human
***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: Objective To investigate the relationship between memory and intensive care sedation . Design and setting Prospect i ve cohort study over 18 months in two general intensive care units ( ICUs ) in district university hospitals . Patients 313 intubated mechanically ventilated adults admitted for more than 24 h , 250 of whom completed the study . Measurements Patients ( n = 250 ) were interviewed in the ward 5 days after discharge from the ICU using the ICU Memory Tool .  Patient characteristics , doses of sedative and analgesic agents , and sedation scores as measured by the Motor Activity Assessment Scale ( MAAS ) were collected from hospital records after the interview . Results Patients with no recall ( 18 % ) were significantly older , had higher baseline severity of illness , and experienced fewer periods of wakefulness ( median proportion of MAAS score 3 ; 0.37 vs. 0.70 ) than those who had memories of the ICU ( 82 % ) . Multivariate analyses showed that increasing proportion of MAAS 0–2 and older age were significantly associated with having no recall . Patients with delusional memories ( 34 % ) had significantly longer ICU stay ( median 6.6 vs. 2.2 days ) , higher baseline severity of illness , higher proportions of MAAS scores 4–6 , and more administration of midazolam than those with recall of the ICU without delusional memories . Conclusions Heavy sedation increases the risk of having no recall , and longer ICU stay increases the risk of delusional memories . The depth of sedation during total ICU stay as recorded with the MAAS may predict the probability of having memories of the ICU CONTEXT Goal -directed delivery of sedative and analgesic medications is recommended as st and ard care in intensive care units ( ICUs ) because of the impact these medications have on ventilator weaning and ICU length of stay , but few of the available sedation scales have been appropriately tested for reliability and validity . OBJECTIVE To test the reliability and validity of the Richmond Agitation-Sedation Scale ( RASS ) . DESIGN Prospect i ve cohort study . SETTING Adult medical and coronary ICUs of a university-based medical center . PARTICIPANTS Thirty-eight medical ICU patients enrolled for reliability testing ( 46 % receiving mechanical ventilation ) from July 21 , 1999 , to September 7 , 1999 , and an independent cohort of 275 patients receiving mechanical ventilation were enrolled for validity testing from February 1 , 2000 , to May 3 , 2001 . MAIN OUTCOME MEASURES Interrater reliability of the RASS , Glasgow Coma Scale ( GCS ) , and Ramsay Scale ( RS ) ; validity of the RASS correlated with reference st and ard ratings , assessment s of content of consciousness , GCS scores , doses of sedatives and analgesics , and bispectral electroencephalography . RESULTS In 290-paired observations by nurses , results of both the RASS and RS demonstrated excellent interrater reliability ( weighted kappa , 0.91 and 0.94 , respectively ) , which were both superior to the GCS ( weighted kappa , 0.64 ; P<.001 for both comparisons ) . Criterion validity was tested in 411-paired observations in the first 96 patients of the validation cohort , in whom the RASS showed significant differences between levels of consciousness ( P<.001 for all ) and correctly identified fluctuations within patients over time ( P<.001 ) . In addition , 5 methods were used to test the construct validity of the RASS , including correlation with an attention screening examination ( r = 0.78 , P<.001 ) , GCS scores ( r = 0.91 , P<.001 ) , quantity of different psychoactive medication dosages 8 hours prior to assessment ( eg , lorazepam : r = - 0.31 , P<.001 ) , successful extubation ( P = .07 ) , and bispectral electroencephalography ( r = 0.63 , P<.001 ) . Face validity was demonstrated via a survey of 26 critical care nurses , which the results showed that 92 % agreed or strongly agreed with the RASS scoring scheme , and 81 % agreed or strongly agreed that the instrument provided a consensus for goal -directed delivery of medications . CONCLUSIONS The RASS demonstrated excellent interrater reliability and criterion , construct , and face validity . This is the first sedation scale to be vali date d for its ability to detect changes in sedation status over consecutive days of ICU care , against constructs of level of consciousness and delirium , and correlated with the administered dose of sedative and analgesic medications Objective : To develop and test the reliability and validity of the State Behavioral Scale for use in describing sedation/agitation levels in