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Critical Illness and Mechanical Ventilation | Early Goal-Directed Sedation Compared With Standard Care in Mechanically Ventilated Critically Ill Patients

Critical Illness and Mechanical Ventilation research study

What is the primary objective of this study?

The Use of sedative drugs in intensive care is widespread. A cohort study conducted in Australia and New Zealand in 2010 revealed a high prevalence of deep sedation within the first 48 hours of mechanical ventilation which was independently linked to prolonged ventilation, hospital and 180 days mortality. Clinical practice is moving towards the use of lighter levels of sedation. Recent RCTs in Europe (JAMA 2012) and previous RCTs (JAMA 2009) supports growing evidence that dexmedetomidine facilitates rousable sedation, shortens ventilation time and attenuates delirium when compared to midazolam and propofol. The investigators confirmed in a pilot study the feasibility, efficacy and safety of a process of care known as Early Goal Directed Sedation (EGDS) that delivers: 1. Early randomization after intubation or arrival in the ICU (intubated). 2. Early Adequate analgesia after randomization. 3. Goal directed sedation titrated to achieve light sedation. 4. Dexmedetomidine based algorithm as the primary sedative agent with avoidance of benzodiazepines. The aim of this study is to assess the effectiveness of Early Goal Directed Sedation when compared to standard care sedation in critically ill patients. The study hypothesis is that Early Goal-Directed Sedation (EGDS), compared to standard care sedation, reduces 90-day all-cause mortality in critically ill patients who require mechanical ventilation.

Who is eligible to participate?

Inclusion Criteria: - Patient has been intubated and is receiving mechanical ventilation - The treating clinician expects that the patient will remain intubated until the day after tomorrow (unlikely to be extubated the following day). - The patient requires immediate ongoing sedative medication for comfort, safety, and to facilitate the delivery of life support measures. Exclusion Criteria: - Age less than 18 years - Patient is pregnant and/or lactating - Has been intubated (excluding time spent intubated within an operating theatre or transport) for greater than 12 hours in an intensive care unit. - Proven or suspected acute primary brain lesion such as traumatic brain injury, intracranial haemorrhage, stroke, or hypoxic brain injury. - Proven or suspected spinal cord injury or other pathology that may result in permanent or prolonged weakness. - Admission as a consequence of a suspected or proven drug overdose or burns. - Administration of ongoing neuromuscular blockade. - A mean arterial blood (MAP) pressure that is less than 50 mmHg despite adequate resuscitation and vasopressor therapy at time of randomisation - Heart rate less than 55 beats per minute unless the patient is being treated with a beta-blocker or a high grade atrio-ventricular block in the absence of a functioning pacemaker. - Known sensitivity to any of the study medications or the constituents of propofol (egg, soya or peanut protein) - Acute fulminant hepatic failure - Patient has been receiving full time residential nursing care. - Death is deemed to be imminent or inevitable during this admission and either the attending physician, patient or substitute decision maker is not committed to active treatment. - Patient has an underlying disease that makes survival to 90 days unlikely - Patient has been previously enrolled in the SPICE study.

Which medical condition, disease, disorder, syndrome, illness, or injury is researched?

Critical Illness and Mechanical Ventilation

Study Interventions

Interventions can include giving participants drugs, medical devices, procedures, vaccines, and other products that are either investigational or already available or noninvasive approaches such as surveys, education, and interviews.

Other:Early goal Directed Sedation

Other:Standard care sedation

Study Arms

Research studies and clinical trials typically have two or more research arms. An arm is a group of people who receive the same treatment in the study.

Early Goal Directed SedationEarly Goal Directed Sedation process of care involves: Early delivery of proposed intervention, shortly after initiating mechanical ventilation; Effective analgesia provided simultaneously and early (analgesia first). Regular and frequent assessment of patient wakefulness/sedative state; Avoidance of benzodiazepines and minimisation of use of propofol; Reduced overall sedation depth with targeted light sedation; Patients randomised to the EGDS arm will receive a sedative infusion of Dexmedetomidine withor without minimal propofol in order to maintain a RASS of -2 to +1. Dexmedetomidine infusion will be continued until sedation is no longer clinically indicated up to a maximum of 28 days after enrolment.

Standard care Sedation ArmPatients randomised to the standard care sedation arm will receive process of care sedation directed by the treating clinician. Based on the information from our observational study and the EGDS Pilot trial, most patients in this group are likely to receive midazolam and /or propofol. These agents will be infused to achieve the default target of Light sedation (RASS -2 to +1) whenever clinically appropriate and as specified by the treating clinician. The use remifentanil or dexmedetomidine for initial and maintenance sedation will be precluded.

Study Status

Active, not recruiting

Start Date: November 2013

Completed Date: August 2018

Phase: Phase 3

Type: Interventional

Design:

Primary Outcome: Mortality

Secondary Outcome: Ventilation free days

Study sponsors, principal investigator, and references

Principal Investigator: Yahya Shehabi, MD, FCICM, FANZCA, EMBA

Lead Sponsor: Australian and New Zealand Intensive Care Research Centre

Collaborator: National Health and Medical Research Council, Australia

More information:https://clinicaltrials.gov/show/NCT01728558

Shehabi Y, Bellomo R, Reade MC, Bailey M, Bass F, Howe B, McArthur C, Seppelt IM, Webb S, Weisbrodt L; Sedation Practice in Intensive Care Evaluation (SPICE) Study Investigators; ANZICS Clinical Trials Group. Early intensive care sedation predicts long-term mortality in ventilated critically ill patients. Am J Respir Crit Care Med. 2012 Oct 15;186(8):724-31. doi: 10.1164/rccm.201203-0522OC. Epub 2012 Aug 2.

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