Abstract
BackgroundMechanically ventilated patients may receive more sedation during the night than during the day, potentially delaying extubation. We compared nighttime and daytime benzodiazepine and opioid administration in adult patients enrolled in a multicenter sedation trial comparing protocolized sedation alone or protocolized sedation combined with daily sedation interruption; and we evaluated whether nighttime and daytime doses were associated with liberation from mechanical ventilation.MethodsThis is a secondary analysis of a randomized trial which was conducted in 16 North American medical-surgical ICUs. In all 423 patients, nurses applied a validated sedation scale hourly to titrate benzodiazepine and opioid infusions to achieve a light level of sedation. Using fentanyl equivalents and midazolam equivalents, we compared dosages administered during night (19:00 to 07:00) and day (07:00 to 19:00) shifts. Using multivariable logistic regression we evaluated the association between nighttime and daytime opioid and sedative doses, and spontaneous breathing trial (SBT) conduct, SBT success, and extubation.ResultsNighttime benzodiazepine and opioid doses were significantly higher than daytime doses (mean difference midazolam equivalents 23.3 mg, 95 % CI 12.9, 33.8, p < 0.0001; mean difference fentanyl equivalents 356 mcg, 95 % CI 130, 582, p = 0.0021). Mean Sedation Agitation Scale score was similar between night and day, and was at target (3.2 vs 3.3, 95 % CI −0.05, 0.02, p = 0.35). Self-reported nurse workload was similar during the night and day. Patients were more often restrained during day shifts (76.3 % vs 73.7 %, p < 0.0001), and there were more unintentional device removals during the day compared with night (15.9 % vs 9.1 %, p < 0.0001). Increases in nighttime drug doses were independently associated with failure to meet SBT screening criteria, SBT failure, and the decision not to extubate the patient despite successful SBT.ConclusionPatients received higher doses of opioids and benzodiazepines at night. Higher nighttime doses were associated with SBT failure and delayed extubation.Trial registrationClinicalTrials.gov NCT00675363. Registered 7 May 2008.Electronic supplementary materialThe online version of this article (doi:10.1186/s13054-016-1405-3) contains supplementary material, which is available to authorized users.
Highlights
Ventilated patients may receive more sedation during the night than during the day, potentially delaying extubation
Among 423 patients enrolled in the SLEAP study, patient characteristics were similar between the daily interruption (DI) and control groups
Increased nocturnal sedation has important adverse patient consequences, as we found it was independently associated with delayed extubation
Summary
Ventilated patients may receive more sedation during the night than during the day, potentially delaying extubation. We compared nighttime and daytime benzodiazepine and opioid administration in adult patients enrolled in a multicenter sedation trial comparing protocolized sedation alone or protocolized sedation combined with daily sedation interruption; and we evaluated whether nighttime and daytime doses were associated with liberation from mechanical ventilation. Ventilated patients may receive more sedation during the night compared with the day [5], potentially delaying extubation [6]. SLEAP was a multicenter trial that randomized mechanically ventilated adult patients to protocolized sedation (PS) alone (control), or protocolized sedation combined with daily interruption (DI) of sedation [8]. The DI group received higher doses of opioids and benzodiazepines, potentially reflecting nurse apprehension about patient discomfort or the risk of adverse events during DI
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