18 research outputs found
Diurnal variation of analgosedation doses in mechanically ventilated patients including ECMO: a single centre observational cohort study
No full textDiurnal variation of analgosedation doses in mechanically ventilated patients including ECMO: a single centre observational cohort study
No full textSupplemental Material - Methadone as an opioid and sedative weaning strategy in adults receiving extracorporeal membrane oxygenation
No full textSupplemental Material for Methadone as an opioid and sedative weaning strategy in adults receiving extracorporeal membrane oxygenation by Christopher Remmington, Victor Liew, Fraser Hanks, Luigi Camporota, Oliver Stubbs, Angelo Sousa, and Nicholas A Barrett in Perfusion</p
Extracorporeal membrane oxygenation and diurnal analgosedation:A comparative retrospective study in ventilated patients
No full textBackground: Diurnal variation of analgosedation may worsen patient outcomes. However, there is no data reporting diurnal variation in patients receiving extracorporeal membrane oxygenation (ECMO). Objectives: To compare diurnal variation of analgosedation doses in mechanically ventilated adult patients and those receiving ECMO. Setting: Five ICUs (65 beds) including an ECMO unit, with patient recruitment from July 2021 to July 2023. Methods: Retrospective single-centre cohort study including patients aged ≥ 16 years receiving continuous intravenous (IV) opioid (fentanyl) and/or sedative (midazolam and/or propofol), receiving mechanical ventilation with or without ECMO. We collected data on all intravenous analgosedation doses (excluding boluses) from 07:00 to 18:59 (day) or from 19:00 to 06:59 (nighttime) for 48 h. Results: We identified 1277 patients; of whom 166 (13.0 %) received ECMO and 1111 (87.0 %) received no ECMO. Most were male 815 (63.8 %), median (interquartile range (IQR)) age 58 (42–70) years. We found no diurnal variation of analgosedation doses in ECMO patients. However, we found higher doses of fentanyl (mean difference 1.7 µg/kg, 95 % Confidence Interval (CI): 1.0, 2.4 μg/kg, p < 0.001) and propofol (mean difference 2.3 mg/kg, 95 % CI: 1.7, 2.9 mg/kg, p < 0.001) at nighttime compared to daytime in non-ECMO patients. A higher proportion of ECMO patients received neuromuscular blocking drugs compared to non-ECMO group 120 (72.3 %) vs 138 (12.4 %); p < 0.001. Conclusions: We found higher doses of fentanyl and propofol IV infusion doses at nighttime in non-ECMO patients. However, we found no diurnal variation of analgosedation doses in ECMO patients, most likely due to deep sedation and use of neuromuscular blocking medicines. Implications for clinical practice: Patient factors, critical illness factors and type of ICU admission are likely contributory factors to differences in diurnal variation of analgosedation doses in ECMO and non-ECMO populations.</p
Barriers and facilitators to protocolised analgosedation in mechanically ventilated adult patients: a protocol for a mixed methods scoping review
No full textAn analgosedation protocol is a way of guiding healthcare professionals how much sedation is given to patients in ICU with associated monitoring using validated pain and sedation scores. There are international guidelines advising on the management of analgosedation in mechanical ventilated patients, helping to inform the content and structure of an analgosedation protocol. However, the certainty of evidence reporting the effect of analgosedation protocols, with or without daily sedation interruption, for improving patient outcomes including length of mechanical ventilation, length of ICU stay and lower mortality is low according to two published Cochrane Systematic Reviews. The certainty was low in these studies due to conflicting results and heterogeneity in randomised controlled trials. Additionally, few studies report the challenges of implementing an analgosedation protocol in the clinical setting. A review of the current literature in this scoping review will provide the opportunity to explore implementation drivers of using sedation protocols in clinical practice in mechanically ventilated (including ECMO) patients.
It is important to conduct this review to understand the structure and content of analgosedation protocols used in critically ill (mechanically ventilated) adult patients. Additionally, we will conduct this review to understand any barriers, facilitators, contextual factors, and fidelity measures of using analgosedation protocols to inform adaptability, scalability and sustainability. We conducted a preliminary search of MEDLINE, the Cochrane Database of Systematic Reviews and JBI Evidence Synthesis and found no published systematic or scoping reviews and no registered scoping or literature reviews on this topic.
Review question
1. What is the structure and content of analgosedation protocols used in mechanically ventilated adult patients?
2. What are the barriers, facilitators, contextual factors, and fidelity of using analgosedation protocols in mechanically ventilated adult patients.
