3,760 research outputs found
Alpha-2 agonists for sedation of mechanically ventilated adults in intensive care units : a systematic review
Funding The National Institute for Health Research Health Technology Assessment programme. The Health Services Research Unit is core funded by the Chief Scientist Office of the Scottish Government Health and Social Care Directorates.Peer reviewedPublisher PD
The Role of Systematic Reviews in Pharmacovigilance Planning and Clinical Trials Authorisation Application: Example from the SLEEPS Trial
BACKGROUND: Adequate sedation is crucial to the management of children requiring assisted ventilation on Paediatric Intensive Care Units (PICU). The evidence-base of randomised controlled trials (RCTs) in this area is small and a trial was planned to compare midazolam and clonidine, two sedatives widely used within PICUs neither of which being licensed for that use. The application to obtain a Clinical Trials Authorisation from the Medicines and Healthcare products Regulatory Agency (MHRA) required a dossier summarising the safety profiles of each drug and the pharmacovigilance plan for the trial needed to be determined by this information. A systematic review was undertaken to identify reports relating to the safety of each drug. METHODOLOGY/PRINCIPAL FINDINGS: The Summary of Product Characteristics (SmPC) were obtained for each sedative. The MHRA were requested to provide reports relating to the use of each drug as a sedative in children under the age of 16. Medline was searched to identify RCTs, controlled clinical trials, observational studies, case reports and series. 288 abstracts were identified for midazolam and 16 for clonidine with full texts obtained for 80 and 6 articles respectively. Thirty-three studies provided data for midazolam and two for clonidine. The majority of data has come from observational studies and case reports. The MHRA provided details of 10 and 3 reports of suspected adverse drug reactions. CONCLUSIONS/SIGNIFICANCE: No adverse reactions were identified in addition to those specified within the SmPC for the licensed use of the drugs. Based on this information and the wide spread use of both sedatives in routine practice the pharmacovigilance plan was restricted to adverse reactions. The Clinical Trials Authorisation was granted based on the data presented in the SmPC and the pharmacovigilance plan within the clinical trial protocol restricting collection and reporting to adverse reactions
Evaluating The Effects Of A Nurse-Led Intervention For Delirium And Pain Management Among Older Adults In The Surgical Intensive Care Unit
Delirium, a prevalent disorder in older adults, is an acute brain dysfunction characterized by disturbances in attention, awareness and cognition not explained by a pre-existing neurocognitive disorder. The ICU Liberation Executing the ABCDEF Bundle Daily (iLEAD) is a nurse-driven intervention aimed at reducing the consequences of delirium in the intensive care unit (ICU). It was posited that when nurses routinely assess non-modifiable risk factors and manage modifiable risk factors for delirium, including those related to pain and pain management, patient outcomes will improve. This dissertation research: 1) systematically reviewed the use of the pharmacotherapy dexmedetomidine to treat or prevent delirium (Chapter 2); 2) compared patient outcomes in older adults with delirium in the surgical ICU (SICU) before and after implementation of the iLEAD intervention (Chapter 3); and 3) assessed the relationship among pain, its treatment with opioids, and the onset of delirium in the post-implementation cohort (Chapter 4). The pre- and post-iLEAD intervention cohorts consisted of 93 patients who developed delirium while admitted to the SICU at the Hospital of the University of Pennsylvania. The analysis evaluated the effects of implementing the iLEAD protocol on the number of days of delirium, SICU and hospital length of stay, 30-day readmission and 30-day mortality. In addition, this research examined the role of pain, pain management with opioids, and delirium onset. Results from this study have meaningfully contributed to better informed care of older adult patients with delirium in critical care environments
The implausibility of ‘usual care’ in an open system: sedation and weaning practices in Paediatric Intensive Care Units (PICUs) in the United Kingdom (UK)
Background: The power of the randomised controlled trial depends upon its capacity to operate in a closed
system whereby the intervention is the only causal force acting upon the experimental group and absent in the
control group, permitting a valid assessment of intervention efficacy. Conversely, clinical arenas are open systems
where factors relating to context, resources, interpretation and actions of individuals will affect implementation and
effectiveness of interventions. Consequently, the comparator (usual care) can be difficult to define and variable in
multi-centre trials. Hence outcomes cannot be understood without considering usual care and factors that may
affect implementation and impact on the intervention.
Methods: Using a fieldwork approach, we describe PICU context, ‘usual’ practice in sedation and weaning from
mechanical ventilation, and factors affecting implementation prior to designing a trial involving a sedation and
ventilation weaning intervention. We collected data from 23 UK PICUs between June and November 2014 using
observation, individual and multi-disciplinary group interviews with staff.
Results: Pain and sedation practices were broadly similar in terms of drug usage and assessment tools. Sedation
protocols linking assessment to appropriate titration of sedatives and sedation holds were rarely used (9 % and 4 %
of PICUs respectively). Ventilator weaning was primarily a medical-led process with 39 % of PICUs engaging senior
nurses in the process: weaning protocols were rarely used (9 % of PICUs). Weaning methods were variably based
on clinician preference. No formal criteria or use of spontaneous breathing trials were used to test weaning
readiness. Seventeen PICUs (74 %) had prior engagement in multi-centre trials, but limited research nurse
availability. Barriers to previous trial implementation were intervention complexity, lack of belief in the evidence and
inadequate training. Facilitating factors were senior staff buy-in and dedicated research nurse provision.
Conclusions: We examined and identified contextual and organisational factors that may impact on the
implementation of our intervention. We found usual practice relating to sedation, analgesia and ventilator weaning
broadly similar, yet distinctively different from our proposed intervention, providing assurance in our ability to
evaluate intervention effects. The data will enable us to develop an implementation plan; considering these factors
we can more fully understand their impact on study outcomes
- …