The role of daily sedation interruption/vacation/holds to prevent ventilator-associated pneumonia in the ventilated critically ill patient

Specialized care, through prevention, is the basic and efficient approach towards guaranteeing a healthy society. Patients admitted in ICU become vulnerable to a number of infections. An example of such an infection is Ventilation-associated pneumonia.  Techniques such as daily sedation interruption/vacation/holds have been applied to offer specialized care in such a case. The DSI/holds is applied immediately the patient is admitted to the ICU to prevent the disease. Various studies have been carried out to indicate the importance of DSI/ holds in VAP prevention. From Kress, Pohlman, O’Connor, and Hall (2000), the impact of Daily Sedation Interruption (DSI) in preventing Ventilator-Associated Pneumonia (VAP) has been great due to the technique’s ability to support body systems’ adjustments. Additionally, Klompas (2010) states that the role of DSI is far-reaching since it has improved health conditions of people with acute symptoms. Specifically, prevention of VAP has been sufficiently covered by DSI. Critically analyzing Kalanuria, Zai & Mirski (2014) indicates the roles DSI has in the prevention of VAP including accelerating extubation and enhancing body adjustment to a sedation-free environment (Kalanuria, Zai & Mirski, 2014). Evidence showing the efficiency of DSI has been documented, thus illustrating the significance of the roles that it has in the management of VAP. The daily sedation interruptions/holds are preferred to sedation protocols since they help in recovering the alertness of patients. As a result, they are able to evaluate the possibility of weaning the patient. The DSI treatment also helps in the prevention of infections such as pneumonia. In this coverage, critically examining the roles that DSI has on prevention of VAP are poised help in understanding the essence of using it rather than other prevention techniques. The paper also analyses the implications of nursing practices on the health of patients. It also gives a detailed evidence of current studies that have been carried out in relation to the use of DSI.

Ventilator-Associated Pneumonia

Ventilator-associated Pneumonia can be defined as a lung infection commonly diagnosed among patients under breathing machines between forty-eight and seventy-two hours (Agustyn (2007). The condition develops when a patient’s lungs are exposed to air from the ventilator breathing machine hence causing lacerations in the capillary endothelium and epithelium (Charles, 2013). The ventilation machine also causes mechanical damage to the lungs which leads to leakage of fluids, proteins, and blood in the lungs hence the occurrence of VAP (Khan, Ceriana, & Donner, 2017).

DSI/Holds

According to Mehta (2012), sedation is solely used to induce sleep while undergoing treatment. The daily sedation is commenced immediately the patient is placed under ventilated machines (Nassar Junior & Park, 2016). The inclusion criteria for the DSIs involves all adult patients aged 18 years and above, as well as those who are not eligible for weaning. The exclusion criteria, on the other hand, entails pregnant women, and those who are mentally unstable (Shahabi, Yousefi, Yazdannik, & Alikiaii, 2016). DSI prevents VAP through accelerating extubation, which in turn, averts discharges from the cuff (Yousefi, Shahabi, Yazdannik, and Alikiaii, 2016).

 

Current Evidence Relating to Daily Sedation Interruption/Holds

Ventilator Associated Pneumonia (VAP) is a common healthcare infection affecting 10 to 20% of patients in mechanical ventilation machines in the ICU (Hellyer, Ewan, Wilson and Simpson, 2016). Mechanical ventilation is undertaken in order to support breathing and thus provide ventilation to a patient. While VAP develops within 48 to 72 hours after a patient is admitted in mechanical ventilation, it is regarded as one of the most frequent problems with a high morbidity, prolonged hospital stays and associated high costs. Mechanical ventilation requires constant sedation to relieve a patient’s discomfort since more often, it leads to accumulation of sedatives, over-sedation and the vulnerability to VAP resulting from the high risk of aspiration and the suppression of coughing reflex. Daily Sedation Interruption (DSI) is the main measure that prevents the spread of VAP among patients receiving mechanical ventilation. A study performed by Yousefi et al. (2016) critically analyzes current evidence on the application of DSI, especially on VAP treatments.