3. What outcomes are reported associated with using analgosedation protocols in mechanically ventilated adult patients?
Objectives
1. To identify the structure and content of sedation protocols used in mechanically ventilated adult patients
2. To establish reported barriers, facilitators, contextual factors, and fidelity measures of using analgosedation protocols in mechanically ventilated adult patients.
3. To understand any reported outcomes associated with using analgosedation protocols in mechanically ventilated adult patients.
Inclusion criteria
1. All published evidence reporting structure and content of analgosedation protocols
2. All published evidence reporting barriers, facilitators, contextual factors, or fidelity of using analgosedation protocols
3. All published evidence reporting daily sedation interruptions
4. Adult mechanically ventilated ICU patients.
5. Studies published in English
6. Studies published between 1999 - 2025
Exclusion criteria
1. Unpublished studies.
2. Grey literature - reports, theses, presentations, policy papers
Concept
The use of analgosedation protocols in mechanically ventilated adult patients, including those receiving extracorporeal membrane oxygenation on intensive care units.
Context
Adult intensive care units internationally.
Types of sources
This scoping review will consider randomised controlled trials, non-randomised controlled trials, observational studies, qualitative studies, case-control studies and analytical cross-sectional studies for inclusion. In addition, the references of systematic reviews and scoping reviews will be checked for relevant studies that meet the inclusion criteria.
Methods
The proposed scoping review will be conducted in accordance with the Joanna Briggs Institute (JBI) methodology for scoping reviews.
Search strategy
We will use a search strategy to locate published studies. A three-step search strategy will be utilized in this review. The search strategy developed by Aitken and colleagues (an earlier Cochrane Review published in 2018) will be used and adapted to include all published studies reporting analgosedation protocols in critically ill adult patients using search electronic databases including Cochrane Library, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), EMBASE (Ovid), MEDLINE (Ovid), and Web of Science from January 1999 (see Appendix 1) [39]. We will search for conference proceedings using the Web of Science Conference Proceedings Citation Index – Science and Social Science and Humanities. We will search for published studies in respective databases from January 1999 to 2025 as the first randomised controlled trial on the use of a sedation protocol in adult patients was reported by Brook and colleagues in 1999 [36]. We will verify our search strategy with an experienced University librarian.
The search strategy shall exclude studies reporting the use of analgosedation protocols in children and we will remove the search filter that includes randomised control trials only. The search strategy, including all identified keywords and index terms, will be adapted for each included database and/or information source. We will review the reference lists of included studies to highlight other studies that may be relevant. We will exclude editorials, commentaries and animal studies. CR will contact authors if required for full-text articles.
Study/Source of evidence selection
Following the search, all identified citations will be uploaded into Covidence 2025 and duplicates removed. An initial screen will be completed by one author to remove obvious exclusions and remove off topic, omission of grey literature. Following a pilot test, two independent reviewers will screen data titles, abstracts and full text articles against pre-specified inclusion and exclusion criteria using Covidence software and study selection.
Potentially relevant sources will be retrieved in full and their citation details imported into Covidence. We will assess the full text of selected citations in detail against pre-specified inclusion criteria by two or more independent reviewers. Reasons for exclusion of sources of evidence at full-text stage that do not meet the inclusion criteria will be recorded and reported in the scoping review. Any disagreements that arise between the reviewers at each stage of the selection process will be resolved through discussion, or with an additional reviewer/s. This approach is in accordance with methods advocated for rapid reviews.
Data extraction
We will develop a bespoke data extraction form, and pilot it using 3-5 included studies and adapt if required. Two reviewers will independently extract study characteristics (e.g., publication year, author, journal, participants, target population, study design, setting, type of ICU, and if an ECMO centre) as well as detailed data on the structure and content of analgosedation protocols (see Appendix 2). Additionally, two reviewers will independently extract information on reported barriers, facilitators, contextual factors or fidelity on using analgosedation protocols, and any associated outcomes.
We will resolve discrepancies and disagreements that arise between the reviewers through discussion, or with an additional reviewer/s. If appropriate, authors of papers will be contacted to request missing or additional data, where required.
Data analysis and presentation
We will use a Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) flow diagram to describe the results of the search and the study inclusion process in full in the final scoping review. We will categorise the characteristics of included studies (for e.g., participants, the setting (type of ICU), country etc) in a summary table using descriptive statistics. We will report any studies describing structural and content elements and implementation outcomes of analgosedation protocols and categorise in a separate summary table. We will code qualitative data reporting barriers, facilitators, contextual factors, and fidelity using directed content analysis. NVivo software will be used to code characteristics into overall categorises.
