Daily Interruption Of Sedative Infusions Research Articles

Early Mobilization in the ICU: An Update

Over the past 10 to 15 years, a culture shift in ICU care has occurred at several leading institutions across the United States. The traditional model of deep anesthesia with prolonged bedrest in mechanically ventilated patients has been replaced with a model of minimal sedation with early mobilization.1 In 2000, Kress reported a landmark study addressing sedation minimization by daily interruption of sedative infusions in mechanically ventilated patients. This study evaluated 128 adult patients who were mechanically ventilated and received continuous sedative infusion; the intervention group (who received daily sedation holidays) had a decrease in duration of mechanical ventilation of 2.4 days per patient in comparison to the control group (interruptions in sedation at the discretion of the attending physician) and a decrease in length of ICU stay by 3.5 days per patient.2 This contributed to an ICU culture change over the next decade, in which more intensive efforts to minimize sedation were made. In a follow-up study published in JAMA in 2012, daily sedation holidays were re-examined by comparing daily sedation interruption combined with a protocol based sedation strategy (designed to reduce overall sedation) to a protocol based sedation strategy alone. In this study, neither the duration of mechanical ventilation nor length of ICU stay was reduced by the addition of daily sedation interruption. The authors concluded that this likely reflected positively on the change in sedation strategy over 10 years following the initial study by Kress. Rather than the usual care of deep sedation in mechanically ventilated patients that resulted in a clinical benefit from daily sedation interruption, the more current model of global sedation minimization now negated the previous beneficial effects of daily sedation interruption.3

Daily Interruptions of Sedation: A Clinical Approach to Improve Outcomes in Critically Ill Patients

The continuous infusion of sedative agents is often necessary for critically ill patients. However, it has been associated with several disadvantages. Numerous interventions to reduce these risks have been evaluated, including the practice of interrupting sedative infusions on a daily basis. A literature search was conducted, and 7 studies were reviewed to evaluate the safety and effectiveness of daily interruption of sedative infusions and its outcomes. The implementation of daily sedation interruptions was suggested to minimize multiple complications associated with continuous sedative infusions and was not associated with intensive care-related complications or long-term psychological effects. Additional studies have revealed perceived barriers to the implementation of daily sedation interruptions. Further randomized controlled trials enrolling larger, more diverse samples are needed to provide more evidence regarding the safety and effectiveness of this intervention.

Daily Sedation Interruption; A Glass Half Empty?

The last decade witnessed an exponential rise in the number of publications addressing management of sedation during critical illness. In 1998 Kollef and colleagues1 suggested that the use of continuous infusions of sedatives may be associated with prolonged duration of mechanical ventilation and intensive care unit (ICU) stay. This was followed by a landmark study by Kress and colleagues2 who demonstrated significant reduction in ventilation time and ICU stay with daily interruption of sedative infusions (DSI). Subsequent investigations have been consistent with the notion that strategies that reduce sedation depth such as algorithms and protocols for sedation management3-5 and the use of validated sedation scales6 can improve patient outcomes. This academic exuberance led to an endorsement of these strategies, and in particular DSI, by the UK Department of Health ( www.clean-safe-care.nhs.uk ), the Institute for Healthcare Improvement ( www.IHI.org ) and Safer Health Care Now! ( www.saferhealthcarenow.ca ).

Daily interruption of sedative infusions in an adult medical–surgical intensive care unit: randomized controlled trial

This article is a report of a study conducted to determine if a nursing-implemented protocol of daily interruption of sedative infusions vs. sedation as directed by the intensive care unit team would decrease duration of mechanical ventilation. Continuous rather than intermittent infusion of sedative and analgesic agents leads to greater stability in sedation level, but has been correlated with prolongation of mechanical ventilation and hospitalization of critical care patients. Daily interruption of sedative infusions in mechanically ventilated patients has reduced the duration of mechanical ventilation and length of stay in intensive care. A randomized controlled trial was carried out from November 2004 to March 2006 with 97 patients receiving mechanical ventilation and continuous infusion of sedative drugs in an intensive care unit in Greece. The primary outcome measure was the duration of mechanical ventilation. Secondary outcomes were length of intensive care unit stay, length of hospital stay, overall mortality, total doses of sedative and analgesic medicines and Ramsay scores and duration of cessation of sedative infusions per day. The median duration of mechanical ventilation was 8.7 days vs. 7.7 days (P = 0.7). Length of intensive care unit stay (median: 14 vs. 12, P = 0.5) and in the hospital (median: 31 vs. 21, P = 0.1) was similar between the intervention and control groups. The absence of statistically significant differences in these variables remained when patients with brain injury were examined separately. The nursing-implemented protocol of daily interruption of sedative infusions was neither beneficial nor harmful compared with usual practice, which has as its primary target the earliest possible awakening of patients.

