Sedation management in the post-COVID era: A personalised, patient-orientated approach

A personalised, patient-orientated approach to ICU sedation

Authors

  • Neil John Glassford Department of Intensive Care Medicine, Monash Medical Centre, Monash Health, Clayton Road, Clayton
  • Yahya Shehabi Monash Health School of Clinical Sciences, Monash University, Clayton, Victoria, Melbourne, Australia https://orcid.org/0000-0003-4707-7462

DOI:

https://doi.org/10.54205/ccc.v32.265724

Keywords:

Hypnotics and sedatives, Delirium, Critical illness, Mechanical ventilation, Dexmedetomidine

Abstract

Intensive care patients are older, frailer, and more co-morbid than ever before, and remain at risk of a variety of adverse outcomes, both in ICU, and after discharge. Sedation and delirium play an intricate role in this complex system, and it can be difficult to determine if they are a contributor or consequence in any given situation.  During the COVID-19 pandemic, the increased frequency of complex ventilatory management, including prone ventilation and neuromuscular blockade, necessitated deep sedation in many cases. In concert with infection control concerns and staffing pressures, the delivery of precision symptom- and patient-oriented sedation has waned in favour of strategies felt to be globally safe.  Using the SPICE III study as a lens to understand both the importance of exploring heterogeneity of effect in large, complex RCTs of critically ill patients, and the importance of an individualised approach to sedation in the intensive care unit, we demonstrate the evolution of our understanding of sedation in this challenging environment.  By following the principles that define the cornerstones of best contemporary sedation practice we can once more grow beyond the boundaries of clinical practice guidelines in the provision of personalised, patient-orientated sedation in the post-COVID intensive care unit.

Author Biography

Yahya Shehabi, Monash Health School of Clinical Sciences, Monash University, Clayton, Victoria, Melbourne, Australia

Professor Shehabi, a senior clinician academic and experienced clinical trialist with extensive track record in leading multinational large scale RCTs, competitive NHMRC and industry collaborative grant funding, knowledge dissemination through publications in high impact journals and presentations at major critical care meetings. He is a respected opinion leader in critical care, nationally and internationally.

Since 2015, he has published and been involved in more than 45 (13 first author) peer reviewed original research, invited editorials and book chapters with 4300 citations with h-index 26 and i10-index 41 (total 48). Dr Shehabi has been an NHMRC GRP member in 2014/15/16/17/19 and 2020. He is a peer reviewer for many high impact journals including NEJM, JAMA, Am J Resp Crit Care Medicine, Crit Care Med and Inten Care Medicine.

Professor Shehabi led the Sedation Practice in Intensive Care Evaluation (SPICE) research programme from concept, design, execution, and publications. In collaboration with the Australian and Intensive Care Society Clinical Trials Group (ANZIC CTG), multiple SPICE studies have been conducted and published in leading critical care journals. SPICE I, the foundation of the SPICE program, conducted in 4 countries in 43 ICUs. It uncovered for the first time an independent association between deep sedation in the first 48 hrs of mechanical ventilation and 6 months mortality. SPICE II, a pilot trial conducted in 8 ICUs, tested a new concept of early goal directed sedation using dexmedetomidine as a candidate intervention. SPICE III, a pivotal trial of 4000 patients recruited in 74 ICUs tested the hypothesis that early sedation with dexmedetomidine may reverse early deep sedation and reduce mortality. SPICE IV is the next succession of the SPICE program in older population of ICU patients.

In collaboration with Canadian Critical Care Trials Group, Dr Shehabi assembled a team of investigators in Australia to conduct the BALANCE trial, Bacteraemia Antibiotic Length Actually Needed for Clinical Effectiveness. In collaboration with Infectious disease consultants at MU, a successful NHMRC grant was secured for the completion of the trial.

He has been the chief investigator of the randomised multicentre RCT, the ProGUARD trial, funded by the Intensive Care Foundation, in 12 ICUs in Australia, evaluating the utility of Procalcitonin in patients with undifferentiated infections in ICU. The results of which were published in the AJRCCM in 2012. Since then, he collaborated widely with international colleagues and participated in multiple publications in the Lancet Inf Dis and the Cochrane reviews on the utility of Procalcitonin in managing respiratory infections.

Through his research, Professor Shehabi is considered a national and an international authority on sedation and delirium management and on the use of dexmedetomidine in critical care and perioperative medicine. He actively participated in the Society Critical Care Medicine taskforce which composed and published the widely disseminated PADIS guidelines, published in Crit Care Med in 2018. He is part of an international delirium interest group evaluating the prevention and impact delirium in hospital and ICU patients. He has led the SaferCare Victoria sedation and delirium management plan, known as the Vic-PAD ICU. The first stage was conducted in 13 ICUs in Victoria prior to the COVID-19 pandemic.

Dr Shehabi established a successful collaboration with medical pharma and device companies securing > A$ 3 million in direct and in-kind funding over the last 5 years.

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2024-01-16

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John Glassford N, Shehabi Y. Sedation management in the post-COVID era: A personalised, patient-orientated approach: A personalised, patient-orientated approach to ICU sedation. Clin Crit Care [Internet]. 2024 Jan. 16 [cited 2024 May 2];32(1):e240001. Available from: https://he02.tci-thaijo.org/index.php/ccc/article/view/265724

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Vol. 32 (2024): January - December

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