July 25, 2003

New tool monitors ICU sedation levels

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Dr. E. Wesley Ely assesses George Scharber, a patient in MICU, using the RASS scale.

New tool monitors ICU sedation levels

Doctors at Vanderbilt University Medical Center have developed a system to effectively monitor the administration of pain control and sedation to patients in the Intensive Care Units — one that previously did not exist.

In the past, medical teams were able to monitor the cardiovascular, pulmonary and renal functions of patients in ICU, but there was no instrument available to monitor the brain on a frequent and repetitive basis.

RASS, Richmond Agitation-Sedation Scale, was developed by the Medical College of Virginia in Richmond. Dr. E. Wesley Ely, associate professor of Medicine, associate director of research, Tennessee Valley Geriatric Research Education and Clinical Center (GRECC), and his team took the basis of the scale to the next level, applied it and validated it. The results were published in a recent issue of The Journal of the American Medical Association.

“It is surprising but true that the medical community did not have any validated scales to guide sedative use over time within patients in the ICU, which is exactly how these instruments need to be used in clinical practice,” Ely said.

“We need patients at a safe and comfortable sedation level without being too deeply sedated. Many patients were so deeply sedated that it committed them to the ventilator because the medical team could not tell they were getting better.

“With RASS, we now have a way that the medical team can communicate succinctly and reliably and provide a goal-directed target for sedation for our patients,” he said. “Basically, we can direct the use of these helpful but potentially dangerous medications so that we optimize outcomes for the patients.

“We have already begun receiving calls from around the country from hospitals. This tool will be implemented on a large scale.”

According to the conclusions of the study: “This is the first sedation scale to be validated for its ability to detect changes in sedation status over consecutive days of ICU care, against constructs of level of consciousness and delirium, and correlated with the administered dose of sedative and analgesic medications.”

The single hospital study looked at 313 patients. The vast majority were on ventilators.

Using the new evaluation method, medical teams can now implement the RASS scale in order to titrate sedation and pain control much more precisely and so that it is better tailored to the individual needs of a given patient. RASS takes less than 20 seconds to administer.

“The RASS has an expanded set of scores at pivotal levels of sedation that are determined by patients’ response to verbal vs. physical stimuli, which will help the clinician in titrating medications,” the study states.

In their ongoing cohort investigation, Dr. Josh Peterson — assistant professor of Medicine and recipient of a Vanderbilt Physician Scientist Development Award on this research project for which Dr. Ely is serving as a mentor — the investigators expect to see shorter hospital stays, reduced medical costs as well as better outcomes as this scoring system gains broader use.

“Working with Dr. Grant R. Wilkinson and the Clinical Pharmacology Division will help us to understand the relationships between the sedatives and analgesics and the development of brain dysfunction in ICU patients.”

Brenda Truman, RN, MSN, ACNP, Allergy Pulmonary and Critical Care Medicine, Clinical Research Nurse, has seen marked improvements in the appropriateness of sedation levels of Vanderbilt patients since RASS was implemented.

“This has provided a standardized tool,” Truman said. “There is a uniform language with RASS — everyone knows what the scores mean.

“This is a big leap. It has been a great tool for the nurses, but it has also been very useful for our patient’s families. Ultimately we’re giving better care because of RASS. We are able to deliver sedation in a more controlled way.”

Dr. Gordon R. Bernard, Professor of Medicine, said the addition of RASS is invaluable to the medical community, which is evident in the rate at which it has been embraced as a new monitoring tool.

“This is far-reaching,” Bernard said. “Wes Ely has mobilized the ICU community and provided it with tools to get a better understanding of brain dysfunction, delirium and long-term dysfunction. We are clearly at the forefront of this effort.”

Prior to RASS, the Glasgow Coma Scale (GSC) was a validated tool for trauma patients where there was known brain damage. But this scale was not well-suited for use in most other types of critically-ill patients.

According to Ely, “The heart of the matter is this – RASS needs to be used daily in managing patients,” he said. “Patients should not just get these very potent medications without an agreed upon target, and with this research we have provided medical teams around the world with the mechanism to implement drastically improved care for our sickest patients.”