An Analgesia–Delirium–Sedation Protocol for Critically Ill Trauma Patients Reduces Ventilator Days and Hospital Length of Stay

Analgesics and sedatives are required to maintain a calm and comfortable mechanically ventilated injured patient. Continuous sedative infusions have been shown to lengthen mechanical ventilation and hospital length of stay. Daily interruption of sedative infusions may reduce both of these variables. Implementation of an Analgesia-Delirium-Sedation (ADS) Protocol using objective assessments with a goal of maintaining an awake and comfortable patient may obviate the need for daily interruption of infusions in critically ill trauma patients. We examined the effects of such a protocol on ventilator duration, intensive care unit (ICU) length of stay, hospital slength of stay, and medication requirements. A multidisciplinary team designed the protocol. Objective measures of pain (visual/objective pain assessment scale-VAS/OPAS), agitation (Richmond Agitation-Sedation Scale-RASS), and delirium [Confusion Assessment Method {CAM-ICU}] were used. Medications were titrated to a RASS of -1 to +1 and VAS/OPAS <4. Haloperidol was used to treat delirium in CAM-ICU positive patients. Retrospective review of the local Project IMPACT database for a 6-month period in 2004 was compared with the same seasonal period in 2006 in which the ADS protocol was used. All mechanically ventilated trauma patients receiving infusions of narcotic, propofol, or benzodiazepine were included. Age, APACHE II score, Injury Severity Score, ventilator days, ventilator-free days at day 28, ICU length of stay, and hospital length of stay are reported as median values (interquartile range). Medication usage is reported as mean values (+/-SD). Differences in data were analyzed using Wilcoxon's rank-sum test or t test, as appropriate. Gender, mortality, and mechanism of injury were analyzed using chi analysis. A total of 143 patients were included. Patients who died during their hospitalization were excluded except in the analysis of ventilator-free days at day 28. After exclusions, 61 patients were in the control group and 58 in the protocol group. The median duration of mechanical ventilation in the protocol group was 1.2 days (0.5-3.0) which was significantly reduced compared with 3.2 days (1.0-12.9) in the control group (p = 0.027). Analysis of ventilator-free days at day 28 found that the protocol group had 26.4 ventilator-free days (13.9-27.4) compared with 22.8 days (10.5-26.9) in the control group (p = 0.007). The median ICU length of stay was 5.9 days (2.3-18.2) in the control group and 4.1 days (2.5-8.3) in the protocol group (p = 0.21). Hospital length of stay was 12 days (7-17) in the protocol group in contrast to 18 days (10-27) in the control group (p = 0.036). Opiate equivalents and propofol use per patient was significantly reduced in the protocol group from 2,465 mg (+/-1,242 mg) to 1,641 mg (+/-1,250 mg) and 19,232 mg (+/-22,477 mg) to 10,057 (+/-14,616 mg), respectively (p < 0.001, p = 0.01). An objective assessment- based ADS protocol without daily interruption of medication infusion decreases ventilator days and hospital length of stay in critically ill trauma patients.

Daily interruption of sedative infusions and complications of critical illness in mechanically ventilated patients.

In critically ill patients receiving mechanical ventilation, daily interruption of sedative infusions decreases duration of mechanical ventilation and intensive care unit length of stay. Whether this sedation strategy reduces the incidence of complications commonly associated with critical illness is not known. Blinded, retrospective chart review. University-based hospital in Chicago, IL. One hundred twenty-eight patients receiving mechanical ventilation and continuous infusions of sedative drugs in a medical intensive care unit. None. We performed a blinded, retrospective evaluation of the database from our previous trial of 128 patients randomized to daily interruption of sedative infusions vs. sedation as directed by the medical intensive care unit team without this strategy. Seven distinct complications associated with mechanical ventilation and critical illness were identified: a) ventilator-associated pneumonia; b) upper gastrointestinal hemorrhage; c) bacteremia; d) barotrauma; e) venous thromboembolic disease; and f) cholestasis or g) sinusitis requiring surgical intervention. The incidence of complications was evaluated for each patient's hospital course. One hundred twenty-six of 128 charts were available for review. Patients undergoing daily interruption of sedative infusions experienced 13 complications (2.8%) vs. 26 (6.2%) in those subjected to conventional sedation techniques (p =.04). Daily interruption of sedative infusions in critically ill patients undergoing mechanical ventilation reduces intensive care unit length of stay and, in turn, decreases the incidence of complications of critical illness associated with prolonged intubation and mechanical ventilation.

Daily Interruption of Sedative Infusions in Critically Ill Patients Undergoing Mechanical Ventilation

Daily Interruption of Sedative Infusions in Critically Ill Patients Undergoing Mechanical Ventilation

Daily interruption of sedative infusions reduced duration of mechanical ventilation and intensive care unit stay in critically ill patients

Kress JP, Pohlman AS, O'Connor MF, et al . Daily interruption of sedative infusions in critically ill patients undergoing mechanical ventilation. N Engl J Med2000 May 18; 342 : 1471...

Daily interruption of sedative infusions in critically ill patients undergoing mechanical ventilation.

Department of Anesthesiology; Wake Forest University School of Medicine; Winston-Salem, North Carolina Department of Anesthesiology; Duke University; Durham, North Carolina