Practices in sedation, analgesia, mobilization, delirium, and sleep deprivation in adult intensive care units (SAMDS-ICU): an international survey before and during the COVID-19 pandemic

(1)Intensive Care Unit of the Hospital da Mulher, Salvador, BA, Brazil.

(2)Programa de Pós-Graduação em Medicina e Saúde, Faculdade de Medicina da Bahia, Universidade Federal da Bahia, Salvador, Bahia, Brazil.

(3)Intensive Care Unit, Hospital Universitário Professor Edgard Santos, Salvador, Brazil.

(4)Intensive Care Unit of the Hospital da Mulher, Salvador, BA, Brazil.

(5)Programa de Pós-Graduação em Medicina e Saúde, Faculdade de Medicina da Bahia, Universidade Federal da Bahia, Salvador, Bahia, Brazil.

(6)Departamento de Pediatria, Hospital Universitário Pedro Ernesto, Universidade Do Estado Do Rio de Janeiro, Rio de Janeiro, Brazil.

(7)Department of Critical Care and Postgraduate Program in Translational Medicine, D'Or Institute for Research and Education (IDOR), Rio de Janeiro, Brazil.

(8)Programa de Pós-Graduação em Clínica Médica, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil.

(9)Laboratório de Fisiopatologia Experimental, Programa de Pós-Graduação em Ciências da Saúde, Universidade do Extremo Sul Catarinense, Criciúma, Santa Catarina, Brazil.

(10)Faculdade de Medicina da Bahia, Universidade Federal da Bahia, Salvador, BA, Brazil.

(11)Department of Anesthesia and Intensive Care Unit, Regional University Hospital of Montpellier, St-Eloi Hospital, University of Montpellier, PhyMedExp, INSERM U1046, CNRS UMR, 9214, Montpellier, CEDEX 5, France.

(12)Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India.

(13)Internal Medicine Department, Critical Care Unit, Hospital Clínico Universidad de Chile, Santiago, Chile.

(14)Critical Care Department, Vega Baja Orihuela Hospital, Alicante, Spain.

(15)Intensive Care Unit, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina.

(16)Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA.

(17)Center for Health Services Research, Vanderbilt University Medical Center, Nashville, TN, USA.

(18)Center for Quality Aging, Vanderbilt University Medical Center, Nashville, TN, USA.

(19)Geriatric Research Education and Clinical Center (GRECC) Service at the Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, TN, USA.

(20)Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, TN, USA.

(21)Department of Pharmaceutical Services, Vanderbilt University Medical Center, Nashville, TN, USA.

(22)Tennessee Valley Healthcare System VA Medical Center, Nashville, TN, USA.

(23)Division of Pulmonary and Critical Care Medicine, University of Chicago, Chicago, IL, USA.

(24)Polyvalent Intensive Care Unit, Hospital de São Francisco Xavier, CHLO, Lisbon, Portugal.

(25)CHRC, CEDOC, NOVA Medical School, New University of Lisbon, Lisbon, Portugal.

(26)Center for Clinical Epidemiology and Research Unit of Clinical Epidemiology, OUH Odense University Hospital, Odense, Denmark.

(27)Department of Critical Care and Perioperative Medicine, School of Clinical Sciences, Monash University, Melbourne, VIC, Australia.

(28)Intensive Care Unit, Hospital Américo Boavida, Luanda, Angola. 

BACKGROUND: Since the publication of the 2018 Clinical Guidelines about sedation, analgesia, delirium, mobilization, and sleep deprivation in critically ill patients, no evaluation and adequacy assessment of these recommendations were studied in an international context. This survey aimed to investigate these current practices and if the COVID-19 pandemic has changed them.

METHODS: This study was an open multinational electronic survey directed to physicians working in adult intensive care units (ICUs), which was performed in two steps: before and during the COVID-19 pandemic.RESULTS: We analyzed 1768 questionnaires and 1539 (87%) were complete. Before the COVID-19 pandemic, we received 1476 questionnaires and 292 were submitted later. The following practices were observed before the pandemic: the Visual Analog Scale (VAS) (61.5%), the Behavioral Pain Scale (BPS) (48.2%), the Richmond Agitation Sedation Scale (RASS) (76.6%), and the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) (66.6%) were the most frequently tools used to assess pain, sedation level, and delirium, respectively; midazolam and fentanyl were the most frequently used drugs for inducing sedation and analgesia (84.8% and 78.3%, respectively), whereas haloperidol (68.8%) and atypical antipsychotics (69.4%) were the most prescribed drugs for delirium treatment; some physicians regularly prescribed drugs to induce sleep (19.1%) or ordered mechanical restraints as part of their routine (6.2%) for patients on mechanical ventilation; non-pharmacological strategies were frequently applied for pain, delirium, and sleep deprivation management. During the COVID-19

pandemic, the intensive care specialty was independently associated with best practices. Moreover, the mechanical ventilation rate was higher, patients received sedation more often (94% versus 86.1%, p < 0.001) and sedation goals were discussed more frequently in daily rounds. Morphine was the main drug used for analgesia (77.2%), and some sedative drugs, such as midazolam, propofol, ketamine and quetiapine, were used more frequently. CONCLUSIONS: Most sedation, analgesia and delirium practices were comparable before and during the COVID-19 pandemic. During the pandemic, the intensive care specialty was a variable that was independently associated with the best practices. Although many findings are in accordance with evidence-based recommendations, some practices still need improvement.