sexta-feira, janeiro 11, 2008

Interrupção da Sedação acoplada a teste de desmame reduz tempo de Ventilação mecânica

Na Ultima edição do Lancet, pesquisadores da Vanderbilt University School of Medicine demonstram que o uso de medidas simples como interrupção diária da sedação associada ao screening de viabilidade de desmame pode reduzir a morbi-mortalidade de pacientes críticos. Reduções significativas do tempo de ventilação mecânica foram observadas e ainda mais importante houve redução de mortalidade com um NNT=7.4.
Diversas das intervenções (farmacológicas ou não) em medicina intensiva tem custo elevado, risco de efeitos colaterais significativos e frequentemente não demonstram ser tão eficientes quanto a medida implementada por Girad e cols.





The Lancet 2008; 371:126-134
DOI:10.1016/S0140-6736(08)60105-1

Articles

Efficacy and safety of a paired sedation and ventilator weaning protocol for mechanically ventilated patients in intensive care (Awakening and Breathing Controlled trial): a randomised controlled trial

Dr Timothy D Girard MD email address c d Corresponding Author Information, John P Kress MD g, Barry D Fuchs MD h, Jason WW Thomason MD c, William D Schweickert MD g, Brenda T Pun RN c, Darren B Taichman MD h, Jan G Dunn RN b, Anne S Pohlman RN g, Paul A Kinniry MD h, James C Jackson PsyD c d, Angelo E Canonico MD a, Prof Richard W Light MD c, Ayumi K Shintani PhD e, Jennifer L Thompson MPH e, Sharon M Gordon PsyD d f, Prof Jesse B Hall MD g, Prof Robert S Dittus MD d f, Prof Gordon R Bernard MD c and Prof E Wesley Ely MD c d f
Summary
Background

Approaches to removal of sedation and mechanical ventilation for critically ill patients vary widely. Our aim was to assess a protocol that paired spontaneous awakening trials (SATs)—ie, daily interruption of sedatives—with spontaneous breathing trials (SBTs).
Methods

In four tertiary-care hospitals, we randomly assigned 336 mechanically ventilated patients in intensive care to management with a daily SAT followed by an SBT (intervention group; n=168) or with sedation per usual care plus a daily SBT (control group; n=168). The primary endpoint was time breathing without assistance. Data were analysed by intention to treat. This study is registered with ClinicalTrials.gov, number NCT00097630.
Findings

One patient in the intervention group did not begin their assigned treatment protocol because of withdrawal of consent and thus was excluded from analyses and lost to follow-up. Seven patients in the control group discontinued their assigned protocol, and two of these patients were lost to follow-up. Patients in the intervention group spent more days breathing without assistance during the 28-day study period than did those in the control group (14·7 days vs 11·6 days; mean difference 3·1 days, 95% CI 0·7 to 5·6; p=0·02) and were discharged from intensive care (median time in intensive care 9·1 days vs 12·9 days; p=0·01) and the hospital earlier (median time in the hospital 14·9 days vs 19·2 days; p=0·04). More patients in the intervention group self-extubated than in the control group (16 patients vs six patients; 6·0% difference, 95% CI 0·6% to 11·8%; p=0·03), but the number of patients who required reintubation after self-extubation was similar (five patients vs three patients; 1·2% difference, 95% CI −5·2% to 2·5%; p=0·47), as were total reintubation rates (13·8% vs 12·5%; 1·3% difference, 95% CI −8·6% to 6·1%; p=0·73). At any instant during the year after enrolment, patients in the intervention group were less likely to die than were patients in the control group (HR 0·68, 95% CI 0·50 to 0·92; p=0·01). For every seven patients treated with the intervention, one life was saved (number needed to treat was 7·4, 95% CI 4·2 to 35·5).
Interpretation

Our results suggest that a wake up and breathe protocol that pairs daily spontaneous awakening trials (ie, interruption of sedatives) with daily spontaneous breathing trials results in better outcomes for mechanically ventilated patients in intensive care than current standard approaches and should become routine practice.
Affiliations

a. Department of Medicine, Saint Thomas Hospital, Nashville, TN, USA
b. Saint Thomas Research Institute, Saint Thomas Hospital, Nashville, TN, USA
c. Department of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, TN, USA
d. Center for Health Services Research, Vanderbilt University School of Medicine, Nashville, TN, USA
e. Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, TN, USA
f. VA Tennessee Valley Geriatric Research, Education and Clinical Center (GRECC), VA Service, Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, TN, USA
g. Department of Medicine, Section of Pulmonary and Critical Care, University of Chicago, Chicago, IL, USA
h. Department of Medicine, Division of Pulmonary, Allergy and Critical Care Medicine, University of Pennsylvania School of Medicine, Philadelphia, PA, USA

Corresponding Author InformationCorrespondence to: Dr Timothy D Girard, Division of Allergy, Pulmonary, and Critical Care Medicine, Center for Health Services Research, 6th Floor MCE 6110, Vanderbilt University School of Medicine, Nashville, TN 37232-8300, USA