CARING FOR THECRITICALLY ILL PATIENT
A Randomized Clinical Trial
Linda L. Chlan, PhD, RNCraig R. Weinert, MD, MPH Annie Heiderscheit, PhD, MT-BCMary Fran Tracy, PhD, RNDebra J. Skaar, PharmDJill L. Guttormson, PhD, RNKay Savik, MS
RITICALLY ILL MECHANICALLY
ventilatedpatientsreceivein-travenoussedativeandanal-gesic medications to reduceanxietyandpromotecomfortandven-tilator synchrony. These potent medi-cations are often administered at highdosesforprolongedperiodsandareas-sociated with adverse effects such asbradycardia, hypotension, gut dysmo-tility, immobility, weakness, and de-lirium.
Despite protocols and seda-tion assessment tools that guideclinicians,patientsstillexperiencesig-nificant levels of anxiety.
Unrelieved anxiety and fear are notonly unpleasant symptoms that clini-cianswanttopalliate,butincreasedsym-pathetic nervous system activity cancause dyspnea and increased myocar-dial oxygen demand.
Sustained anxi-etyandsympatheticnervoussystemac-tivation can decrease the ability toconcentrate, rest, or relax.
Mechani-cally ventilated patients have little con-trol over pharmacological interven-tions to relieve anxiety; dosing andfrequencyofsedativeandanalgesicmedi-cations are controlled by intensive careunit (ICU) clinicians. Interventions are
CollegeofNursing,OhioStateUni-versity,Columbus(DrChlan);DepartmentofPulmo-nary,Allergy,CriticalCare,andSleepMedicine,Schoolof Medicine (Dr Weinert), Center for Spirituality andHealing(DrHeiderscheit),DepartmentofExperimen-tal and Clinical Pharmacology, College of Pharmacy(DrSkaar),andSchoolofNursing(MsSavik),Univer-sityofMinnesota,Minneapolis;UniversityofMinne-sotaMedicalCenter,Fairview(DrsWeinertandTracy);and College of Nursing, Marquette University, Mil-waukee, Wisconsin (Dr Guttormson).
LindaL.Chlan,PhD,RN,Col-lege of Nursing, Ohio State University, 398 NewtonHall, 1585 Neil Ave, Columbus, OH 43210 (firstname.lastname@example.org).
DerekC. Angus, MD, MPH, Contributing Editor,
Alternatives to sedative medications, such as music, may alleviate theanxiety associated with ventilatory support.
Totestwhetherlisteningtoself-initiatedpatient-directedmusic(PDM)canreduce anxiety and sedative exposure during ventilatory support in critically ill patients.
Design, Setting, and Patients
Randomized clinical trial that enrolled 373 pa-tients from 12 intensive care units (ICUs) at 5 hospitals in the Minneapolis-St Paul,Minnesota, area receiving acute mechanical ventilatory support for respiratory failurebetweenSeptember2006andMarch2011.Ofthepatientsincludedinthestudy,86%were white, 52% were female, and the mean (SD) age was 59 (14) years. The pa-tientshadamean(SD)AcutePhysiology,AgeandChronicHealthEvaluationIIIscoreof 63 (21.6) and a mean (SD) of 5.7 (6.4) study days.
Self-initiated PDM (n=126) with preferred selections tailored by amusictherapistwheneverdesiredwhilereceivingventilatorysupport,self-initiateduseof noise-canceling headphones (NCH; n=122), or usual care (n=125).
Main Outcomes and Measures
Daily assessments of anxiety (on 100-mm visualanalog scale) and 2 aggregate measures of sedative exposure (intensity and frequency).
0.21 (95% CI,
0.05) points/day (
=.01). The PDM group hadreducedsedationfrequencyby
AmongICUpatientsreceivingacuteventilatorysup-portforrespiratoryfailure,PDMresultedingreaterreductioninanxietycomparedwithusual care, but not compared with NCH. Concurrently, PDM resulted in greater re-duction in sedation frequency compared with usual care or NCH, and greater reduc-tion in sedation intensity compared with usual care, but not compared with NCH.
clinicaltrials.gov Identifier: NCT00440700
Published online May 20, 2013. doi:10.1001/jama.2013.5670 www.jama.com
For editorial comment see p 2386.
©2013 American Medical Association. All rights reserved.
June 12, 2013—Vol 309, No. 22
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