Abstract
ObjectivesWe sought to study the association between sedation status, medications (benzodiazepines, opioids, and antipsychotics), and clinical outcomes in a resource-limited setting.DesignA longitudinal study of critically ill participants on mechanical ventilation.SettingFive intensive care units (ICUs) in four public hospitals in Lima, Peru.PatientsOne thousand six hundred fifty-seven critically ill participants were assessed daily for sedation status during 28 days and vital status by day 90.ResultsAfter excluding data of participants without a Richmond Agitation Sedation Scale score and without sedation, we followed 1338 (81%) participants longitudinally for 18,645 ICU days. Deep sedation was present in 98% of participants at some point of the study and in 12,942 ICU days. Deep sedation was associated with higher mortality (interquartile odds ratio (OR) = 5.42, 4.23–6.95; p < 0.001) and a significant decrease in ventilator (− 7.27; p < 0.001), ICU (− 4.38; p < 0.001), and hospital (− 7.00; p < 0.001) free days. Agitation was also associated with higher mortality (OR = 39.9, 6.53–243, p < 0.001). The most commonly used sedatives were opioids and benzodiazepines (9259 and 8453 patient days respectively), and the latter were associated with a 41% higher mortality in participants with a higher cumulative dose (75th vs 25th percentile, interquartile OR = 1.41, 1.12–1.77; p < 0.01). The overall cumulative dose of benzodiazepines and opioids was high, 774.5 mg and 16.8 g, respectively, by day 7 and by day 28; these doses approximately doubled. Haloperidol was only used in 3% of ICU days; however, the use of it was associated with a 70% lower mortality (interquartile OR = 0.3, 0.22–0.44, p < 0.001).ConclusionsDeep sedation, agitation, and cumulative dose of benzodiazepines were all independently associated with higher 90-day mortality. Additionally, deep sedation was associated with less ventilator-, ICU-, and hospital-free days. In contrast, haloperidol was associated with lower mortality in our study.
Highlights
Sedation and analgesia are essential components in the care of mechanically ventilated patients in the intensive care unit (ICU) to provide comfort, improve patientventilator synchrony, and reduce anxiety and agitation [1]
Deep sedation was associated with less ventilator, ICU, and hospital-free days
The results of our study indicate that despite strong evidence that correlates sedation depth with worse clinical outcomes, most ICU patients were deeply sedated during their ICU stay
Summary
Sedation and analgesia are essential components in the care of mechanically ventilated patients in the intensive care unit (ICU) to provide comfort, improve patientventilator synchrony, and reduce anxiety and agitation [1]. Deep sedation has been associated with negative patient-centered outcomes including delirium [2, 3], a common complication in the ICU, with a prevalence as high as 82% [4]. Standardized management of sedation reduces the use of sedatives without negatively affecting patient safety or increasing psychological stress [14]. Despite these recognized benefits, sedation practices remain variable, with a tendency towards over-sedation and a lack of routine delirium assessment [1, 15]. We explore the association between sedation status, use of sedation and antipsychotics medications, and patient centered-outcomes in a cohort of critically ill, mechanically ventilated patients in five ICUs in Lima, Peru
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