Choosing and Implementing an Evaluation Scale

Desirable features of sedation evaluation instruments should include rigorous multidisciplinary development; ease of administration, recall, and interpretation; well- designed discrete criteria for each level; sufficient sedation levels for effective drug titration; assessment of agitation; and demonstration of inter-rater reliability and validity in relevant patient populations [48]. Each ICU has to choose the best tools for its patient population and to plan specific intervention to introduce it in daily care [63].

Teaching protocols used for implementation of sedation scales have shown good results among ICU caregivers. Different methods have been used to implement evaluation tools in clinical practice. Typically, they are based on introductory inservice for nurses and operators followed by graded, staged educational interventions at regular intervals. Web-based, freely available teaching interventions have been also proposed (www.icudelirium.org, www.sedaicu.it).

Some emerging problems remain, particularly about the fluctuation of consciousness. ARDS patients are prone to sudden changes in their state of consciousness due to the effects of drugs, sleep disruption, organic and metabolic disease, or delirium. Assessment of sedation once a shift is indispensable but not sufficient. Among the different possibilities (minimal/maximal level, prevalent level, worst level), it is important to state the duration of each value within the observed shift. Sedation and agitation need to be reassessed both on a regular basis and during any clinical modification, to promptly capture all the modifications requiring intervention. Moreover, it is relatively common for patients to manifest sudden aggressive behavior when recovering from sedation and without fully awakening. For this reason, it is important to boost interdisciplinary communication between nurses and physicians in order to be aware of and prevent these problems.

Lastly, making a sedation assessment during the night is frequently challenging. Most analgesics and sedatives are known to make patients sleepy, but without reaching a restorative, physiological sleep [64]. If a critically ill patient appears calm and keeps his/her eyes closed during the night, he/she should not be stimulated just to make a sedation assessment. He/she could be observed during unavoidable procedures happening in the ICU during the night, in order to discriminate normal sleep (with arousals due to noise or light) from sedation or coma.