Rene Robert1,2,3, Amélie Le Gouge4,5, Nancy Kentish-Barnes6, Mélanie Adda7, Juliette Audibert8, François Barbier9, Simon Bourcier10,11, Jeremy Bourenne12, Alexandre Boyer13,14, Jérôme Devaquet15, Guillaume Grillet16, Olivier Guisset13,17, Anne-Claire Hyacinthe18, Mercé Jourdain19,20, Nicolas Lerolle21,22, Olivier Lesieur23, Emmanuelle Mercier24,25,26, Jonathan Messika27, Anne Renault28,29, Isabelle Vinatier30, Elie Azoulay31, Arnaud W Thille32,33,31, Jean Reignier34,35. 1. Université de Poitiers, Poitiers, France. rene.robert@chu-poitiers.fr. 2. Inserm CIC 1402, ALIVE, Poitiers, France. rene.robert@chu-poitiers.fr. 3. Service de Médecine Intensive Réanimation, CHU Poitiers, 2 rue la Milétrie, 86021, Poitiers Cedex, France. rene.robert@chu-poitiers.fr. 4. Inserm CIC 1415, Tours, France. 5. CHU Tours, Tours, France. 6. Service de Médecine Intensive Réanimation, Groupe de Recherche Famiréa, CHU Saint-Louis, Paris, France. 7. APHM, URMITE, UMR CNRS 7278, Hôpital Nord, Réanimation des Détresses Respiratoires et Infections Sévères, Aix-Marseille Université, Marseille, France. 8. Service de Réanimation Polyvalente, CH de Chartres, Chartres, France. 9. Service de Réanimation Médicale, CHR d'Orléans, Orléans, France. 10. Université Paris-Descartes, Paris, France. 11. Service de Médecine Intensive Réanimation, Assistance Publique des Hôpitaux de Paris, CHU Cochin, Paris, France. 12. APHM, Hôpital La Timone, Réanimation et surveillance continue, Aix-Marseille Université, Marseille, France. 13. Université de Bordeaux, Bordeaux, France. 14. Service de Réanimation Médicale, CHU Bordeaux, Bordeaux, France. 15. Service de Réanimation Polyvalente, Hôpital Foch, Suresnes, France. 16. CH Bretagne Sud, Service de Réanimation Polyvalente, Lorient, France. 17. Service de Réanimation Médicale, CHU Bordeaux, Hôpital Saint-André, Bordeaux, France. 18. Service de Réanimation Polyvalente, Centre Hospitalier Annecy Genevois, Pringy, France. 19. Université de Lille, Lille, France. 20. Service de Réanimation Polyvalente, Inserm U1190, CHRU de Lille - Hôpital Roger Salengro, Lille, France. 21. Université d'Angers, Angers, France. 22. Département de Réanimation médicale et Médecine hyperbare, CHU Angers, Angers, France. 23. Service de Réanimation Polyvalente, CH de La Rochelle, La Rochelle, France. 24. Université de Tours, Tours, France. 25. CHU de Tours, Service de Médecine Intensive Réanimation, Hôpital Bretonneau, Tours, France. 26. Réseau CRICS, Tours, France. 27. APHP; Nord-Université de Paris, Service de Réanimation médico-chirurgicale, Hôpital Louis Mourier, Colombes; Inserm U 1137, Paris, France, Colombes, France. 28. Université de Bretagne Occidentale, Brest, France. 29. Service de Réanimation Médicale, CHU de la Cavale Blanche, Brest, France. 30. Service de Réanimation Polyvalente, CHD de la Vendée, La Roche-sur-Yon, France. 31. Service de Médecine Intensive Réanimation, CHU Poitiers, 2 rue la Milétrie, 86021, Poitiers Cedex, France. 32. Université de Poitiers, Poitiers, France. 33. Inserm CIC 1402, ALIVE, Poitiers, France. 34. Université de Nantes, Nantes, France. 35. Service de Médecine Intensive Réanimation, CHU de Nantes, Nantes, France.
Abstract
PURPOSE: Little is known on the incidence of discomfort during the end-of-life of intensive care unit (ICU) patients and the impact of sedation on such discomfort. The aim of this study was to assess the incidence of discomfort events according to levels of sedation. METHODS: Post-hoc analysis of an observational prospective multicenter study comparing immediate extubation vs. terminal weaning for end-of-life in ICU patients. Discomforts including gasps, significant bronchial obstruction or high behavioural pain scale score, were prospectively assessed by nurses from mechanical ventilation withdrawal until death. Level of sedation was assessed using the Richmond Agitation-Sedation Scale (RASS) and deep sedation was considered for a RASS - 5. Psychological disorders in family members were assessed up until 12 months after the death. RESULTS: Among the 450 patients included in the original study, 226 (50%) experienced discomfort after mechanical ventilation withdrawal. Patients with discomfort received lower doses of midazolam and equivalent morphine, and were less likely to have deep sedation than patients without discomfort (59% vs. 79%, p < 0.001). After multivariate logistic regression, extubation (as compared terminal weaning) was the only factor associated with discomfort, whereas deep sedation and administration of vasoactive drugs were two factors independently associated with no discomfort. Long-term evaluation of psychological disorders in family members of dead patients did not differ between those with discomfort and the others. CONCLUSION: Discomfort was frequent during end-of-life of ICU patients and was mainly associated with extubation and less profound sedation.
PURPOSE: Little is known on the incidence of discomfort during the end-of-life of intensive care unit (ICU) patients and the impact of sedation on such discomfort. The aim of this study was to assess the incidence of discomfort events according to levels of sedation. METHODS: Post-hoc analysis of an observational prospective multicenter study comparing immediate extubation vs. terminal weaning for end-of-life in ICU patients. Discomforts including gasps, significant bronchial obstruction or high behavioural pain scale score, were prospectively assessed by nurses from mechanical ventilation withdrawal until death. Level of sedation was assessed using the Richmond Agitation-Sedation Scale (RASS) and deep sedation was considered for a RASS - 5. Psychological disorders in family members were assessed up until 12 months after the death. RESULTS: Among the 450 patients included in the original study, 226 (50%) experienced discomfort after mechanical ventilation withdrawal. Patients with discomfort received lower doses of midazolam and equivalent morphine, and were less likely to have deep sedation than patients without discomfort (59% vs. 79%, p < 0.001). After multivariate logistic regression, extubation (as compared terminal weaning) was the only factor associated with discomfort, whereas deep sedation and administration of vasoactive drugs were two factors independently associated with no discomfort. Long-term evaluation of psychological disorders in family members of dead patients did not differ between those with discomfort and the others. CONCLUSION: Discomfort was frequent during end-of-life of ICU patients and was mainly associated with extubation and less profound sedation.
Authors: Andres Laserna; Alejandro Durán-Crane; María A López-Olivo; John A Cuenca; Cosmo Fowler; Diana Paola Díaz; Yenny R Cardenas; Catherine Urso; Keara O'Connell; Clara Fowler; Kristen J Price; Charles L Sprung; Joseph L Nates Journal: Intensive Care Med Date: 2020-08-24 Impact factor: 17.440