One reviewer (CR) will apply the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework to individual studies and across all studies to assess the level of adoption and sustainable implementation of analgosedation protocols. We hope this approach will provide a rich understanding of the content, development, stakeholder engagement, and implementation of sedation protocols in intensive care clinical practice. Unique implementation outcomes for each RE-AIM domain will be counted. We will use descriptive statistics (frequency, counts/% of counts, mean, and standard deviation) to describe study characteristics, and the number of RE-AIM implementation outcomes found across included studies.
A narrative summary will accompany the tabulated and/or charted results and will describe how the results relate to the reviews primary and secondary objectives.
Critical appraisal
We will use the Mixed Methods Appraisal Tool (MMAT) to critically appraise the quality and risk of bias of qualitative research, randomised controlled trials, non-randomised studies, quantitative descriptive studies, and mixed methods studies. One reviewer will use the MMAT to appraisal each study and calculate a MMAT score % to describe the overall quality of each included study. MMAT study scores greater than 50% will be described as “high quality” study, 50% as “moderate quality” study and less than 50% as “low quality” study.
Acknowledgements - not applicable
Funding:
Christopher Remmington (Doctoral Clinical and Practitioner Academic Fellowship, NIHR304092) is funded by the National Institute for Health and Care Research (NIHR) for this research project. Dr Cathrine McKenzie (Senior Clinical Practitioner Research Award, SCPRA, NIHR 304615). The views expressed in this publication are those of the author(s) and not necessarily those of the NIHR, National Health Service (NHS) or the UK Department of Health and Social Care.
Declarations: not applicable
Author contributions
CR and LR conceptualised this review. CR drafted the protocol under the supervision of LR, CM and LC. All authors read and approved the protocol.
Conflicts of interest: there is no conflict of interest in this project
Barriers and facilitators to protocolised analgosedation in mechanically ventilated adult patients: a protocol for a mixed methods scoping review
No full textAn analgosedation protocol is a way of guiding healthcare professionals how much sedation is given to patients in ICU with associated monitoring using validated pain and sedation scores. There are international guidelines advising on the management of analgosedation in mechanical ventilated patients, helping to inform the content and structure of an analgosedation protocol. However, the certainty of evidence reporting the effect of analgosedation protocols, with or without daily sedation interruption, for improving patient outcomes including length of mechanical ventilation, length of ICU stay and lower mortality is low according to two published Cochrane Systematic Reviews. The certainty was low in these studies due to conflicting results and heterogeneity in randomised controlled trials. Additionally, few studies report the challenges of implementing an analgosedation protocol in the clinical setting. A review of the current literature in this scoping review will provide the opportunity to explore implementation drivers of using sedation protocols in clinical practice in mechanically ventilated (including ECMO) patients.
It is important to conduct this review to understand the structure and content of analgosedation protocols used in critically ill (mechanically ventilated) adult patients. Additionally, we will conduct this review to understand any barriers, facilitators, contextual factors, and fidelity measures of using analgosedation protocols to inform adaptability, scalability and sustainability. We conducted a preliminary search of MEDLINE, the Cochrane Database of Systematic Reviews and JBI Evidence Synthesis and found no published systematic or scoping reviews and no registered scoping or literature reviews on this topic.
Review question
1. What is the structure and content of analgosedation protocols used in mechanically ventilated adult patients?
2. What are the barriers, facilitators, contextual factors, and fidelity of using analgosedation protocols in mechanically ventilated adult patients.
3. What outcomes are reported associated with using analgosedation protocols in mechanically ventilated adult patients?
Objectives
1. To identify the structure and content of sedation protocols used in mechanically ventilated adult patients
2. To establish reported barriers, facilitators, contextual factors, and fidelity measures of using analgosedation protocols in mechanically ventilated adult patients.
3. To understand any reported outcomes associated with using analgosedation protocols in mechanically ventilated adult patients.
Inclusion criteria
1. All published evidence reporting structure and content of analgosedation protocols
2. All published evidence reporting barriers, facilitators, contextual factors, or fidelity of using analgosedation protocols
3. All published evidence reporting daily sedation interruptions
4. Adult mechanically ventilated ICU patients.
5. Studies published in English
6. Studies published between 1999 - 2025
Exclusion criteria
1. Unpublished studies.
2. Grey literature - reports, theses, presentations, policy papers
Concept
The use of analgosedation protocols in mechanically ventilated adult patients, including those receiving extracorporeal membrane oxygenation on intensive care units.
