Changes in Sedation Management in German Intensive Care Units
Background: The aim of this study, conducted in 2006, was to find out whether changes in sedation management in German intensive care units took place in comparison with our survey from 2002.
Methods: We conducted a follow-up survey with a descriptive and comparative cross-sectional multi-center design. A postal survey was sent between January and May 2006, up to four times, to the same 269 hospitals that participated in our first survey in 2002. The same questionnaire as in 2002 was used with a few additional questions.
Results: Two hundred fourteen (82%) hospitals replied. Sixty-seven percent of the hospitals carried out changes in sedation management since the 2002 survey. Reasons for changes were published literature (46%), national guidelines (29%), and scientific lectures (32%). Sedation protocols (8% versus 52%) and a sedation scale (21% versus 46%) were used significantly more frequently. During sedation periods of up to 24 hours, significantly less midazolam was used (46% versus 35%). In comparison to 2002, sufentanil and epidural analgesia were used much more frequently in all phases of sedation, and fentanyl more rarely. For periods of greater than 72 hours, remifentanil was used more often. A daily sedation break was introduced by 34% of the hospitals, and a pain scale by 21%.
Conclusion: The increased implementation of protocols and scoring systems for the measurement of sedation depth and analgesia, a daily sedation break, and the use of more short-acting analgesics and sedatives account for more patient-oriented analgesia and sedation in 2006 compared with 2002.

Most mechanically ventilated patients require analgesia and sedation. Adequate analgesia and sedation should ensure that the patient can receive intensive medical care without undue stress or pain. As with insufficient sedation, excessively deep sedation also may lead to increased morbidity, increased costs, and a prolonged stay in the intensive care unit (ICU). Recent advances with drugs that are more controllable, better ventilation techniques and sedation strategies, and the use of scoring systems and sedation protocols enable optimization of sedation. However, the optimal sedation strategy remains a controversial issue at present. Despite controversies, a shift from deeper to lighter sedation, thereby maintaining the normal circadian rhythm, is emerging within the published literature.

Apart from sedation, emphasis should be placed on adequate monitoring of analgesia. Whipple and colleagues have shown that 70% of patients admitted to an ICU recollected suffering pain. Regular review of pain scores followed by appropriate therapy leads to a reduction in morbidity and a reduction in duration of mechanical ventilation.

Soliman and colleagues have shown that sedation practice and the use of differing scoring systems and guidelines are quite different between countries. In 2002, a national survey of analgesia and sedation practice in German ICUs was undertaken. The goal of the present study was to find out whether new trends or significant changes in ICU analgesia and sedation practice among mechanically ventilated patients in ICUs have emerged since the last survey and the publication of national guidelines for analgesia and sedation practice in Germany in 2005. The major recommendations of the guidelines consist of the application of scores for analgesia and sedation, with a patient-oriented depth of sedation, implementation of written sedation protocols, application of short-acting drugs, and use of regional anesthesia techniques.