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When will we ever learn?

Continuous sedation and analgesia are deemed necessary in most intensive care units (ICUs) worldwide, although there is a large variation in clinical practice. The choice of agents and dosing regimes differs. In particular, the patients on mechanical ventilation are considered an important group within the ICU where sedation and analgesia play an important role. The last decades have continuously given us evidence about various unwanted effects of continuous sedation and analgesia: prolonged length of stay in the ICU, prolonged time on mechanical ventilation, difficult weaning, adverse drug effects, drug tolerance and addiction, and long-term adverse effects as increased post-traumatic stress disorders. A study in this issue of Acta Anaesthesiologica Scandinavica reveals common practice about the administration of sedation and analgesia in Norwegian ICUs. This is in many respects disappointing documentation: most respondents (ICU physicians and nurses in charge of the unit) report that in general, the ICUs to a small extent use written protocols for sedation and analgesia, withdrawal protocols or practice daily sedation stop. This is not unique for Norway and probably reflects the attitude in many ICUs worldwide. Why is evidence regarding sedation and analgesia so hard to transform into daily routines in our ICUs? My response to such a question is that this is not a specific problem with sedation and analgesia. ICUs have problems using low tidal volumes in Adult Respiratory Distress Syndrome (ARDS), to give our patients enough nutrition, in particular using the enteral route, and to prevent nosocomial ICU infections, to mention some other important areas. The long and winding road from finding evidence to its use in individual patient care is complex. The message may be lost at several steps along this way. Often evidence from several sources is forged into clinical guidelines. Such guidelines may be produced by hospitals, by national bodies or by professional societies. Often several ‘competing’ guidelines exist. In the prevention and treatment of ventilator-associated pneumonia, there are several recent guidelines at the moment. This complicates the picture, and the quest for the ‘best’ guideline may be difficult. The validity of guidelines is also questioned in various ways. Guidelines may be corrupted, they may be sponsored by the industry or the authors have significant conflicts of interest. In an analysis of guidelines and consensus reports regarding mechanical ventilation, adherence to methodological standards was found to be low. More than half of the reports were either sponsored by industry funding, or the authors declared conflict of interest. Guidelines are also rapidly outdated. In a study from 2007 of 100 published meta-analysis, the median ‘survival’ (time to new evidence that significantly altered the conclusions) was 2.9 years within cardiovascular guidelines and 6.6 years in noncardiovascular guidelines. The next step is the implementation of clinical guidelines into local treatment protocols. Not all guidelines may directly be transferred into the specific clinical setting of individual ICUs and must at least be translated and adopted in various ways. As an example, a suggested drug may not be available in that country, or case mix of the ICU differs considerably form the original population behind the guidelines. To what extent our ICUs really include good and updated clinical guidelines into local routines are largely unknown. The study in this issue of our journal indicates that in most Norwegian ICUs, this is at least not done with regard to sedation and analgesia. Acta Anaesthesiol Scand 2012; 56: 1–2 Printed in Singapore. All rights reserved © 2012 The Author Acta Anaesthesiologica Scandinavica © 2012 The Acta Anaesthesiologica Scandinavica Foundation