Context
Adult intensive care units internationally.
Types of sources
This scoping review will consider randomised controlled trials, non-randomised controlled trials, observational studies, qualitative studies, case-control studies and analytical cross-sectional studies for inclusion. In addition, the references of systematic reviews and scoping reviews will be checked for relevant studies that meet the inclusion criteria.
Methods
The proposed scoping review will be conducted in accordance with the Joanna Briggs Institute (JBI) methodology for scoping reviews.
Search strategy
We will use a search strategy to locate published studies. A three-step search strategy will be utilized in this review. The search strategy developed by Aitken and colleagues (an earlier Cochrane Review published in 2018) will be used and adapted to include all published studies reporting analgosedation protocols in critically ill adult patients using search electronic databases including Cochrane Library, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), EMBASE (Ovid), MEDLINE (Ovid), and Web of Science from January 1999 (see Appendix 1) [39]. We will search for conference proceedings using the Web of Science Conference Proceedings Citation Index – Science and Social Science and Humanities. We will search for published studies in respective databases from January 1999 to 2025 as the first randomised controlled trial on the use of a sedation protocol in adult patients was reported by Brook and colleagues in 1999 [36]. We will verify our search strategy with an experienced University librarian.
The search strategy shall exclude studies reporting the use of analgosedation protocols in children and we will remove the search filter that includes randomised control trials only. The search strategy, including all identified keywords and index terms, will be adapted for each included database and/or information source. We will review the reference lists of included studies to highlight other studies that may be relevant. We will exclude editorials, commentaries and animal studies. CR will contact authors if required for full-text articles.
Study/Source of evidence selection
Following the search, all identified citations will be uploaded into Covidence 2025 and duplicates removed. An initial screen will be completed by one author to remove obvious exclusions and remove off topic, omission of grey literature. Following a pilot test, two independent reviewers will screen data titles, abstracts and full text articles against pre-specified inclusion and exclusion criteria using Covidence software and study selection.
Potentially relevant sources will be retrieved in full and their citation details imported into Covidence. We will assess the full text of selected citations in detail against pre-specified inclusion criteria by two or more independent reviewers. Reasons for exclusion of sources of evidence at full-text stage that do not meet the inclusion criteria will be recorded and reported in the scoping review. Any disagreements that arise between the reviewers at each stage of the selection process will be resolved through discussion, or with an additional reviewer/s. This approach is in accordance with methods advocated for rapid reviews.
Data extraction
We will develop a bespoke data extraction form, and pilot it using 3-5 included studies and adapt if required. Two reviewers will independently extract study characteristics (e.g., publication year, author, journal, participants, target population, study design, setting, type of ICU, and if an ECMO centre) as well as detailed data on the structure and content of analgosedation protocols (see Appendix 2). Additionally, two reviewers will independently extract information on reported barriers, facilitators, contextual factors or fidelity on using analgosedation protocols, and any associated outcomes.
We will resolve discrepancies and disagreements that arise between the reviewers through discussion, or with an additional reviewer/s. If appropriate, authors of papers will be contacted to request missing or additional data, where required.
Data analysis and presentation
We will use a Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) flow diagram to describe the results of the search and the study inclusion process in full in the final scoping review. We will categorise the characteristics of included studies (for e.g., participants, the setting (type of ICU), country etc) in a summary table using descriptive statistics. We will report any studies describing structural and content elements and implementation outcomes of analgosedation protocols and categorise in a separate summary table. We will code qualitative data reporting barriers, facilitators, contextual factors, and fidelity using directed content analysis. NVivo software will be used to code characteristics into overall categorises.
One reviewer (CR) will apply the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework to individual studies and across all studies to assess the level of adoption and sustainable implementation of analgosedation protocols. We hope this approach will provide a rich understanding of the content, development, stakeholder engagement, and implementation of sedation protocols in intensive care clinical practice. Unique implementation outcomes for each RE-AIM domain will be counted. We will use descriptive statistics (frequency, counts/% of counts, mean, and standard deviation) to describe study characteristics, and the number of RE-AIM implementation outcomes found across included studies.
A narrative summary will accompany the tabulated and/or charted results and will describe how the results relate to the reviews primary and secondary objectives.