young intubated patients supported on mechanical ventilation . Design : In this prospect i ve , psychometric evaluation , pairs of trained pediatric critical care nurse evaluators simultaneously and independently assessed a convenience sample of pediatric intensive care unit patients along eight state/behavioral dimensions and a numeric rating scale ( NRS ) of 0 ( extremely se date d ) to 10 ( extremely agitated ) . The eight dimensions were derived from the sedation/agitation literature and expert opinion and included respiratory drive , response to ventilation , coughing , best response to stimulation , attentiveness to careprovider , tolerance to care , consolability , and movement after consoled , each with 3–5 levels . Setting : An 18-bed pediatric medical – surgical intensive care unit and 26-bed pediatric cardiovascular intensive care unit in a university-affiliated academic children ’s hospital . Patients : A total of 91 intubated mechanically ventilated patients 6 wks to 6 yrs of age provided a median of two observations ( interquartile range , 1–3 ) for a total of 198 sets of observations . Excluded were postoperative patients or those receiving neuromuscular blockade . Interventions : Patients were observed for 1 min , and then incremental levels of stimulation were applied until patient response . After 2 mins of consoling , the state behavioral assessment and NRS were completed . Measurements : Weighted kappa and intraclass coefficients were generated to assess interrater reliability of the eight dimension and NRS ratings . Distinct state behavior profiles were empirically identified from the dimension ratings using hierarchical cluster analysis using a squared Euclidean distance measure and between-groups linkage . Construct validity of these profiles was assessed by comparing group mean NRS scores using one-way analysis of variance . Main Results : Weighted kappa scores for all 198 dimension ratings ranged from .44 to .76 , indicating moderate to good interrater reliability . The intraclass coefficient of .79 was high for NRS ratings . Cluster analysis revealed five distinct state profiles , with mean NRS ratings of 1.1 , 2.5 , 4.0 , 5.3 , and 7.6 , all of which differed significantly from each other ( F = 75.8 , p < .001 ) , supporting the profiles ’ construct validity . Conclusions : Based on empirically derived state behavior profiles , we have constructed the State Behavioral Scale to allow systematic description of the sedation – agitation continuum in young pediatric patients supported on mechanical ventilation . Further studies including prospect i ve validation and describing the effect of State Behavioral Scale implementation on clinical outcomes , including the quality of sedation and length of mechanical ventilation , are warranted Objective : To determine whether use of a sedation algorithm to promote a high level of tolerance to the intensive care environment and preserve consciousness affected time to arousal and duration of mechanical ventilation in patients without acute brain injury . Design : Two-phase , prospect i ve , controlled study . Setting : University-affiliated medical intensive care unit . Patients : Patients without acute brain injury requiring mechanical ventilation for at least 24 hrs . Interventions : During the control phase , sedatives and analgesics were adjusted according to the physician ’s decision . During the algorithm phase , sedatives and analgesics were adjusted according to an algorithm developed by a multidisciplinary team including nurses and physicians . The algorithm was based on regular assessment s of consciousness and tolerance to the intensive care unit environment using the Adaptation to Intensive Care Environment instrument and was design ed to achieve tolerance and maintain a high level of consciousness . St and ard practice s , including weaning from the ventilator , were the same during both study phases . Measurements and Main Results : A total of 102 patients were enrolled ( control group , n = 54 ; algorithm group , n = 48 ) . Median duration of mechanical ventilation was significantly shorter in the algorithm group ( 4.4 days [ interquartile range , 2.1–9.8 ] ) compared with the control group ( 10.3 days [ 3.5–17.2 ] , p = .014 ) , representing a 57.3 % reduction . In Cox multivariate analysis , the risk of remaining on mechanical ventilation was 0.48 times ( 95 % confidence interval , 0.29–0.78 ) lower for algorithm patients compared with controls . The median time to arousal was also significantly shorter in patients in the algorithm group ( 2 days [ 2–5 ] ) compared with the control group ( 4 days [ 2–9 ] , p = .006 ) . Conclusions : The use of a sedation algorithm to promote tolerance to the intensive care environment and preserve consciousness in patients without acute brain injury result ed in a marked decrease in the duration of mechanical ventilation . This reduction was at least partly attributable to a shorter time to arousal after initiation of mechanical ventilation Objective : To evaluate the effect of the implementation of a nursing-driven protocol of sedation on duration of intubation . Design : Before- and -after prospect i ve study . Setting : 18-bed medical-surgical intensive care unit . Patients : Patients receiving mechanical ventilation longer than 48 hrs who were ready to wean . Interventions : During the observational period , sedatives and analgesics were adjusted according to physicians ’ orders . During the intervention period , sedatives and analgesics were adjusted by nurses according to an algorithm-based sedation guideline , including a sedation scale . Measurements and Main Results : A total of 356 patients were included in the study ( 176 patients in the observational period and 189 patients in the intervention period ) . There were no significant differences in the duration of intubation between the two periods ( median , 7 [ interquartile range , 5–13 ] days vs. 7 [ interquartile range , 5–9 ] days ) . In a Kaplan-Meier analysis , the probability of successful extubation was higher during the intervention period than during the observational period ( log-rank = 0.02 ) . During the intervention period , patients were more awake without a significant increment in the nurse workload ; however , there was no significant decrease in the total doses of sedatives and analgesics administered . Conclusions : The implementation of a nursing-driven protocol of sedation may improve the probability of successful extubation in a heterogeneous population of mechanically ventilated patients OBJECTIVE Subjective scales to assess agitation and sedation in adult intensive care unit ( ICU ) patients have rarely been tested for validity or reliability . We revised and prospect ively tested the  Sedation-Agitation Scale ( SAS ) for interrater reliability and compared it with the Ramsay scale and the Harris scale to test construct validity . DESIGN A convenience sample of ICU patients was simultaneously and independently examined by pairs of trained evaluators by using the revised SAS , Ramsay , and Harris Scales . SETTING Multidisciplinary 34-bed ICU in a nonuniversity , academic medical center . PATIENTS Forty-five ICU patients ( surgical and medical ) were examined a total of 69 times by evaluator pairs . MEASUREMENTS AND MAIN RESULTS The mean patient age was 63.2 yrs , 36 % were female , and 71 % were intubated . When classified by using SAS , 45 % were anxious or agitated ( SAS 5 to 7 ) , 26 % were calm ( SAS 4 ) , and 29 % were se date d ( SAS 1 to 3 ) . Interrater correlation was high for SAS ( r2 = .83 ; p < .001 ) and the weighted kappa score for interrater agreement was 0.92 ( p < .001 ) . Of 41 assessment s scored as Ramsay 1 , 49 % scored SAS 6 , 41 % were SAS 5 , 5 % were SAS 4 , and 2 % each were SAS 3 or 7 . SAS was highly correlated with the Ramsay ( r2 = .83 ; p < .001 ) and Harris ( r2 = .86 ; p < .001 ) scales . CONCLUSIONS SAS is both reliable ( high interrater agreement ) and valid ( high correlation with the Harris and Ramsay scales ) in assessing agitation and sedation in adult ICU patients .  SAS provides additional information by stratifying agitation into three categories ( compared with one for the Ramsay scale ) without sacrificing validity or reliability STUDY OBJECTIVE To determine whether the use of continuous i.v . sedation is associated with prolongation of the duration of mechanical ventilation . DESIGN Prospect i ve observational cohort study . SETTING The medical ICU of Barnes-Jewish Hospital , a university-affiliated urban teaching hospital . PATIENTS Two hundred forty-two consecutive ICU patients requiring mechanical ventilation . INTERVENTIONS Patient surveillance and data collection . MEASUREMENTS AND RESULTS The primary outcome measure was the duration of mechanical ventilation . Secondary outcome measures included ICU and hospital lengths of stay , hospital mortality , and acquired organ system derangements . A total of 93 ( 38.4 % ) mechanically ventilated patients received continuous i.v . sedation while 149 ( 61.6 % ) patients received either bolus administration of i.v . sedation ( n=64 ) or no i.v . sedation ( n=85 ) following intubation . The duration of mechanical ventilation was significantly longer for 
    Output:
    
