High mortality in Brazilian intensive care units can be a problem of laws rather than a technical one: focus on sedation practices - Critical Care Science (CCS)
In the care of ventilated critically ill patients, there is a consistent relationship between deeper sedation and worse intensive care unit (ICU) outcomes.(,) Deep sedation in the first 48 hours of an ICU stay has been associated with delayed time to extubation, higher need for tracheostomy, longer ICU stays, and increased risk of hospital and long-term death.() This association in patients with acute respiratory distress syndrome (ARDS) and other severely ill patients is of particular concern. In this sense, perhaps the greatest advances in critical patient care can be summarized by the ABCDEF bundle in critical care (Assess, prevent, and manage pain; Both spontaneous awakening trials and spontaneous breathing trials; Choice of analgesia and sedation; Delirium-assess, prevent, and manage; Early mobility and exercise; and Family engagement and empowerment); in this approach, light sedation as opposed to deep sedation seems to be preferred.(,) Each individual component of the bundle is evidence-based and has been validated in multiple clinical trials. The bundle combines the individual impact of each intervention into a synergistic process of care that improves ICU outcomes and can mitigate the burden of postintensive care unit syndrome in survivors. Authors have already demonstrated improving both short-term need (length of delirium, need for physical restraints, days on mechanical ventilation) and long-term outcomes (ICU readmission, discharge to facility) in critically ill patients when these recommendations are practiced.()
In recent years, high-income countries have shown an important reduction in the mortality of critically ill patients, a fact that has not been replicated in lowand middle-income countries. However, why does it not occur? Let us evaluate critical illness data in Brazil, a continental and multicultural country that has failed systematically to reduce critical illness, morbidity and mortality. Recent well-conducted randomized clinical trials (RCTs) in Brazil(,) have demonstrated the inability of some clinical teams to achieve the internationally recommended goals of light sedation. The CHECKLIST trial() (n = 6,877), including any patients admitted to adult ICUs, showed low adherence (control group, 35.0% versus intervention group, 40.5%, p = 0.05) of the ICU staff in providing moderate sedation to alert and calm patients (Richmond Agitation-Sedation Scale – RASS -3 to 0). Patient´s in-hospital mortality (truncated at 60 days) was 33.9% (mean Simplified Acute Physiology Score 3 – SAPS 3 at admission, 51.2 [standard deviation – SD, 17.9] in the control group and 54.2 [SD, 17.5] in the intervention group). Another RCT, the Acute Respiratory Distress Syndrome Trial (ART)() (n = 1,010), which evaluated patients with moderate to severe ARDS, showed that 96.8% of the control group and 73.3% of the intervention group (p < 0.001) needed neuromuscular blockage (a proxy of deep sedation practice), with a global patient mortality of 52.3%. This practice of deep sedation seems to be more common in lowand middle-income countries.() However, in high-income countries, a multinational PRactice of VENTilation patients (PROVENT) trial (studying 2,377 ARDS patients in ICUs in 50 European countries) showed that only 21.7% of patients received neuromuscular blockage; mortality rates of 40.3 to 46.1% were found for moderate and severe ARDS, respectively.() Ratifying the numbers, a multicenter Brazilian Epidemiology of Respiratory Insufficiency in Critical Care (ERICC) study evaluated 773 adult patients admitted to 45 ICUs and showed a hospital mortality of 52% among ARDS patients;() recently, the analysis of the first 254,288 COVID-19 patients admitted to Brazilian hospitals showed a mortality of 80% among those who needed invasive mechanical ventilation.()
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In the care of ventilated critically ill patients, there is a consistent relationship between deeper sedation and worse intensive care unit (ICU) outcomes.(,) Deep sedation in the first 48 hours of an ICU stay has been associated with delayed time to extubation, higher need for tracheostomy, longer ICU stays, and increased risk of hospital and long-term death.() This association in patients with acute respiratory distress syndrome (ARDS) and other severely ill patients is of particular concern. In this sense, perhaps the greatest advances in critical patient care can be summarized by the ABCDEF bundle in critical care (Assess, prevent, and manage pain; Both spontaneous awakening trials and spontaneous breathing trials; Choice of analgesia and sedation; Delirium-assess, prevent, and manage; Early mobility and exercise; and Family engagement and empowerment); in this approach, light sedation as opposed to deep sedation seems to be preferred.(,) Each individual component of the bundle is evidence-based and has been validated in multiple clinical trials. The bundle combines the individual impact of each intervention into a synergistic process of care that improves ICU outcomes and can mitigate the burden of postintensive care unit syndrome in survivors. Authors have already demonstrated improving both short-term need (length of delirium, need for physical restraints, days on mechanical ventilation) and long-term outcomes (ICU readmission, discharge to facility) in critically ill patients when these recommendations are practiced.()
In recent years, high-income countries have shown an important reduction in the mortality of critically ill patients, a fact that has not been replicated in lowand middle-income countries. However, why does it not occur? Let us evaluate critical illness data in Brazil, a continental and multicultural country that has failed systematically to reduce critical illness, morbidity and mortality. Recent well-conducted randomized clinical trials (RCTs) in Brazil(,) have demonstrated the inability of some clinical teams to achieve the internationally recommended goals of light sedation. The CHECKLIST trial() (n = 6,877), including any patients admitted to adult ICUs, showed low adherence (control group, 35.0% versus intervention group, 40.5%, p = 0.05) of the ICU staff in providing moderate sedation to alert and calm patients (Richmond Agitation-Sedation Scale - RASS -3 to 0). Patient´s in-hospital mortality (truncated at 60 days) was 33.9% (mean Simplified Acute Physiology Score 3 - SAPS 3 at admission, 51.2 [standard deviation - SD, 17.9] in the control group and 54.2 [SD, 17.5] in the intervention group). Another RCT, the Acute Respiratory Distress Syndrome Trial (ART)() (n = 1,010), which evaluated patients with moderate to severe ARDS, showed that 96.8% of the control group and 73.3% of the intervention group (p < 0.001) needed neuromuscular blockage (a proxy of deep sedation practice), with a global patient mortality of 52.3%. This practice of deep sedation seems to be more common in lowand middle-income countries.() However, in high-income countries, a multinational PRactice of VENTilation patients (PROVENT) trial (studying 2,377 ARDS patients in ICUs in 50 European countries) showed that only 21.7% of patients received neuromuscular blockage; mortality rates of 40.3 to 46.1% were found for moderate and severe ARDS, respectively.() Ratifying the numbers, a multicenter Brazilian Epidemiology of Respiratory Insufficiency in Critical Care (ERICC) study evaluated 773 adult patients admitted to 45 ICUs and showed a hospital mortality of 52% among ARDS patients;() recently, the analysis of the first 254,288 COVID-19 patients admitted to Brazilian hospitals showed a mortality of 80% among those who needed invasive mechanical ventilation.()
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