Daily Sedation Interruption Research Articles

Effect of Daily Sedative Interruption on Sleep Stages of Mechanically Ventilated Patients Receiving Midazolam by Infusion

Daily sedative interruption (DSI) may reduce excessive sedation and shorten the duration of mechanical ventilation. It is not clear, however, how DSI affects sleep characteristics. For patients receiving mechanical ventilation, we compared the effect on sleep quality of DSI and continuous sedation (CS). Twenty-two mechanically ventilated patients who were receiving midazolam by infusion were randomly assigned to two groups, DSI (n = 11) or CS (n = 11). In the DSI group, sedatives were interrupted until the patients awoke and expressed discomfort, after which midazolam or opioids were administered intermittently as needed during the daytime (0600 to 2100 hours); during the night (2100 to 0600) midazolam was administered intravenously to maintain Ramsay sedation scale 4 to 5. In the CS group, the sedatives were titrated to obtain Ramsay sedation scale 4 to 5 throughout the day. The polysomnography of each patient was recorded continuously over a 24 hour period. Sleep stages were analysed using Rechtschaffen and Kales criteria. In the DSI group, the amount of stage 3 and 4 non-rapid eye movement sleep (slow wave sleep) was longer (6 vs 0 minutes, P = 0.04) and rapid eye movement sleep was longer than in CS (54 vs 0 minutes, P = 0.02). In the CS group, total sleep time during night-time was longer (8.7 vs 7.3 hours, P = 0.047) and frequency of arousal was lower (2.2 vs 4.4 event/hour, P = 0.03) than those in the DSI group. All mechanically ventilated patients demonstrated abnormal sleep architecture, but, compared with CS, DSI increased the amount of slow wave sleep and rapid eye movement sleep.

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 ).

Sedation and renal impairment in critically ill patients: a post hoc analysis of a randomized trial

IntroductionNot sedating critically ill patients reduces the time patients receive mechanical ventilation, decreases the time in the intensive care department and reduces the total hospital length of stay. We hypothesized that no sedation improves hemodynamic stability, decreases the need for vasoactive drugs, diminishes the need for extra fluids and lowers the risk of acute kidney injury.MethodsWe performed an evaluation on the database from our previous trial of 140 patients randomized to either no sedation vs. sedation with a daily interruption of sedatives. A total of 113 patients were included in the previous statistical analysis. Ten patients had pre-existing renal impairments and were excluded. Data were collected from observational cards and blood samples.ResultsA total of 103 patients were included in this retrospective review. We registered an increased urine output in the group receiving no sedation compared to the sedated control group (1.15 ml/kg/hour (0.59 to 1.53) vs. 0.88 ml/kg/hour (0.052 to 1.26), P = 0.03). In addition we saw a decrease in the number of patients with renal impairment according to the RIFLE classification (indicating Risk of renal dysfunction; Injury to the kidney; Failure of kidney function, Loss of kidney function and End-stage kidney disease) in the group receiving no sedation compared to the sedated control group (25 (51%) vs. 41 (76%), P = 0.012). The difference in the two groups with respect to mean arterial blood pressure, fluid balance and use of vasoactive drugs was not significant.ConclusionsA no sedation strategy to patients undergoing mechanical ventilation increases the urine output and decreases the number of patients with renal impairments.Trial registrationClinicalTrials.gov registration number NCT00466492.

Long-term psychological effects of a no-sedation protocol in critically ill patients

IntroductionA protocol of no sedation has been shown to reduce the time patients receive mechanical ventilation and to reduce intensive care and total hospital length of stay. The long-term psychological effects of this strategy have not yet been described. The purpose of the study was to test whether a strategy of no sedation alters long-term psychological outcome compared with a standard strategy with sedation.MethodsDuring intensive care stay, 140 patients requiring mechanical ventilation were randomized to either no sedation or sedation with daily interruption of sedation. This study was done as a single-blinded cohort study. After discharge, patients were interviewed by a neuropsychologist assessing quality of life, depression, anxiety, and posttraumatic stress disorder.ResultsTwo years after randomization, 38 patients were eligible for interview, and 26 patients were interviewed (13 from each group). No difference was found with respect to quality of life (Medical Outcome Study, 36-item short-form health survey). Both mental and physical components were nonsignificant. The Beck depression index was low in both groups (one patient in intervention group versus three patients in the control group were depressed, p = 0.32). Evaluated with the Impact of Events Scale, both groups had low stress scores (one in the intervention group versus two in the control group had scores greater than 32; p = 0.50). State anxiety scores were also low (28 in the control group versus 30 in the intervention group, p = 0.58).ConclusionsOur data suggest that a protocol of no sedation applied to critically ill patients undergoing mechanical ventilation does not increase the risk of long-term psychological sequelae after intensive care compared with standard treatment with sedation.