agent
***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: Objective To investigate the relationship between memory and intensive care sedation . Design and setting Prospect i ve cohort study over 18 months in two general intensive care units ( ICUs ) in district university hospitals . Patients 313 intubated mechanically ventilated adults admitted for more than 24 h , 250 of whom completed the study . Measurements Patients ( n = 250 ) were interviewed in the ward 5 days after discharge from the ICU using the ICU Memory Tool .  Patient characteristics , doses of sedative and analgesic agents , and sedation scores as measured by the Motor Activity Assessment Scale ( MAAS ) were collected from hospital records after the interview . Results Patients with no recall ( 18 % ) were significantly older , had higher baseline severity of illness , and experienced fewer periods of wakefulness ( median proportion of MAAS score 3 ; 0.37 vs. 0.70 ) than those who had memories of the ICU ( 82 % ) . Multivariate analyses showed that increasing proportion of MAAS 0–2 and older age were significantly associated with having no recall . Patients with delusional memories ( 34 % ) had significantly longer ICU stay ( median 6.6 vs. 2.2 days ) , higher baseline severity of illness , higher proportions of MAAS scores 4–6 , and more administration of midazolam than those with recall of the ICU without delusional memories . Conclusions Heavy sedation increases the risk of having no recall , and longer ICU stay increases the risk of delusional memories . The depth of sedation during total ICU stay as recorded with the MAAS may predict the probability of having memories of the ICU CONTEXT Goal -directed delivery of sedative and analgesic medications is recommended as st and ard care in intensive care units ( ICUs ) because of the impact these medications have on ventilator weaning and ICU length of stay , but few of the available sedation scales have been appropriately tested for reliability and validity . OBJECTIVE To test the reliability and validity of the Richmond Agitation-Sedation Scale ( RASS ) . DESIGN Prospect i ve cohort study . SETTING Adult medical and coronary ICUs of a university-based medical center . PARTICIPANTS Thirty-eight medical ICU patients enrolled for reliability testing ( 46 % receiving mechanical ventilation ) from July 21 , 1999 , to September 7 , 1999 , and an independent cohort of 275 patients receiving mechanical ventilation were enrolled for validity testing from February 1 , 2000 , to May 3 , 2001 . MAIN OUTCOME MEASURES Interrater reliability of the RASS , Glasgow Coma Scale ( GCS ) , and Ramsay Scale ( RS ) ; validity of the RASS correlated with reference st and ard ratings , assessment s of content of consciousness , GCS scores , doses of sedatives and analgesics , and bispectral electroencephalography . RESULTS In 290-paired observations by nurses , results of both the RASS and RS demonstrated excellent interrater reliability ( weighted kappa , 0.91 and 0.94 , respectively ) , which were both superior to the GCS ( weighted kappa , 0.64 ; P<.001 for both comparisons ) . Criterion validity was tested in 411-paired observations in the first 96 patients of the validation cohort , in whom the RASS showed significant differences between levels of consciousness ( P<.001 for all ) and correctly identified fluctuations within patients over time ( P<.001 ) . In addition , 5 methods were used to test the construct validity of the RASS , including correlation with an attention screening examination ( r = 0.78 , P<.001 ) , GCS scores ( r = 0.91 , P<.001 ) , quantity of different psychoactive medication dosages 8 hours prior to assessment ( eg , lorazepam : r = - 0.31 , P<.001 ) , successful extubation ( P = .07 ) , and bispectral electroencephalography ( r = 0.63 , P<.001 ) . Face validity was demonstrated via a survey of 26 critical care nurses , which the results showed that 92 % agreed or strongly agreed with the RASS scoring scheme , and 81 % agreed or strongly agreed that the instrument provided a consensus for goal -directed delivery of medications . CONCLUSIONS The RASS demonstrated excellent interrater reliability and criterion , construct , and face validity . This is the first sedation scale to be vali date d for its ability to detect changes in sedation status over consecutive days of ICU care , against constructs of level of consciousness and delirium , and correlated with the administered dose of sedative and analgesic medications Objective : To develop and test the reliability and validity of the State Behavioral Scale for use in describing sedation/agitation levels in