A prospective evaluation of empiric versus protocol-based sedation and analgesia

Study Objective. To compare empiric and protocol-based therapies of sedatio n and analgesia in terms of pharmacologic cost, effects on mechanical venti lation and intensive care unit (ICU) stay and quality of sedation and analg esia. Design. Prospective study. Setting. A 24-bed medical-surgical-neurologic ICU. Patients. Seventy-two patients evaluated during empiric therapy and 86 duri ng protocol-based therapy. Intervention. Assessment of data collected for 4 months before and 5 months after an evidence-based sedation and analgesia protocol was implemented. Measurements and Main Results. Protocol adherence rate was 83.7%. The hourl y cost (Canadian dollars) of sedation was less with protocol-based therapy ($5.68 +/- 4.27 vs $7.69 +/- 5.29, p<0.01) likely due to increased lorazepa m use. Pharmacologic cost savings may be negated since sedation duration te nded to be longer (122.7 +/- 142.8 vs 88.0 +/- 94.8 hrs, p<0.1) and extubat ion may have been delayed (61.6 +/- 91.4 vs 39.1 +/- 54.7 hrs, p=0.13) with protocol use. Duration of ICU stay after sedation was discontinued was not significantly different before and after protocol implementation. With the protocol, however, the percentage of modified Ramsay sedation scores repre senting discomfort decreased from 22.4 to 11% (p<0.001) and the percentage at a score of 4 increased from 17.2% to 29.6% (p<0.01). The percentage of m odified visual analog measurements representing pain decreased from 9.6 to 5.9% (p<0.05) with the protocol. When data were stratified according to dur ation of sedation, the benefits and delayed extubation associated with prot ocol-based therapy were limited to patients requiring long-term sedation. Conclusion. Compliance with this protocol reduced drug costs and enhanced t he quality of sedation and analgesia for patients requiring long-term sedat ion. Protocol-based therapy with lorazepam may have delayed extubation but did not delay ICU discharge.