Alpha-2 agonists for sedation of mechanically ventilated adults in intensive care units: a systematic review

BACKGROUND: Care of critically ill patients in intensive care units (ICUs) often requires potentially invasive or uncomfortable procedures, such as mechanical ventilation (MV). Sedation can alleviate pain and discomfort, provide protection from stressful or harmful events, prevent anxiety and promote sleep. Various sedative agents are available for use in ICUs. In the UK, the most commonly used sedatives are propofol (Diprivan(®), AstraZeneca), benzodiazepines [e.g. midazolam (Hypnovel(®), Roche) and lorazepam (Ativan(®), Pfizer)] and alpha-2 adrenergic receptor agonists [e.g. dexmedetomidine (Dexdor(®), Orion Corporation) and clonidine (Catapres(®), Boehringer Ingelheim)]. Sedative agents vary in onset/duration of effects and in their side effects. The pattern of sedation of alpha-2 agonists is quite different from that of other sedatives in that patients can be aroused readily and their cognitive performance on psychometric tests is usually preserved. Moreover, respiratory depression is less frequent after alpha-2 agonists than after other sedative agents.

OBJECTIVES: To conduct a systematic review to evaluate the comparative effects of alpha-2 agonists (dexmedetomidine and clonidine) and propofol or benzodiazepines (midazolam and lorazepam) in mechanically ventilated adults admitted to ICUs.

DATA SOURCES: We searched major electronic databases (e.g. MEDLINE without revisions, MEDLINE In-Process & Other Non-Indexed Citations, EMBASE and Cochrane Central Register of Controlled Trials) from 1999 to 2014.

METHODS: Evidence was considered from randomised controlled trials (RCTs) comparing dexmedetomidine with clonidine or dexmedetomidine or clonidine with propofol or benzodiazepines such as midazolam, lorazepam and diazepam (Diazemuls(®), Actavis UK Limited). Primary outcomes included mortality, duration of MV, length of ICU stay and adverse events. One reviewer extracted data and assessed the risk of bias of included trials. A second reviewer cross-checked all the data extracted. Random-effects meta-analyses were used for data synthesis.

RESULTS: Eighteen RCTs (2489 adult patients) were included. One trial at unclear risk of bias compared dexmedetomidine with clonidine and found that target sedation was achieved in a higher number of patients treated with dexmedetomidine with lesser need for additional sedation. The remaining 17 trials compared dexmedetomidine with propofol or benzodiazepines (midazolam or lorazepam). Trials varied considerably with regard to clinical population, type of comparators, dose of sedative agents, outcome measures and length of follow-up. Overall, risk of bias was generally high or unclear. In particular, few trials blinded outcome assessors. Compared with propofol or benzodiazepines (midazolam or lorazepam), dexmedetomidine had no significant effects on mortality [risk ratio (RR) 1.03, 95% confidence interval (CI) 0.85 to 1.24, I (2) = 0%; p = 0.78]. Length of ICU stay (mean difference -1.26 days, 95% CI -1.96 to -0.55 days, I (2) = 31%; p = 0.0004) and time to extubation (mean difference -1.85 days, 95% CI -2.61 to -1.09 days, I (2) = 0%; p < 0.00001) were significantly shorter among patients who received dexmedetomidine. No difference in time to target sedation range was observed between sedative interventions (I (2) = 0%; p = 0.14). Dexmedetomidine was associated with a higher risk of bradycardia (RR 1.88, 95% CI 1.28 to 2.77, I (2) = 46%; p = 0.001).

LIMITATIONS: Trials varied considerably with regard to participants, type of comparators, dose of sedative agents, outcome measures and length of follow-up. Overall, risk of bias was generally high or unclear. In particular, few trials blinded assessors.

CONCLUSIONS: Evidence on the use of clonidine in ICUs is very limited. Dexmedetomidine may be effective in reducing ICU length of stay and time to extubation in critically ill ICU patients. Risk of bradycardia but not of overall mortality is higher among patients treated with dexmedetomidine. Well-designed RCTs are needed to assess the use of clonidine in ICUs and identify subgroups of patients that are more likely to benefit from the use of dexmedetomidine.

STUDY REGISTRATION: This study is registered as PROSPERO CRD42014014101.

FUNDING: The National Institute for Health Research Health Technology Assessment programme. The Health Services Research Unit is core funded by the Chief Scientist Office of the Scottish Government Health and Social Care Directorates.