Feasibility of physical and occupational therapy beginning from initiation of mechanical ventilation*

Physical and occupational therapy are possible immediately after intubation in mechanically ventilated medical intensive care unit patients. The objective of this study was to describe a protocol of daily sedative interruption and early physical and occupational therapy and to specify details of intensive care unit-based therapy, including neurocognitive state, potential barriers, and adverse events related to this intervention. Detailed descriptive study of the intervention arm of a trial of mechanically ventilated patients receiving early physical and occupational therapy. Two tertiary care academic medical centers participating in a randomized controlled trial. Patients underwent daily sedative interruption followed by physical and occupational therapy every hospital day until achieving independent functional status. Therapy began with active range of motion and progressed to activities of daily living, sitting, standing, and walking as tolerated. Forty-nine mechanically ventilated patients received early physical and occupational therapy occurring a median of 1.5 days (range, 1.0-2.1 days) after intubation. Therapy was provided on 90% of MICU days during mechanical ventilation. While endotracheally intubated, subjects sat at the edge of the bed in 69% of all physical and occupational therapy sessions, transferred from bed to chair in 33%, stood in 33%, and ambulated during 15% (n = 26 of 168) of all physical and occupational therapy sessions (median distance of 15 feet; range, 15-20 feet). At least one potential barrier to mobilization during mechanical ventilation (acute lung injury, vasoactive medication administration, delirium, renal replacement therapy, or body mass index ≥ 30 kg/m) was present in 89% of patient encounters. Therapy was interrupted prematurely in 4% of all sessions, most commonly for patient-ventilator asynchrony and agitation. Early physical and occupational therapy is feasible from the onset of mechanical ventilation despite high illness acuity and presence of life support devices. Adverse events are uncommon, even in this high-risk group.

Recall of intensive care unit stay in patients managed with a sedation protocol or a sedation protocol with daily sedative interruption: A pilot study

Purpose Analgesics and sedatives are integral for the relief of pain and anxiety in critically ill patients. However, these agents may contribute to amnesia for intensive care unit (ICU) events; which has been associated with development of posttraumatic stress disorder. Drug administration strategies that minimize sedative use have been associated with less amnesia. The objective of this pilot study was to evaluate recall of ICU stay in patients managed with 2 sedation strategies: a sedation protocol or a combination of sedation protocol and daily sedative/analgesic interruption. Methods A questionnaire was administered on day 3 following ICU discharge to evaluate patients' recollections of pain, anxiety, fear, and sleep, as well as memories for specific ICU procedures. Participants were ICU survivors who had been enrolled in SLEAP - a randomized pilot trial comparing two sedation strategies, at 3 university-affiliated medical/surgical ICUs. Results Twenty-one patients who regained orientation within 72 hours of ICU discharge completed the questionnaire. More than 50% of patients recalled experiencing pain, anxiety, and fear to a moderate or extreme extent; and 57% reported inadequate sleep while in the ICU. Of the 21 patients, 48%, 33%, and 29% had no memories of endotracheal tube suctioning, being on a “breathing machine,” and being bathed, respectively. Conclusion A notable percentage of patients discharged from the ICU report moderate to extreme pain, anxiety, and fear, and inability to sleep during their ICU stay; and 29% to 48% have no recall of specific ICU events.

Sedation practice in three Norwegian ICU s: A survey of intensive care nurses’ perceptions of personal and unit practice

To describe intensive care nurses' perceptions of unit and personal sedation practice in the context of nursing and medical treatment of adult intensive care patients sedated and ventilated for more than 24 hours. Self-administered questionnaire. Three general ICUs in three university hospitals in Norway. Eighty-six questionnaires were returned (response rate 47%). Continuous infusions of fentanyl and midazolam were perceived as most common and nurses often gave both analgesics and sedatives prior to care. Daily interruption of sedation or analgesia-based sedation was not perceived as practice in the units. MAAS was most commonly used, whilst protocols or objective scoring systems were not. Documentation of sedation levels was fairly routine, whereas documentation of patient needs was not perceived as important. Collaboration with physicians was viewed as most important, whilst no significance was assigned to collaboration with relatives. The study shows that a focus on analgesia-based sedation and continual control of the sedation level should be considered in order to decrease the risk of oversedation. Inclusion of relatives' opinions, increased collaboration between nurses and physicians, and implementation of sedation tools, may contribute to even better patient outcome and should be focus in further studies.