young intubated patients supported on mechanical ventilation . Design : In this prospect i ve , psychometric evaluation , pairs of trained pediatric critical care nurse evaluators simultaneously and independently assessed a convenience sample of pediatric intensive care unit patients along eight state/behavioral dimensions and a numeric rating scale ( NRS ) of 0 ( extremely se date d ) to 10 ( extremely agitated ) . The eight dimensions were derived from the sedation/agitation literature and expert opinion and included respiratory drive , response to ventilation , coughing , best response to stimulation , attentiveness to careprovider , tolerance to care , consolability , and movement after consoled , each with 3–5 levels . Setting : An 18-bed pediatric medical – surgical intensive care unit and 26-bed pediatric cardiovascular intensive care unit in a university-affiliated academic children ’s hospital . Patients : A total of 91 intubated mechanically ventilated patients 6 wks to 6 yrs of age provided a median of two observations ( interquartile range , 1–3 ) for a total of 198 sets of observations . Excluded were postoperative patients or those receiving neuromuscular blockade . Interventions : Patients were observed for 1 min , and then incremental levels of stimulation were applied until patient response . After 2 mins of consoling , the state behavioral assessment and NRS were completed . Measurements : Weighted kappa and intraclass coefficients were generated to assess interrater reliability of the eight dimension and NRS ratings . Distinct state behavior profiles were empirically identified from the dimension ratings using hierarchical cluster analysis using a squared Euclidean distance measure and between-groups linkage . Construct validity of these profiles was assessed by comparing group mean NRS scores using one-way analysis of variance . Main Results : Weighted kappa scores for all 198 dimension ratings ranged from .44 to .76 , indicating moderate to good interrater reliability . The intraclass coefficient of .79 was high for NRS ratings . Cluster analysis revealed five distinct state profiles , with mean NRS ratings of 1.1 , 2.5 , 4.0 , 5.3 , and 7.6 , all of which differed significantly from each other ( F = 75.8 , p < .001 ) , supporting the profiles ’ construct validity . Conclusions : Based on empirically derived state behavior profiles , we have constructed the State Behavioral Scale to allow systematic description of the sedation – agitation continuum in young pediatric patients supported on mechanical ventilation . Further studies including prospect i ve validation and describing the effect of State Behavioral Scale implementation on clinical outcomes , including the quality of sedation and length of mechanical ventilation , are warranted Objective : To determine whether use of a sedation algorithm to promote a high level of tolerance to the intensive care environment and preserve consciousness affected time to arousal and duration of mechanical ventilation in patients without acute brain injury . Design : Two-phase , prospect i ve , controlled study . Setting : University-affiliated medical intensive care unit . Patients : Patients without acute brain injury requiring mechanical ventilation for at least 24 hrs . Interventions : During the control phase , sedatives and analgesics were adjusted according to the physician ’s decision . During the algorithm phase , sedatives and analgesics were adjusted according to an algorithm developed by a multidisciplinary team including nurses and physicians . The algorithm was based on regular assessment s of consciousness and tolerance to the intensive care unit environment using the Adaptation to Intensive Care Environment instrument and was design ed to achieve tolerance and maintain a high level of consciousness . St and ard practice s , including weaning from the ventilator , were the same during both study phases . Measurements and Main Results : A total of 102 patients were enrolled ( control group , n = 54 ; algorithm group , n = 48 ) . Median duration of mechanical ventilation was significantly shorter in the algorithm group ( 4.4 days [ interquartile range , 2.1–9.8 ] ) compared with the control group ( 10.3 days [ 3.5–17.2 ] , p = .014 ) , representing a 57.3 % reduction . In Cox multivariate analysis , the risk of remaining on mechanical ventilation was 0.48 times ( 95 % confidence interval , 0.29–0.78 ) lower for algorithm patients compared with controls . The median time to arousal was also significantly shorter in patients in the algorithm group ( 2 days [ 2–5 ] ) compared with the control group ( 4 days [ 