Daily sedative interruption versus intermittent sedation in mechanically ventilated critically ill patients: a randomized trial.

Antonio Nassar Junior,Marcelo Park

doi:10.1186/2110-5820-4-14

Abstract

BackgroundDaily sedative interruption and intermittent sedation are effective in abbreviating the time on mechanical ventilation. Whether one is superior to the other has not yet been determined. Our aim was to compare daily interruption and intermittent sedation during the mechanical ventilation period in a low nurse staffing ICU.MethodsAdult patients expected to need mechanical ventilation for more than 24 hours were randomly assigned, in a single center, either to daily interruption of continuous sedative and opioid infusion or to intermittent sedation. In both cases, our goal was to maintain a Sedation Agitation Scale (SAS) level of 3 or 4; that is patients should be calm, easily arousable or awakened with verbal stimuli or gentle shaking. Primary outcome was ventilator-free days in 28 days. Secondary outcomes were ICU and hospital mortality, incidence of delirium, nurse workload, self-extubation and psychological distress six months after ICU discharge.ResultsA total of 60 patients were included. There were no differences in the ventilator-free days in 28 days between daily interruption and intermittent sedation (median: 24 versus 25 days, P = 0.160). There were also no differences in ICU mortality (40 versus 23.3%, P = 0.165), hospital mortality (43.3 versus 30%, P = 0.284), incidence of delirium (30 versus 40%, P = 0.472), self-extubation (3.3 versus 6.7%, P = 0.514), and psychological stress six months after ICU discharge. Also, the nurse workload was not different between groups, but it was reduced on day 5 compared to day 1 in both groups (Nurse Activity Score (NAS) in the intermittent sedation group was 54 on day 1 versus 39 on day 5, P < 0.001; NAS in daily interruption group was 53 on day 1 versus 38 on day 5, P < 0.001). Fentanyl and midazolam total dosages per patient were higher in the daily interruption group. The tidal volume was higher in the intermittent sedation group during the first five days of ICU stay.ConclusionsThere was no difference in the number of ventilator-free days in 28 days between both groups. Intermittent sedation was associated with lower sedative and opioid doses.Trial registrationClinicalTrials.gov Identifier: NCT00824239.

Highlights

Sedative interruption and intermittent sedation are effective in abbreviating the time on mechanical ventilation
Emergency department and wards were the main sources of admission (29 (48.3%) and 26 (43.3%) patients, respectively)
It was underpowered to show any difference in duration of mechanical ventilation between intermittent sedation and daily interruption of sedation, it suggests that both strategies seem to be safe in terms of complications, and are not different regarding nurse workload - two very important issues in units with profiles similar to ours

Summary

Introduction

Sedative interruption and intermittent sedation are effective in abbreviating the time on mechanical ventilation. Sedation is an important component for the care of critically ill patients who require mechanical ventilation It is commonly overused [1], and, when in excess, it is associated with increased time on mechanical ventilation [2], higher mortality [3], delirium [4] and psychological disturbances [5]. A protocol of no sedation has shown reduced duration of mechanical ventilation compared to daily interruption of sedative infusion, without severe adverse events [9]. Lighter sedation strategies in a lower nursing staff level ICU may expose patients on mechanical ventilation to care-associated risks, such as accidental extubation, since there is a trend between increased nurse staffing levels and decreased adverse patient outcomes in ICU [11]

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