Evidence-Based Practice for ICU Sedation, Central Line Infections and Early Feeding (1 contact hr) Advances in technology give us easy access to a wealth of information to support evidence-based practice. By accessing these resources, nurses can provide patients with the best evidence-based interventions and treatments. This continuing education module reviews the evidence behind three practices: breathing trials for patients on mechanical ventilation, preventing CLABSIs and early feeding of critically ill patients. Pediatric Tracheostomy and Ventilator Care (1 contact hr) Home care for children who require long-term tracheostomies and mechanical ventilatory support has become a common alternative to hospitalization. Nurses play a critical role in preparing and supporting the family and other caregivers to provide care. This continuing education module updates nurses' knowledge of the care of pediatric patients who are on respiratory support.