2–9 ] , p = .006 ) . Conclusions : The use of a sedation algorithm to promote tolerance to the intensive care environment and preserve consciousness in patients without acute brain injury result ed in a marked decrease in the duration of mechanical ventilation . This reduction was at least partly attributable to a shorter time to arousal after initiation of mechanical ventilation Objective : To evaluate the effect of the implementation of a nursing-driven protocol of sedation on duration of intubation . Design : Before- and -after prospect i ve study . Setting : 18-bed medical-surgical intensive care unit . Patients : Patients receiving mechanical ventilation longer than 48 hrs who were ready to wean . Interventions : During the observational period , sedatives and analgesics were adjusted according to physicians ’ orders . During the intervention period , sedatives and analgesics were adjusted by nurses according to an algorithm-based sedation guideline , including a sedation scale . Measurements and Main Results : A total of 356 patients were included in the study ( 176 patients in the observational period and 189 patients in the intervention period ) . There were no significant differences in the duration of intubation between the two periods ( median , 7 [ interquartile range , 5–13 ] days vs. 7 [ interquartile range , 5–9 ] days ) . In a Kaplan-Meier analysis , the probability of successful extubation was higher during the intervention period than during the observational period ( log-rank = 0.02 ) . During the intervention period , patients were more awake without a significant increment in the nurse workload ; however , there was no significant decrease in the total doses of sedatives and analgesics administered . Conclusions : The implementation of a nursing-driven protocol of sedation may improve the probability of successful extubation in a heterogeneous population of mechanically ventilated patients OBJECTIVE Subjective scales to assess agitation and sedation in adult intensive care unit ( ICU ) patients have rarely been tested for validity or reliability . We revised and prospect ively tested the  Sedation-Agitation Scale ( SAS ) for interrater reliability and compared it with the Ramsay scale and the Harris scale to test construct validity . DESIGN A convenience sample of ICU patients was simultaneously and independently examined by pairs of trained evaluators by using the revised SAS , Ramsay , and Harris Scales . SETTING Multidisciplinary 34-bed ICU in a nonuniversity , academic medical center . PATIENTS Forty-five ICU patients ( surgical and medical ) were examined a total of 69 times by evaluator pairs . MEASUREMENTS AND MAIN RESULTS The mean patient age was 63.2 yrs , 36 % were female , and 71 % were intubated . When classified by using SAS , 45 % were anxious or agitated ( SAS 5 to 7 ) , 26 % were calm ( SAS 4 ) , and 29 % were se date d ( SAS 1 to 3 ) . Interrater correlation was high for SAS ( r2 = .83 ; p < .001 ) and the weighted kappa score for interrater agreement was 0.92 ( p < .001 ) . Of 41 assessment s scored as Ramsay 1 , 49 % scored SAS 6 , 41 % were SAS 5 , 5 % were SAS 4 , and 2 % each were SAS 3 or 7 . SAS was highly correlated with the Ramsay ( r2 = .83 ; p < .001 ) and Harris ( r2 = .86 ; p < .001 ) scales . CONCLUSIONS SAS is both reliable ( high interrater agreement ) and valid ( high correlation with the Harris and Ramsay scales ) in assessing agitation and sedation in adult ICU patients .  SAS provides additional information by stratifying agitation into three categories ( compared with one for the Ramsay scale ) without sacrificing validity or reliability STUDY OBJECTIVE To determine whether the use of continuous i.v . sedation is associated with prolongation of the duration of mechanical ventilation . DESIGN Prospect i ve observational cohort study . SETTING The medical ICU of Barnes-Jewish Hospital , a university-affiliated urban teaching hospital . PATIENTS Two hundred forty-two consecutive ICU patients requiring mechanical ventilation . INTERVENTIONS Patient surveillance and data collection . MEASUREMENTS AND RESULTS The primary outcome measure was the duration of mechanical ventilation . Secondary outcome measures included ICU and hospital lengths of stay , hospital mortality , and acquired organ system derangements . A total of 93 ( 38.4 % ) mechanically ventilated patients received continuous i.v . sedation while 149 ( 61.6 % ) patients received either bolus administration of i.v . sedation ( n=64 ) or no i.v . sedation ( n=85 ) following intubation . The duration of mechanical ventilation was significantly longer for 
    Output:
    