Towards the End of Life: an In-depth Exploration of the Role of Admiral Nursing in Dementia Care (Innovative Practice)

There are approximately 150 Admiral Nurses in the UK who work alongside other health and social care professionals to support people with dementia and their family carers. However, the stigma of the disease and the lack of recognition that dementia is a life limiting illness have led to neglect in addressing the end of life challenges. The small in-depth study reported here aimed to add to an extremely limited formal evidence base for the effectiveness of this approach and to develop a greater understanding of the range of knowledge and skills required of them in ensuring they are better able to support families in the later stages of the illness. Findings focus on the experiences of family carers, the impact of performing the Admiral Nurse role and the use of qualitative measures in this setting.

Role and potential influence of technologies on the most relevant challenges for long-term care. ENEPRI Research Report No. 113, 26 June 2012

This report considers three case studies (namely diabetes, dementia and obesity) for setting up a framework to assess the systemic influences of technologies in the long-term care milieu, using a problem-driven approach in relation to health care. Such technologies could be an enabling factor or a catalyser of advances taking place in the health and social sectors. They offer opportunities to support and amplify relevant organisational changes in the context of innovative care models, which stem from overall policies and regulations of a national or regional jurisdiction to address the future sustainability of health and social care.

Interdependency and care over the lifecourse

Interdependency and Care over the Lifecourse draws upon theories of time and space to consider how informal care is woven into the fabric of everyday lives and is shaped by social and economic inequalities and opportunities. The book comprises three parts. The first explores contrasting social and economic contexts of informal care in different parts of the world. The second looks at different themes and dynamics of caring, using fictional vignettes of illness and health, child care, elderly care and communities of care. The book examines the significance to practices of care throughout the lifecourse of: understandings and expectations of care emotional exchanges involved in care memories and anticipations of giving and receiving care the social nature of the spaces and places in which care is carried out the practical time-space scheduling necessary to caring activities. Finally the authors critically examine how the frameworks of caringscapes and carescapes might be used in research, policy and practice. A working example is provided. This book will be of interest to students and researchers of care work, health and social care, geography, sociology of the family and social policy as well as those in business and policy communities trying to gain an understanding of how work and informal care interweave

Innovation care pathways and the healthcare built environment: An explanatory framework and research agenda

The built environment in which health and social care is delivered can have an impact on the efficiency and outcomes of care processes. The health-care estate is large and growing and is expensive to build, adapt and maintain. The design of these buildings is a complex, difficult and political process. Better use of care pathways as an input to the design and use of the built environment has the potential to deliver significant benefits. A number of variations on the idea of care pathways are already used in designing health-care buildings but this is under-researched. This paper provides a framework for thinking about care pathways and the health-care built environment. The framework distinguishes between five different pathway ‘types’ defined for the purpose of understanding the relationship between pathways and infrastructure. The five types are: ‘care pathways’, ‘integrated care pathways’, ‘patient pathways’, ‘patient journeys’ and ‘patient flows’. The built environment implications of each type are discussed and recommendations made for those involved in either building development or care pathway projects.

Care pathways and designing the healthcare built environment: an explanatory framework

The built environment in which health and social care is delivered can have an impact on the efficiency and outcomes of care processes. The health-care estate is large and growing and is expensive to build, adapt and maintain. The design of these buildings is a complex, difficult and political process. Better use of care pathways as an input to the design and use of the built environment has the potential to deliver significant benefits. A number of variations on the idea of care pathways are already used in designing health-care buildings but this is under-researched. This paper provides a framework for thinking about care pathways and the health-care built environment. The framework distinguishes between five different pathway ‘types’ defined for the purpose of understanding the relationship between pathways and infrastructure. The five types are: ‘care pathways’, ‘integrated care pathways’, ‘patient pathways’, ‘patient journeys’ and ‘patient flows’. The built environment implications of each type are discussed and recommendations made for those involved in either building development or care pathway projects.

Using HIT to deliver integrated care for the frail elderly in the UK: current barriers and future challenges

In this paper we briefly describe the results of a 3 year project examining the use of Health Information Technologies (e.g., electronic patient record systems) to deliver integrated care. In particular, we focus on one group of patient (the frail elderly) and efforts to design an e-health supported healthcare pathway (the frail elderly pathway – FEP). The aim of FEP is to bring together clinicians and staff from health and social care and allow them to share patient information. Our findings show that progress in delivering a fully-supported and working FEP has been slow, not least because of the difficulties experienced by healthcare staff in using current IT systems. In addition, there are many strategic and technical issues which remain unresolved (e.g., systems interoperability).

