Regarding sedation in the routine care of the intubated ICU patient.
a) Discuss the Richmond Agitation Sedation Scale under the following headings: purpose, components, advantages, and disadvantages.
b) List three trials investigating the use of dexmedetomidine infusions in the ICU. For each trial briefly outline the methods, key results, and conclusions.
Aim: To explore the evidence and practice surrounding the use of sedatives in the ICU.
Key sources include: ANZICS trials, major landmark trials, and current practice guidelines for sedation. CanMEDS Medical Expert, Scholar.
Discussion: The RASS score is a commonly used scale for agitation/sedation in the ICU daily practice and sedation research. Candidates are expected to understand the evidence base of clinical practice and the drugs we use routinely.
The successful candidate utilised their bedside experience, had a practical approach to the answer by addressing the subheadings and had a broad understanding of the literature on dexmedetomidine.
Part b required only brief outline of the key results and conclusions of the relevant trials. Candidates are not expected to go into depth about individual trials given the time constraints of the examination. A broad outline of the trial aim, results and conclusions sufficed.
The successful candidate demonstrated familiarity with the current research particularly in relation to the ANZICS SPICE trial. Candidates passed if they outlined the major findings and included brief notes on trial design.
The number per trial arm, journal name and date published, and secondary outcomes were NOT required. The trials listed below are provided to guide candidates with information to aid future study.
NEJM May 2019
In ventilated patients does Dexmedetomidine as the primary sedative agent compared with usual sedations affect 90-day mortality?
Is Dexmedetomidine inferior to propofol or midazolam in achieving target sedation level?
JAMA March 2016
Effect of Dexmedetomidine added to standard care on ventilator free time in patients with agitated delirium.
-Low dose nocturnal dexmedetomidine prevents ICU delirium: a RCT placebo-controlled trail
Skrobik AJRCM 2018
Effect of Dexmedetomidine on Mortality and ventilator free days in patients requiring mechanical ventilation with sepsis RCT
a) This breakdown of the RASS lists much more stuff than you could possibly be expected to write in four minutes, and represents a sort of disorganised pool of variably valid points, where readers can fish around for the ones they prefer.
Purpose of the RASS:
Components of the RASS:
Advantages of the RASS
Disadvantages of the RASS
In order of appearance, here are some of the trials the candidates could have listed. The SAQ wording suggests that originally the candidates were expected to remark on the methodology of the studies they listed, but the examiner comments ("a broad outline of the trial aim, results and conclusions sufficed") suggest they realised that most of these studies were either multicentre or single centre RCTs with only subtle and forgettable variations in their design. As such, details of the methods are omitted from the list below.
Sessler, Curtis N., et al. "The Richmond Agitation–Sedation Scale: validity and reliability in adult intensive care unit patients." American journal of respiratory and critical care medicine 166.10 (2002): 1338-1344.
Sessler, Curtis N., Mary Jo Grap, and Gretchen M. Brophy. "Multidisciplinary management of sedation and analgesia in critical care." Seminars in respiratory and critical care medicine. Vol. 22. No. 02. Copyright© 2001 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA. Tel.:+ 1 (212) 584-4662, 2001.
Sessler, Curtis N., and Kim Keane. "Validity and reliability of a new agitation-sedation scale in a medical ICU population." Chest 118.4 (2000): 95S-95S.
Almgren, M., M. Lundmark, and Karin Samuelson. "The Richmond Agitation‐Sedation Scale: translation and reliability testing in a Swedish intensive care unit." Acta anaesthesiologica scandinavica 54.6 (2010): 729-735.