• Quenot Jean-Pierre JP Department of Critical Care Medicine, Bocage University Hospital, Dijon, France. jean-pierre.quenot@chu-dijon.fr, Sylvain Ladoire, Fabrice Devoucoux, Jean-Marc Doise, Romain Cailliod, Nicole Cunin, Hervé Aubé, Bernard Blettery, and Pierre Emmanuel Charles.
• Department of Critical Care Medicine, Bocage University Hospital, Dijon, France. jean-pierre.quenot@chu-dijon.fr
• Crit. Care Med. 2007 Sep 1; 35 (9): 2031-6.

ObjectiveTo determine whether the use of a nurse-implemented sedation protocol could reduce the incidence of ventilator-associated pneumonia in critically ill patients.DesignTwo-phase (before-after), prospective, controlled study.SettingUniversity-affiliated, 11-bed medical intensive care unit.PatientsPatients requiring mechanical ventilation for >or=48 hrs and sedative infusion with midazolam or propofol alone.InterventionsDuring the control phase, sedatives were adjusted according to the physician's decision. During the protocol phase, sedatives were adjusted according to a protocol developed by a multidisciplinary team including nurses and physicians. The protocol was based on the Cambridge scale, and sedation level was adjusted every 3 hrs by the nurses. Standard practices, including weaning from the ventilator and diagnosis of VAP, were the same during both study phases.Measurements And Main ResultsA total of 423 patients were enrolled (control group, n = 226; protocol group, n = 197). The incidence of VAP was significantly lower in the protocol group compared with the control group (6% and 15%, respectively, p = .005). By univariate analysis (log-rank test), only use of a nurse-implemented protocol was significantly associated with a decrease of incidence of VAP (p < .01). A nurse-implemented protocol was found to be independently associated with a lower incidence of VAP after adjustment on Simplified Acute Physiology Score II in the multivariate Cox proportional hazards model (hazard rate, 0.81; 95% confidence interval, 0.62-0.95; p = .03). The median duration of mechanical ventilation was significantly shorter in the protocol group (4.2 days; interquartile range, 2.1-9.5) compared with the control group (8 days; interquartile range, 2.2-22.0; p = .001), representing a 52% relative reduction. Extubation failure was more frequently observed in the control group compared with the protocol group (13% and 6%, respectively, p = .01). There was no significant difference in in-hospital mortality (38% vs. 45% in the protocol vs. control group, respectively, p = .22).ConclusionsIn patients receiving mechanical ventilation and requiring sedative infusions with midazolam or propofol, the use of a nurse-implemented sedation protocol decreases the rate of VAP and the duration of mechanical ventilation.

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