O psicólogo na proteção social especial: atuação junto às vítimas de violação de direitos no CREAS

The objective of this research was to investigate psychologist‟s practices at the Reference Specialized Center of Social Assistance (CREAS), special social care unit of medium complexity of the Unique System of Social Assistance (SUAS). With the creation of CREAS occurred the reorganization of specialized services and programs which were scattered within the socialassitantial network and began to be part of this center, creating a mosaic of actions directed to people with their rights violated. At the same time, there was a significant arrival of psychologists to the field of Social Assistance and their questioning facing specialized social demands and the (un)definitions of SUAS‟ policy concerning to special social protection. Was aimed in this research to investigate how psychologist‟s practices are developed at CREAS using semi-structured interviews and following the practices developed by three psychologists at a CREAS in the state of Rio Grande do Norte (RN), indicated by the Ministry of Social Development and Fight against Hunger (MDS) as one of the national references in 2008. It was highlighted a complex work field, which is delineated between the user´s rights perspective and the maintenance of historical difficulties concerning to the Social Assistance. In which the professional is requested to act toward the fight against rights violation, but does not find a field where is possible inter-sector and articulated work, in addition of being exposed to the precariousness of work and the weakness of employment ties, associated to the lack of formation to work in the area. Accordingly, there is still a range of challenges to psychologists in the building of a profession which confront risk situations and break off rights violation.

Resiliência em assistentes sociais que atuam na proteção social especial- PSE - de Belém do Pará

O presente trabalho identificou a resiliência, enquanto processo de enfrentamento, superação e fortalecimento, presente na atuação profissional dos assistentes sociais, mostrando que esta pode ser utilizada como instrumental teórico-metodológico que tem a Garantia de Direitos como importante mecanismo de proteção para bloquear fatores de risco. Desta forma, a resiliência enquanto instrumental teórico-metodológico poderá dar suporte às teorias do Serviço Social, no que se refere à intervenção e avaliação, por meio da mediação entre mecanismos de risco e proteção, facilitando a ação-reflexão-ação.

Dispositivos institucionais filantrópicos e socioeducativos de atenção à infância na assistência social

This study investigated Social Care as an institution that creates mechanisms for the production of subjectivity in the care of children and adolescents. For this, we used some analytical coordinates, both conjectural and structural, models of care for mapping care in confrontation in the field of Social Care. It was concluded that there was two contradictory paradigms, in the dialectical sense, organizing social care, one being the philanthropic mode and the other the socioeducative mode. The first, which is hegemonic in the field, corresponds to a care entity still organized from philanthropic care and is guided by a minority age logic, articulated by a discourse of criminalizing the lower classes. It is informally based on the legal concept of irregular situations, which would develop preventive, repressive, correctional and moralizing care practices. The construction of a socioeducative mode implies socioeducative care that aims for an effective increase in the rights of children and adolescents, based on their status as subjects and citizens, through democratic, dialogic, participatory, multi-disciplinary and fundamentally emancipatory institutional practices.

El nacionalismo frente a la cuestión social en Argentina (1930-1943) : Discursos, Representaciones y prácticas de las derechas sobre el mundo del trabajo

Nuestra investigación se centró fundamentalmente en las distintas formas en que las derechas respondieron a los conflictos suscitados en el mundo del trabajo durante el período de entreguerras. En primer lugar, advertimos que la cuestión social fue adquiriendo un rol protagónico en la agenda nacionalista tal como puede verse, por ejemplo, a través del análisis de los periódicos. En efecto, los diarios más importantes adscriptos al nacionalismo desarrollaron un discurso radical respecto a los problemas sociales e incluyeron secciones específicas para tratar estas cuestiones y expresar una posición al respecto. Las respuestas del nacionalismo argentino frente a la cuestión obrera han sido múltiples y han abarcado distintas esferas de la vida social. Lejos de esperar que la solución a los problemas sociales proviniera exclusivamente de las medidas restrictivas y represivas hacia el movimiento obrero, los nacionalistas elaboraron programas sociales, políticos, económicos y culturales que formaron parte de su proyecto de nación autoritaria y jerárquica. Los proyectos sociales y las propuestas de organización sindical fueron en gran parte inspirados por los fascismos europeos los cuales incluyeron programas de contención social dentro de un orden político totalitario. En este sentido los nacionalistas argentinos intentaron mediante sus propuestas imponer un orden que contemplara las necesidades básicas de los sectores populares y que preservara las jerarquías sociales limitando la participación política o sindical de los trabajadores y eliminando definitivamente alas fuerzas de la izquierda revolucionaria. Las organizaciones obreras nacionalistas incluyeron todo tipo de trabajadores en sus filas y procuraron captar tanto a los afiliados de los sindicatos autónomos como a los trabajadores socialistas. Algunas de estas organizaciones fueron efímeras mientras que otras tuvieron más éxito y lograron atraer adherentes. Las mismas conformaron la corriente que hemos denominado nacionalismo sindicalista, la cual desarrolló su propia doctrina social fuertemente influenciada por las encíclicas papales. Las manifestaciones nacionalistas en el espacio público porteño han sido también analizadas in extenso. Existieron distintos tipos de manifestaciones para movilizar a los seguidores del nacionalismo y para captar nuevos adherentes, especialmente aquellos provenientes de los sectores populares. Las manifestaciones se convirtieron en el escenario de las disputas ideológicas mantenidas tanto contra la política liberal como contra la revolucionaria. La "revolución nacionalista", según la formulaban sus partidarios, implicaba trascender los aspectos políticos y económicos incorporando transformaciones en otras áreas de la vida social: las costumbres, las formas de vida, los gustos culturales, los valores. Los nacionalistas advirtieron que para lograr este tipo de "revolución" debían hacer usa de los medios de comunicación masivos y diseñar proyectos para regular las industrias culturales. El objetivo de representar a los sectores populares fracasó rotundamente. El discurso nacionalista que condenaba la diversidad étnico-religiosa, que amenazaba con eliminar las distintas voces políticas existentes, y que expresaba un odio visceral a sus enemigos (ya fueran judíos, anarquistas, comunistas, o liberales) fue extremadamente desafortunado para quienes procuraron ensanchar las bases de un movimiento antidemocrático originalmente elitista que, a la luz del contexto internacional y de las condiciones locales, devino en populista

