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The ED-SED Study: A Multicenter, Prospective Cohort Study of Practice Patterns and Clinical Outcomes Associated With Emergency Department SEDation for Mechanically Ventilated Patients

Fuller, Brian M. MD, MSCI1,2; Roberts, Brian W. MD3; Mohr, Nicholas M. MD, MS4,5; Knight, William A. IV MD6,7,8; Adeoye, Opeolu MD6,8; Pappal, Ryan D. BS, BA, NRP9; Marshall, Stacy MD3; Alunday, Robert MD10; Dettmer, Matthew MD11; Goyal, Munish MD12; Gibson, Colin MS13; Levine, Brian J. MD14; Gardner-Gray, Jayna M. MD15,16; Mosier, Jarrod MD17,18; Dargin, James MD19; Mackay, Fraser MD19,20; Johnson, Nicholas J. MD21,22; Lokhandwala, Sharukh MD22; Hough, Catherine L. MD, MS22; Tonna, Joseph E. MD23,24; Tsolinas, Rachel BA25; Lin, Frederick MD26; Qasim, Zaffer A. MBBS26; Harvey, Carrie E. MD27; Bassin, Benjamin MD27; Stephens, Robert J. MD, MSCI2; Yan, Yan MD, MA, MHS, PhD28,29; Carpenter, Christopher R. MD, MSc, FACEP, FAAEM2; Kollef, Marin H. MD30; Avidan, Michael S. MBBCh31

doi: 10.1097/CCM.0000000000003928
Clinical Investigations
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Objectives: To characterize emergency department sedation practices in mechanically ventilated patients, and test the hypothesis that deep sedation in the emergency department is associated with worse outcomes.

Design: Multicenter, prospective cohort study.

Setting: The emergency department and ICUs of 15 medical centers.

Patients: Mechanically ventilated adult emergency department patients.

Interventions: None.

Measurements and Main Results: All data involving sedation (medications, monitoring) were recorded. Deep sedation was defined as Richmond Agitation-Sedation Scale of –3 to –5 or Sedation-Agitation Scale of 2 or 1. A total of 324 patients were studied. Emergency department deep sedation was observed in 171 patients (52.8%), and was associated with a higher frequency of deep sedation in the ICU on day 1 (53.8% vs 20.3%; p < 0.001) and day 2 (33.3% vs 16.9%; p = 0.001), when compared to light sedation. Mean (sd) ventilator-free days were 18.1 (10.8) in the emergency department deep sedation group compared to 20.0 (9.8) in the light sedation group (mean difference, 1.9; 95% CI, –0.40 to 4.13). Similar results according to emergency department sedation depth existed for ICU-free days (mean difference, 1.6; 95% CI, –0.54 to 3.83) and hospital-free days (mean difference, 2.3; 95% CI, 0.26–4.32). Mortality was 21.1% in the deep sedation group and 17.0% in the light sedation group (between-group difference, 4.1%; odds ratio, 1.30; 0.74–2.28). The occurrence rate of acute brain dysfunction (delirium and coma) was 68.4% in the deep sedation group and 55.6% in the light sedation group (between-group difference, 12.8%; odds ratio, 1.73; 1.10–2.73).

Conclusions: Early deep sedation in the emergency department is common, carries over into the ICU, and may be associated with worse outcomes. Sedation practice in the emergency department and its association with clinical outcomes is in need of further investigation.

1Division of Critical Care, Department of Anesthesiology, Washington University School of Medicine in St. Louis, St. Louis, MO.

2Department of Emergency Medicine, Washington University School of Medicine in St. Louis, St. Louis, MO.

3Department of Emergency Medicine, Cooper University Hospital, Cooper Medical School of Rowan University, Camden, NJ.

4Department of Emergency Medicine, Roy J. and Lucille A. Carver College of Medicine, University of Iowa, Iowa City, IA.

5Division of Critical Care, Department of Anesthesiology, Roy J. and Lucille A. Carver College of Medicine, University of Iowa, Iowa City, IA.

6Division of Critical Care, Department of Emergency Medicine, University of Cincinnati Medical Center, Cincinnati, OH.

7Department of Neurology, University of Cincinnati Medical Center, Cincinnati, OH.

8Department of Neurosurgery, University of Cincinnati Medical Center, Cincinnati, OH.