Daily interruption of sedation in patients treated with mechanical ventilation

The evidence evaluating daily interruption of sedation (DIS) in mechanically ventilated patients, the benefits of this intervention, and the barriers to its incorporation into clinical practice are reviewed. Recent epidemiologic studies have identified a high prevalence of oversedation in the intensive care unit (ICU). The practice of DIS, which involves withholding all sedative and analgesic medications until patients are awake on a daily basis, can limit excessive sedation. DIS has been shown to reduce the duration of mechanical ventilation and length of ICU stay, lessen the number of neurodiagnostic tests to assess for changes in mental status, decrease the frequency of complications associated with critical illness, and reduce the total dose of benzodiazepines and opiates administered. Although recent studies support the use of DIS, it remains underutilized in clinical practice and additional trials may be needed before this intervention will gain widespread acceptance. Barriers to the use of DIS include a lack of nursing acceptance and concerns regarding patient removal of invasive devices, patient discomfort, respiratory compromise, and withdrawal syndromes. Some clinicians are also concerned about the possibility of long-term psychological sequelae and the risk of myocardial ischemia during DIS in patients with coronary risk factors. DIS limits oversedation in the ICU without compromising patient comfort or safety and should be incorporated into the routine care of mechanically ventilated patients. Clinicians should be aware of the numerous barriers that prevent the use of DIS and address these at their institution to increase its use.

Predictors for daily interruption of sedation therapy by nurses: A prospective, multicenter study

Purpose The aim of the study was to identify the nurse and patient-related factors predicting daily interruption of sedation (DIS) performance by nurses in the intensive care unit (ICU). Methods Nurses, caring for a mechanically ventilated patient receiving 24 hours or more of a continuously infused sedative, were interviewed at the bedside to determine their willingness to perform DIS on this patient and to determine the influence of 20 nurse- and 47 patient-related factors on DIS completion. Results The 57 (44%) of 130 of nurses willing to perform DIS had performed DIS at least once in the past ( P < .0001) and were not targeting deep sedation (ie, Sedation Agitation Scale [SAS] ≤ 2 [ P = .03]). The DIS performance was less likely with use of higher-dose continuous midazolam ( P = .006), a fraction of inspired oxygen (F io 2) greater than 50% ( P = .03), or positive end-expiratory pressure greater than 5 mm Hg ( P = .006) and in patients either deeply sedated (SAS ≤ 2) ( P = .05) or agitated (SAS ≥ 5) in the past 24 hours ( P = .003). Prior DIS experience (odds ratio [OR], 2.54; P = .004), hours of sedation-related continuing education (OR, 1.13; P = .02), and a target of deep sedation (OR, 0.49; P = .02) were independent nurse-related factors for DIS performance. Nurse's willingness to conduct DIS ranged from 45% to 80% based on the interaction between patient sex, current F io 2, and agitation in past 24 hours. Conclusions Educational strategies and institutional protocols focused on improving use of DIS need to consider the various nurse- and patient-related factors that affect DIS performance by nurses in the ICU.

Transtorno de estresse pós-traumático em pacientes de unidade de terapia intensiva

Post-traumatic stress disorder has been detected in patients after treatment in intensive care unit. The main goal of this study is to review the psychological aspects and therapeutic interventions on those patients after their treatment on intensive care unit. Thirty eight articles have been included. The prevalence of post-traumatic stress disorder has varied from 17% up to 30% and the incidence from 14% to 24%. The risk factors were: previous anxiety historic, depression or panic, having delusional traumatic memories (derived from psychic formations as dreams and delirium), belief effects, depressive behavior, stressing experiences and mechanical ventilation. High doses of opiates, symptoms caused by sedation or analgesia reduction and the use of lorazepam were related with the increase of delirium and delusional memory. The disorder sintomatology can be reduced with hydrocortisone administration, with daily sedation interruption. No other effectiveness psychological intervention study was found.

