Brian M Fuller1,2, Brian W Roberts3, Nicholas M Mohr4,5, William A Knight6,7,8, Opeolu Adeoye6,8, Ryan D Pappal9, Stacy Marshall3, Robert Alunday10, Matthew Dettmer11, Munish Goyal12, Colin Gibson13, Brian J Levine14, Jayna M Gardner-Gray15,16, Jarrod Mosier17,18, James Dargin19, Fraser Mackay19,20, Nicholas J Johnson21,22, Sharukh Lokhandwala22, Catherine L Hough22, Joseph E Tonna23,24, Rachel Tsolinas25, Frederick Lin26, Zaffer A Qasim26, Carrie E Harvey27, Benjamin Bassin27, Robert J Stephens2, Yan Yan28,29, Christopher R Carpenter2, Marin H Kollef30, Michael S Avidan31. 1. Division of Critical Care, Department of Anesthesiology, Washington University School of Medicine in St. Louis, St. Louis, MO. 2. Department of Emergency Medicine, Washington University School of Medicine in St. Louis, St. Louis, MO. 3. Department of Emergency Medicine, Cooper University Hospital, Cooper Medical School of Rowan University, Camden, NJ. 4. Department of Emergency Medicine, Roy J. and Lucille A. Carver College of Medicine, University of Iowa, Iowa City, IA. 5. Division of Critical Care, Department of Anesthesiology, Roy J. and Lucille A. Carver College of Medicine, University of Iowa, Iowa City, IA. 6. Division of Critical Care, Department of Emergency Medicine, University of Cincinnati Medical Center, Cincinnati, OH. 7. Department of Neurology, University of Cincinnati Medical Center, Cincinnati, OH. 8. Department of Neurosurgery, University of Cincinnati Medical Center, Cincinnati, OH. 9. Washington University School of Medicine in St. Louis, St. Louis, MO. 10. Division of Critical Care, Department of Emergency Medicine, University of New Mexico, Albuquerque, NM. 11. Emergency Services and Respiratory Institutes, Cleveland Clinic Foundation, Cleveland, OH. 12. Department of Emergency Medicine, MedStar Washington Hospital Center, Washington, DC. 13. Georgetown University School of Medicine, Washington, DC. 14. Department of Emergency Medicine, Christiana Care Health System, Newark, DE. 15. Department of Emergency Medicine, Henry Ford Health System, Detroit, MI. 16. Division of Pulmonary and Critical Care Medicine, Department of Medicine, Henry Ford Health System, Detroit, MI. 17. Department of Emergency Medicine, University of Arizona College of Medicine, Tucson, AZ. 18. Division of Pulmonary, Allergy, Critical Care and Sleep, Department of Medicine, University of Arizona College of Medicine, Tucson, AZ. 19. Pulmonary and Critical Care Medicine, Lahey Hospital & Medical Center, Burlington, MA. 20. Emergency Medicine, Lahey Hospital & Medical Center, Burlington, MA. 21. Department of Emergency Medicine, University of Washington/Harborview Medical Center, Seattle, WA. 22. Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington/Harborview Medical Center, Seattle, WA. 23. Division of Cardiothoracic Surgery, Department of Surgery, University of Utah Health, Salt Lake City, UT. 24. Division of Emergency Medicine, Department of Surgery, University of Utah Health, Salt Lake City, UT. 25. University of Utah School of Medicine, Salt Lake City, UT. 26. Department of Emergency Medicine, University of Pennsylvania, Philadelphia, PA. 27. Department of Emergency Medicine, University of Michigan Medical School, Ann Arbor, MI. 28. Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, MO. 29. Division of Biostatistics, Washington University School of Medicine, St. Louis, MO. 30. Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University School of Medicine in St. Louis, St. Louis, MO. 31. Department of Anesthesiology, Washington University School of Medicine in St. Louis, St. Louis, MO.
Abstract
OBJECTIVES: To characterize emergency department sedation practices in mechanically ventilated patients, and test the hypothesis that deep sedation in the emergency department is associated with worse outcomes. DESIGN: Multicenter, prospective cohort study. SETTING: The emergency department and ICUs of 15 medical centers. PATIENTS: Mechanically ventilated adult emergency department patients. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: All data involving sedation (medications, monitoring) were recorded. Deep sedation was defined as Richmond Agitation-Sedation Scale of -3 to -5 or Sedation-Agitation Scale of 2 or 1. A total of 324 patients were studied. Emergency department deep sedation was observed in 171 patients (52.8%), and was associated with a higher frequency of deep sedation in the ICU on day 1 (53.8% vs 20.3%; p < 0.001) and day 2 (33.3% vs 16.9%; p = 0.001), when compared to light sedation. Mean (SD) ventilator-free days were 18.1 (10.8) in the emergency department deep sedation group compared to 20.0 (9.8) in the light sedation group (mean difference, 1.9; 95% CI, -0.40 to 4.13). Similar results according to emergency department sedation depth existed for ICU-free days (mean difference, 1.6; 95% CI, -0.54 to 3.83) and hospital-free days (mean difference, 2.3; 95% CI, 0.26-4.32). Mortality was 21.1% in the deep sedation group and 17.0% in the light sedation group (between-group difference, 4.1%; odds ratio, 1.30; 0.74-2.28). The occurrence rate of acute brain dysfunction (delirium and coma) was 68.4% in the deep sedation group and 55.6% in the light sedation group (between-group difference, 12.8%; odds ratio, 1.73; 1.10-2.73). CONCLUSIONS: Early deep sedation in the emergency department is common, carries over into the ICU, and may be associated with worse outcomes. Sedation practice in the emergency department and its association with clinical outcomes is in need of further investigation.
OBJECTIVES: To characterize emergency department sedation practices in mechanically ventilated patients, and test the hypothesis that deep sedation in the emergency department is associated with worse outcomes. DESIGN: Multicenter, prospective cohort study. SETTING: The emergency department and ICUs of 15 medical centers. PATIENTS: Mechanically ventilated adult emergency department patients. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: All data involving sedation (medications, monitoring) were recorded. Deep sedation was defined as Richmond Agitation-Sedation Scale of -3 to -5 or Sedation-Agitation Scale of 2 or 1. A total of 324 patients were studied. Emergency department deep sedation was observed in 171 patients (52.8%), and was associated with a higher frequency of deep sedation in the ICU on day 1 (53.8% vs 20.3%; p < 0.001) and day 2 (33.3% vs 16.9%; p = 0.001), when compared to light sedation. Mean (SD) ventilator-free days were 18.1 (10.8) in the emergency department deep sedation group compared to 20.0 (9.8) in the light sedation group (mean difference, 1.9; 95% CI, -0.40 to 4.13). Similar results according to emergency department sedation depth existed for ICU-free days (mean difference, 1.6; 95% CI, -0.54 to 3.83) and hospital-free days (mean difference, 2.3; 95% CI, 0.26-4.32). Mortality was 21.1% in the deep sedation group and 17.0% in the light sedation group (between-group difference, 4.1%; odds ratio, 1.30; 0.74-2.28). The occurrence rate of acute brain dysfunction (delirium and coma) was 68.4% in the deep sedation group and 55.6% in the light sedation group (between-group difference, 12.8%; odds ratio, 1.73; 1.10-2.73). CONCLUSIONS: Early deep sedation in the emergency department is common, carries over into the ICU, and may be associated with worse outcomes. Sedation practice in the emergency department and its association with clinical outcomes is in need of further investigation.
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