9Washington University School of Medicine in St. Louis, St. Louis, MO.

10Division of Critical Care, Department of Emergency Medicine, University of New Mexico, Albuquerque, NM.

11Emergency Services and Respiratory Institutes, Cleveland Clinic Foundation, Cleveland, OH.

12Department of Emergency Medicine, MedStar Washington Hospital Center, Washington, DC.

13Georgetown University School of Medicine, Washington, DC.

14Department of Emergency Medicine, Christiana Care Health System, Newark, DE.

15Department of Emergency Medicine, Henry Ford Health System, Detroit, MI.

16Division of Pulmonary and Critical Care Medicine, Department of Medicine, Henry Ford Health System, Detroit, MI.

17Department of Emergency Medicine, University of Arizona College of Medicine, Tucson, AZ.

18Division of Pulmonary, Allergy, Critical Care and Sleep, Department of Medicine, University of Arizona College of Medicine, Tucson, AZ.

19Pulmonary and Critical Care Medicine, Lahey Hospital & Medical Center, Burlington, MA.

20Emergency Medicine, Lahey Hospital & Medical Center, Burlington, MA.

21Department of Emergency Medicine, University of Washington/Harborview Medical Center, Seattle, WA.

22Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington/Harborview Medical Center, Seattle, WA.

23Division of Cardiothoracic Surgery, Department of Surgery, University of Utah Health, Salt Lake City, UT.

24Division of Emergency Medicine, Department of Surgery, University of Utah Health, Salt Lake City, UT.

25University of Utah School of Medicine, Salt Lake City, UT.

26Department of Emergency Medicine, University of Pennsylvania, Philadelphia, PA.

27Department of Emergency Medicine, University of Michigan Medical School, Ann Arbor, MI.

28Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, MO.

29Division of Biostatistics, Washington University School of Medicine, St. Louis, MO.

30Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University School of Medicine in St. Louis, St. Louis, MO.

31Department of Anesthesiology, Washington University School of Medicine in St. Louis, St. Louis, MO.

This work was performed at Washington University School of Medicine in St. Louis, University of Iowa, Cooper University Hospital, University of New Mexico, The Cleveland Clinic, MedStar Washington Hospital Center, Christiana Care Health System, University of Cincinnati, Henry Ford Health System, University of Arizona/Banner University Medical Center-Tucson, Lahey Hospital & Medical Center, University of Washington Harborview Medical Center, University of Utah Health, University of Pennsylvania, and Michigan Medicine.

The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (http://journals.lww.com/ccmjournal).

Dr. Roberts’ institution received funding from National Heart, Lung, and Blood Institute (NHLBI) K23HL126979. Drs. Roberts, Pappal, Lokhandwala, and Tonna received support for article research from the National Institutes of Health (NIH). Dr. Knight received funding from Bard Medical and Genentech (speaker bureau for both). Dr. Pappal’s institution received funding from National Center for Advancing Translational Sciences of the NIH under Award Number UL1 TR002345. Dr. Johnson’s institution received funding from NHLBI and Medic One Foundation; he received funding from the NIH (U01HL123008-02). Dr. Lokhandwala was supported by NIH/NHLBI T32 HL007287-39. Dr. Hough’s institution received funding from the NIH (U01HL123008-02). Dr. Tonna was supported by a career development award (K23HL141596) from the NHLBI of the NIH, and, in part, by the University of Utah Study Design and Biostatistics Center, with funding in part from the National Center for Research Resources and the National Center for Advancing Translational Sciences, NIH, through Grant 5UL1TR001067-02 (formerly 8UL1TR000105 and UL1RR025764); he received funding from NIH/NSF and Philips Healthcare. Dr. Carpenter disclosed he is a Member of American College of Emergency Physicians Clinical Policy Committee, a Chair of Schwartz-Reisman Emergency Medicine Research Institute International Advisory Board, and a Speaker for Best Evidence in Emergency Medicine (continuing medical education [CME] product) and for Emergency Medical Abstracts (CME product). Dr. Avidan received funding from UptoDate. Dr. Kollef received funding from the Barnes-Jewish Hospital Foundation. The remaining authors have disclosed that they do not have any potential conflicts of interest.

For information regarding this article, E-mail: fullerb@wustl.edu

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