A statistical analysis of Yousefi et al. (2016) shows that control groups under sedation interruption had approximately two times success rate as compared to other sedation intervention groups’ success rates. The study applied clinical trial to eighty patients. A personal appreciation to Yousefi et al. (2016) analysis indicates that patients who were under circulatory sedation infusion made it favorable to apply intervention and control groups in their study. The evidence indicated in the study is that VAP patients under the clinical trial’s study designate control groups were effective toward VAP prevention as compared to other intervention groups. The strengths in the study are that better control of daily sedation can be monitored to determine the promising amount of sedation interruptions in a day. DSI was also noted to accelerate extubation, by preventing secretions behind the cuff and subsequently reducing VAP. I appreciate the study because it was definitive that control groups worked better, thus indicating that control of sedation would greatly help in preventing VAP. The major weakness is that patients subjected to intervention groups did not benefit from the study and required full treatment using DSI.  Moreover, another challenge experienced was that that daily interruption of sedation resulted in patient discomfort, unintentional device removal, and increased workload to the clinicians attending to patients. Finally, it is imperative to note that for critically ill patients receiving mechanical ventilation, DSI did not reduce the duration of mechanical ventilation nor did it bring forth any notable additional benefits.

On the other hand, an analysis of VAP prevention strategies from Klompas (2010) indicates that the strategies other than DSI have a higher failure rate. A personal analysis on Klompas (2010) indicates that usual care to patients under the ventilator when subjected under daily weaning had their median duration to stay under the ventilator decreased by 1.5 days. Nevertheless, application of DSI to wean reduces the mean duration by 3.5 days. Reviewing studies indicated a variety of results, which were reliable in showing the validity of using DSI in preventing VAP (Klompas, 2010). Klompas (2010), therefore, presented a convincing study that DSI is an effective strategy to prevent and reduce VAP intensity among patients undergoing mechanical ventilation.

In conclusion, the discussion above points out that currently available evidence from pragmatic trials indicate that the role of DSI in the prevention of VAP is elemental. Therefore, in as much as there is still room for further research in this area, it is my analytical view that the strengths of the evidence indicated in the studies supersede the weaknesses, thus demonstrating the essence of using DSI to treat VAP critically ill patients under mechanical ventilation machines.

 

 

Issues and Benefits Relating to Daily Sedation Interruption/ Holds

The major issue regarding the administration of DSI is the right time needed to perform successful extubation. According to Mehta (2012), nurses have been tasked to identify the appropriate time to use DSI and develop the DSI protocol. Immediate response using DSI is critical in reducing the patient’s number of days in the ICU (Mehta, 2012). However, analysis on Nassar Junior and Park (2016) indicates that sedation helps in calming the patient, especially when experiencing pain.

The second issue concerning the Daily sedation interruption is oversedation. Oversedation is a common occurrence and is associated with adverse effects on the patient. According to Wip and Napolitano (2009), determining the appropriate amount of sedation is a risk that has been raised in the prevention of VAP. Their study indicated that a randomized trial had challenges in determining between using sedation infusions of n=66 and n=60. As to determine the right amount of sedation, it requires taking a risk. Proper sedation is highly beneficial for a patient’s recovery. Such effects include an increase in the time spent in the mechanical ventilation. It also leads to a prolonged stay in the ICU. Moreover, oversedation leads to an increase in brain dysfunction of the patient. However, as per the study conducted by Nassar Junior and Park (2016), mild sedation interruptions do not have a major impact on the patient. Therefore, in the treatment of VAP, sedation is not a major issue, but the timing of sedation is the factor to consider (Nassar Junior & Park, 2016).  Another issue relating to DSI/Holds is the emergence of drug interactions in patients. Most patients in the ICU have pharmacodynamics and pharmacokinetics which are subject to drug interactions, hemodynamic instability among other effects. The associated complications lead to an increased difficulty in achieving the intended results from the DSI.

Kress et al. (2000) analyze DSI’s major benefit in reducing the length of stay in the ICU through minimizing the duration of a critically ill patient in mechanical ventilation. Improvement of a VAP patient’s health is also achieved as a result of DSI application (Kress et al., 2000).  DSI reduces the rate of pneumonia infection. There have also been beliefs that daily sedation interruptions could lead to a person developing psychological effects if they are not given deep sedatives. Therefore, under the effective management of issues and risks in DSI application in the prevention of VAP, the benefits certify that patients under mechanical ventilation do not contract the disease.

The implication for Nurses Practices on Patients Undergoing Daily Sedation Interruption

Healthcare practitioners and stakeholders have a role to play towards ensuring that the role of DSI in VAP prevention is a collective responsibility. Teamwork is effective in care provision especially in disease prevention because it is a crucial aspect that would guarantee the success of prevention care. A critical analysis on Kress et al. (2000) indicates that teamwork between healthcare practitioners and other stakeholders such as family members ensure that DSI has paramount benefits in the prevention of VAP (Kress et al. 2000). Teamwork creates an intensive care process by applying every resource in enhancing the role of DSI. Therefore, teamwork is an important element that guarantees the success of DSI in the prevention of VAP.