Critical appraisal
We will use the Mixed Methods Appraisal Tool (MMAT) to critically appraise the quality and risk of bias of qualitative research, randomised controlled trials, non-randomised studies, quantitative descriptive studies, and mixed methods studies. One reviewer will use the MMAT to appraisal each study and calculate a MMAT score % to describe the overall quality of each included study. MMAT study scores greater than 50% will be described as “high quality” study, 50% as “moderate quality” study and less than 50% as “low quality” study.
Acknowledgements - not applicable
Funding:
Christopher Remmington (Doctoral Clinical and Practitioner Academic Fellowship, NIHR304092) is funded by the National Institute for Health and Care Research (NIHR) for this research project. Dr Cathrine McKenzie (Senior Clinical Practitioner Research Award, SCPRA, NIHR 304615). The views expressed in this publication are those of the author(s) and not necessarily those of the NIHR, National Health Service (NHS) or the UK Department of Health and Social Care.
Declarations: not applicable
Author contributions
CR and LR conceptualised this review. CR drafted the protocol under the supervision of LR, CM and LC. All authors read and approved the protocol.
Conflicts of interest: there is no conflict of interest in this project
Critical care pharmacy service provision and workforce in adult extracorporeal membrane oxygenation centres: a multicentre cross-sectional survey
No full textBackground: There is good evidence describing pharmacy workforce and service provision in general critical care units. However, no data exist from adult extracorporeal membrane oxygenation (ECMO) centres. Aim: To describe workforce characteristics, pharmacy service provision, and pharmaceutical care activities in critical care units (CCUs) providing an adult ECMO service in the United Kingdom (UK) and compare to national staffing standards for CCUs. Method: We conducted a multicentre, cross-sectional electronic survey inviting one pharmacy professional response per UK ECMO centre. We collated information on workforce, service provision, and pharmaceutical care activities provided by pharmacy teams in adult CCUs with an ECMO service. Results: The survey response rate was 90.9%: representatives of 10/11 tertiary hospitals providing ECMO services responded. Median critical care pharmacist to critical care bed was 1:12.1 (IQR: 1:9.4–1:14.9). Most centres (90.0%) did not meet national standards for pharmacy professionals to critical care bed staffing ratios for weekday services. Total critical care beds covered by the critical care pharmacy team varied across the UK: median (IQR) – 45 (37–80) beds. Two centres funded pharmacist time for ECMO activity, and one centre funded a pharmacy technician post. Median peak ECMO activity was 4 ECMO patients in a single day (IQR: 3–5). Most respondents reported reduced pharmacy service at weekends compared to weekday, with limited on-site support. Conclusion: Most responding ECMO centres in the UK reported pharmacy staffing ratios below nationally agreed critical care standards. There was high variability in clinical pharmacy services to ECMO patients over 7 days.</p
Twelve fighting years : homosexuals in Houston, 1969-1981
No full textThis study is not a blow by blow history of honosexuals in Houston, but an examination of the growing sense of community felt by homosexuals in the city, that began to appear in the early seventies, and was reflected in their numerous and diverse organizations. The investigation will specifically focus on the political and religious development of Houston's homosexual minority, chapters 1 and 2 respectively. For homosexuals, the development of political power was crucial in removing legal restrictions in order that the rest of the community might flourish. Of course, religion has been a traditional mainstay of community development for centuries, but Christianity condemned homosexuality as a sin. How, then, this study asks, did homosexuals in Houston organize politically, and how did they organize religiously? The time period covered by the study extends from the stonewall Riot in New York in 1969, proudly regarded, rightly or wrongly, as the birth of the gay rights movement, to the election of Kathryn Whitmire as mayor of Houston in 1981. However, the historical literature on homosexuals remains scant even today, and, in addition, as many of the homosexual organizations are volunteer based, recordkeeping has often been neglected. This author, therefore, utilized extensive interviewing within the community as the prime mode of research, supported by the publications of the individual organizations, the city's two mainline newspapers, the Houston post and the Houston Chronicle , and the community newspapers that have served the homosexual minority since 1970. In terms of religion, it became increasingly evident that homosexuals had created alternatives to the mainline churches, which had rejected them. However, the different alternatives proved to be neither similar in function, nor purpose, but each served the community, politically, homosexuals in Houston displayed the same lack of agreement, but had managed to forge an effective organization, the Gay Political Caucus (GPC), that gave them a critical influence in city politics. Together, religion and politics had pushed the city's homosexuals toward an operating notion of community.History, Department o