El nacionalismo frente a la cuestión social en Argentina (1930-1943) : Discursos, Representaciones y prácticas de las derechas sobre el mundo del trabajo

Nuestra investigación se centró fundamentalmente en las distintas formas en que las derechas respondieron a los conflictos suscitados en el mundo del trabajo durante el período de entreguerras. En primer lugar, advertimos que la cuestión social fue adquiriendo un rol protagónico en la agenda nacionalista tal como puede verse, por ejemplo, a través del análisis de los periódicos. En efecto, los diarios más importantes adscriptos al nacionalismo desarrollaron un discurso radical respecto a los problemas sociales e incluyeron secciones específicas para tratar estas cuestiones y expresar una posición al respecto. Las respuestas del nacionalismo argentino frente a la cuestión obrera han sido múltiples y han abarcado distintas esferas de la vida social. Lejos de esperar que la solución a los problemas sociales proviniera exclusivamente de las medidas restrictivas y represivas hacia el movimiento obrero, los nacionalistas elaboraron programas sociales, políticos, económicos y culturales que formaron parte de su proyecto de nación autoritaria y jerárquica. Los proyectos sociales y las propuestas de organización sindical fueron en gran parte inspirados por los fascismos europeos los cuales incluyeron programas de contención social dentro de un orden político totalitario. En este sentido los nacionalistas argentinos intentaron mediante sus propuestas imponer un orden que contemplara las necesidades básicas de los sectores populares y que preservara las jerarquías sociales limitando la participación política o sindical de los trabajadores y eliminando definitivamente alas fuerzas de la izquierda revolucionaria. Las organizaciones obreras nacionalistas incluyeron todo tipo de trabajadores en sus filas y procuraron captar tanto a los afiliados de los sindicatos autónomos como a los trabajadores socialistas. Algunas de estas organizaciones fueron efímeras mientras que otras tuvieron más éxito y lograron atraer adherentes. Las mismas conformaron la corriente que hemos denominado nacionalismo sindicalista, la cual desarrolló su propia doctrina social fuertemente influenciada por las encíclicas papales. Las manifestaciones nacionalistas en el espacio público porteño han sido también analizadas in extenso. Existieron distintos tipos de manifestaciones para movilizar a los seguidores del nacionalismo y para captar nuevos adherentes, especialmente aquellos provenientes de los sectores populares. Las manifestaciones se convirtieron en el escenario de las disputas ideológicas mantenidas tanto contra la política liberal como contra la revolucionaria. La "revolución nacionalista", según la formulaban sus partidarios, implicaba trascender los aspectos políticos y económicos incorporando transformaciones en otras áreas de la vida social: las costumbres, las formas de vida, los gustos culturales, los valores. Los nacionalistas advirtieron que para lograr este tipo de "revolución" debían hacer usa de los medios de comunicación masivos y diseñar proyectos para regular las industrias culturales. El objetivo de representar a los sectores populares fracasó rotundamente. El discurso nacionalista que condenaba la diversidad étnico-religiosa, que amenazaba con eliminar las distintas voces políticas existentes, y que expresaba un odio visceral a sus enemigos (ya fueran judíos, anarquistas, comunistas, o liberales) fue extremadamente desafortunado para quienes procuraron ensanchar las bases de un movimiento antidemocrático originalmente elitista que, a la luz del contexto internacional y de las condiciones locales, devino en populista