Junior support staff has a role to play to ensure that patients undergoing DSI receive quality care. Critically analyzing juniors support staff tasks as per Wip and Napolitano (2009), the most basic activity of junior support staff such as nurses is to ensure patients are under the right medication bundle. They have to guarantee patient safety by choosing the best VAP prevention bundles, and in this case, coming up with the best DSI protocol. Upon clarification from senior healthcare personnel, nurses implement the treatment strategy in which, in this case, is DSI. Through implementing the DSI, nurses help in facilitating patient safety and recovery. In my view, junior support staff is tasked with the timely delivery of DSI as per a critical analysis on Kayir, Ulusoy, and Dogan (2018), Timely delivery helps in close assessment of the entire recovery process. Junior support staff is, therefore, tasked with the timely delivery, which consequently, leads to improving patient condition.

Nursing practices also have implications for patients. Patients who receive sedation interruption protocols from nurses experience lesser complications as compared to those who receive deep sedation from the same nurses. It is important to note that the administration of daily interruptions does not have any difference as to when interruption protocols are used by the nurses. When nurses administer too much sedation to the patient, they have negative effects such as the development of pneumonia and increased time in the ventilation machine. The daily interruptions for the sedations reduce drug bioaccumulation among the patients. By doing so, patients become more alert giving nurses an opportunity to evaluate weaning. Therefore, nursing implications have a positive impact on the health of patients under the ICU.

Family support is also needed to ensure DSI administration is successfully done. Family support ensures that patients receive quality health care services by preventing them from self-extubation and necessitating hemodynamic stability in the ventilation machines. A critical analysis of Vet et al. (2014) indicates that family support in the study protocol ensure all factors are kept constant in the randomized controlled trial. Family members at the bedside help in ensuring their patient are given the right treatment. In my view, family support interactively ensures care support is granted. Also, moral support by giving hope to the patient is an implication that family support should offer.

 

Practice/Conclusion

From the above discussion, it is evident that patients in ventilation machines are at a higher risk of developing Ventilation-Associated Pneumonia. Patients admitted in the ICU should, therefore, be put on daily sedation interruptions/ hold to prevent the development of the infection. The role of DSI in the prevention of VAP is of great importance in speeding up the prevention of the disease. The critical review of VAP and its prevention through daily sedation interruption/hold has equipped me with sufficient knowledge on how to implement the strategy in a healthcare scenario. Mechanical ventilation has been cited as a sensitive treatment procedure among critically ill patients who need close examination. In practice, if there is a way to perform treatment without mechanical ventilation, it would be the best option to take since it helps in avoiding the risks attached to it. Understanding the pathophysiology of VAP would greatly help in an equipped and effective approach to controlling the disease. Offering directions in its management and prevention would be an easy task as compared to before. Having acquired knowledge on DSI and VAP makes one feel ready to tackle any issue of the disease since DSI has proven to be a reliable prevention strategy. Such means that knowledge acquired would help in molding future healthcare practices. However, intense research is still needed in the VAP prevention strategy since it would help in effective and appropriate treatment by overcoming the noted risks. More so, it prompts me always to be cautious while handling each patient and relying on evidence-based approaches to controlling VAP. Nurses have a great role to play in care provision, and it is upon them to merit patient safety. Therefore, knowledge of the role of DSI in the prevention of VAP would positively influence future health care practices.

References

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Hellyer, T. P., Ewan, V., Wilson, P., & Simpson, A. J. (2016). The Intensive Care Society recommended bundle of interventions for the prevention of ventilator-associated pneumonia. Journal of the Intensive Care Society17(3), 238–243. https://doi.org/10.1177/1751143716644461

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Khan, Z., Ceriana, P., & Donner, C. (2017). Ventilator-associated pneumonia or ventilator-induced pneumonia. Multidisciplinary Respiratory Medicine12(1), 1-2. doi: 10.1186/s40248-017-0086-3

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Vet, N., de Wildt, S., Verlaat, C., Knibbe, C., Mooij, M., & Hop, W. et al. (2014). Daily interruption of sedation in critically ill children: study protocol for a randomized controlled trial. Trials15(1), 55. doi: 10.1186/1745-6215-15-55

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