ADHERENCE TO SEDATION AND ANALGESIA PROTOCOLS AND THEIR IMPACT ON INTENSIVE CARE OUTCOMES

Abstract

Background: Sedation and analgesia management is a fundamental component of intensive care, particularly for mechanically ventilated patients. In the intensive care unit (ICU), nurses are primarily responsible for continuous assessment of pain, agitation, and sedation using validated tools, documentation of target sedation goals, and titration of medications according to established protocols. In resource-constrained settings such as Pakistan, variability in nurse training, staffing ratios, and protocol implementation may affect adherence to evidence-based practices and, in turn, patient outcomes. Objective: To evaluate adherence to sedation and analgesia protocols in a tertiary care ICU and to determine their impact on clinical outcomes. Study Design: Observational analytical study. Settings: Intensive Care Unit, Nishtar Hospital, Multan, Pakistan. Duration of Study: January to June 2025. Methods: Ninety adult ICU patients receiving sedation and/or analgesia were enrolled. Adherence was measured using a composite score that incorporated documentation of sedation assessment with the Richmond Agitation-Sedation Scale (RASS), pain assessment using CPOT or NRS, clearly defined sedation targets, consistent dose titration, and daily sedation interruption when clinically indicated. Based on overall scores, patients were categorized into high, moderate, or low adherence groups. Primary outcomes were ICU mortality and ICU length of stay. Secondary outcomes included duration of mechanical ventilation, incidence of delirium, ventilator-associated pneumonia, and re-intubation. Multivariable logistic regression was performed to adjust for age, APACHE II score, mechanical ventilation status, and vasopressor use. Results: The mean age of participants was 51.6 ± 15.2 years, and 62.2% were male. High adherence to sedation and analgesia protocols was observed in 48.9% of patients, moderate adherence in 31.1%, and low adherence in 20.0%. Compared with low adherence, high adherence was associated with shorter median duration of mechanical ventilation (3 vs 6 days, p < 0.001), reduced ICU length of stay (4 vs 9 days, p < 0.001), lower incidence of delirium (20.5% vs 50.0%, p = 0.019), and decreased ICU mortality (6.8% vs 27.8%, p = 0.028). After adjustment for potential confounders, high adherence remained independently associated with lower ICU mortality (adjusted odds ratio 0.21, 95% CI 0.05–0.89) and reduced delirium (adjusted odds ratio 0.30, 95% CI 0.10–0.92). Conclusion: Structured, nurse-led adherence to sedation and analgesia protocols was independently associated with improved ICU outcomes, including lower mortality, reduced delirium, and shorter mechanical ventilation duration. Strengthening nurse training, standardized documentation, and consistent protocol implementation may improve critical care outcomes in tertiary care hospitals in Pakistan.