El nacionalismo frente a la cuestión social en Argentina (1930-1943) : Discursos, Representaciones y prácticas de las derechas sobre el mundo del trabajo

Nuestra investigación se centró fundamentalmente en las distintas formas en que las derechas respondieron a los conflictos suscitados en el mundo del trabajo durante el período de entreguerras. En primer lugar, advertimos que la cuestión social fue adquiriendo un rol protagónico en la agenda nacionalista tal como puede verse, por ejemplo, a través del análisis de los periódicos. En efecto, los diarios más importantes adscriptos al nacionalismo desarrollaron un discurso radical respecto a los problemas sociales e incluyeron secciones específicas para tratar estas cuestiones y expresar una posición al respecto. Las respuestas del nacionalismo argentino frente a la cuestión obrera han sido múltiples y han abarcado distintas esferas de la vida social. Lejos de esperar que la solución a los problemas sociales proviniera exclusivamente de las medidas restrictivas y represivas hacia el movimiento obrero, los nacionalistas elaboraron programas sociales, políticos, económicos y culturales que formaron parte de su proyecto de nación autoritaria y jerárquica. Los proyectos sociales y las propuestas de organización sindical fueron en gran parte inspirados por los fascismos europeos los cuales incluyeron programas de contención social dentro de un orden político totalitario. En este sentido los nacionalistas argentinos intentaron mediante sus propuestas imponer un orden que contemplara las necesidades básicas de los sectores populares y que preservara las jerarquías sociales limitando la participación política o sindical de los trabajadores y eliminando definitivamente alas fuerzas de la izquierda revolucionaria. Las organizaciones obreras nacionalistas incluyeron todo tipo de trabajadores en sus filas y procuraron captar tanto a los afiliados de los sindicatos autónomos como a los trabajadores socialistas. Algunas de estas organizaciones fueron efímeras mientras que otras tuvieron más éxito y lograron atraer adherentes. Las mismas conformaron la corriente que hemos denominado nacionalismo sindicalista, la cual desarrolló su propia doctrina social fuertemente influenciada por las encíclicas papales. Las manifestaciones nacionalistas en el espacio público porteño han sido también analizadas in extenso. Existieron distintos tipos de manifestaciones para movilizar a los seguidores del nacionalismo y para captar nuevos adherentes, especialmente aquellos provenientes de los sectores populares. Las manifestaciones se convirtieron en el escenario de las disputas ideológicas mantenidas tanto contra la política liberal como contra la revolucionaria. La "revolución nacionalista", según la formulaban sus partidarios, implicaba trascender los aspectos políticos y económicos incorporando transformaciones en otras áreas de la vida social: las costumbres, las formas de vida, los gustos culturales, los valores. Los nacionalistas advirtieron que para lograr este tipo de "revolución" debían hacer usa de los medios de comunicación masivos y diseñar proyectos para regular las industrias culturales. El objetivo de representar a los sectores populares fracasó rotundamente. El discurso nacionalista que condenaba la diversidad étnico-religiosa, que amenazaba con eliminar las distintas voces políticas existentes, y que expresaba un odio visceral a sus enemigos (ya fueran judíos, anarquistas, comunistas, o liberales) fue extremadamente desafortunado para quienes procuraron ensanchar las bases de un movimiento antidemocrático originalmente elitista que, a la luz del contexto internacional y de las condiciones locales, devino en populista

Why do health economists promote technology adoption rather than the search for efficiency? A proposal for a change in our approach to economic evaluation in health care

Acknowledgments Financial Support: HERU and HSRU receive a core grant from the Chief Scientist’s Office of the Scottish Government Health and Social Care Directorates, and the Centre for Clinical epidemiology & Evaluation is funded by Vancouver Coastal Health Authority. The model used for the illustrative case study in this paper was developed as part of a NHS Technology Assessment Review, funded by the National Institute for Health Research (NIHR) Health Technology Assessment Program (project number 09/146/01). The views and opinions expressed in this paper are those of the authors and do not necessarily reflect those of the Scottish Government, NHS, Vancouver Coastal Health, NIHR HTA Program or the Department of Health. The authors wish to thank Kathleen Boyd and members of the audience at the UK Health Economists Study Group, for comments received on an earlier version of this paper. We also wish to thank Cynthia Fraser (University of Aberdeen) for literature searches undertaken to inform the manuscript, and Mohsen Sadatsafavi (University of British Columbia) for comments on an earlier draft