Evaluation of the Impact of a tele-ICU Pharmacist on the Management of Sedation in Critically III Mechanically Ventilated Patients

An organized and uniform approach to managing sedation in critically ill patients has been associated with improved outcomes, but the most effective means of optimizing sedative medication use in clinical practice has not been fully determined. Pharmacist interventions directed at improving sedation guideline compliance have been shown to reduce the duration of mechanical ventilation. To determine the impact that pharmacy staffing configurations that include a tele-ICU pharmacist have on compliance with an intensive care unit (ICU) sedation guideline in critically ill mechanically ventilated patients requiring continuous-infusion sedative medications. Compliance with an established ICU sedation guideline, the performance of daily sedative interruptions, and the number of sedative medication-related interventions were evaluated before and after expansion of the ICU pharmacist staffing model to include comprehensive off-hours pharmacist coverage supported with established tele-ICU resources. In both groups, sedation was managed by the primary ICU team. In the intervention group, a pharmacist working in the tele-ICU center performed electronic record audits and made sedative medication recommendations to the primary team. The addition of third shift tele-ICU pharmacist support was associated with a significant increase in the percentage of patients who received a daily sedative interruption (45% vs 54%; p < 0.0001). This occurred in the context of significant increases in the total number of ICU pharmacist interventions (36 vs 49.4 per 100 patient days, p < 0.0001), the number of therapeutic interventions (20.4 vs 26.1 per 100 patient days, p < 0.001), and the number of sedative-related interventions (0.9 vs 4.4 per 100 patient days, p < 0.0001). Tele-ICU resources can be utilized to increase compliance with an established ICU sedation guideline and extend the benefits that daytime ICU clinical pharmacy services provide. Increased ICU pharmacist availability may have additional benefits not measured in this study.

A protocol of no sedation for critically ill patients receiving mechanical ventilation: a randomised trial

Standard treatment of critically ill patients undergoing mechanical ventilation is continuous sedation. Daily interruption of sedation has a beneficial effect, and in the general intesive care unit of Odense University Hospital, Denmark, standard practice is a protocol of no sedation. We aimed to establish whether duration of mechanical ventilation could be reduced with a protocol of no sedation versus daily interruption of sedation. Of 428 patients assessed for eligibility, we enrolled 140 critically ill adult patients who were undergoing mechanical ventilation and were expected to need ventilation for more than 24 h. Patients were randomly assigned in a 1:1 ratio (unblinded) to receive: no sedation (n=70 patients); or sedation (20 mg/mL propofol for 48 h, 1 mg/mL midazolam thereafter) with daily interruption until awake (n=70, control group). Both groups were treated with bolus doses of morphine (2.5 or 5 mg). The primary outcome was the number of days without mechanical ventilation in a 28-day period, and we also recorded the length of stay in the intensive care unit (from admission to 28 days) and in hospital (from admission to 90 days). Analysis was by intention to treat. This study is registered with ClinicalTrials.gov, number NCT00466492. 27 patients died or were successfully extubated within 48 h, and, as per our study design, were excluded from the study and statistical analysis. Patients receiving no sedation had significantly more days without ventilation (n=55; mean 13.8 days, SD 11.0) than did those receiving interrupted sedation (n=58; mean 9.6 days, SD 10.0; mean difference 4.2 days, 95% CI 0.3-8.1; p=0.0191). No sedation was also associated with a shorter stay in the intensive care unit (HR 1.86, 95% CI 1.05-3.23; p=0.0316), and, for the first 30 days studied, in hospital (3.57, 1.52-9.09; p=0.0039), than was interrupted sedation. No difference was recorded in the occurrences of accidental extubations, the need for CT or MRI brain scans, or ventilator-associated pneumonia. Agitated delirium was more frequent in the intervention group than in the control group (n=11, 20%vs n=4, 7%; p=0.0400). No sedation of critically ill patients receiving mechanical ventilation is associated with an increase in days without ventilation. A multicentre study is needed to establish whether this effect can be reproduced in other facilities. Danish Society of Anesthesiology and Intensive Care Medicine, the Fund of Danielsen, the Fund of Kirsten Jensa la Cour, and the Fund of Holger og Ruth Hess.

Safety and efficacy of a nurse-driven sedation protocol with daily sedation interruption in the ICU

Sedation algorithms have been shown to reduce the duration of mechanical ventilation in the ICU. We evaluated the effect of the implementation of a nurse-driven sedation protocol with daily sedation interruption in our ICU.

Pushing the envelope to reduce sedation in critically ill patients

Expanded AbstractCitationStrom T, Martinussen T, Toft P: A protocol of no sedation for critically ill patients receiving mechanical ventilation: a randomized trial. Lancet 2010, 375:475-480 [1].BackgroundStandard treatment of critically ill patients undergoing mechanical ventilation is continuous sedation. Daily interruption of sedation has a beneficial effect, and in the general intensive care unit of Odense University Hospital, Denmark, standard practice is a protocol of no sedation. We aimed to establish whether duration of mechanical ventilation could be reduced with a protocol of no sedation versus daily interruption of sedation.MethodsOf 428 patients assessed for eligibility, we enrolled 140 critically ill adult patients who were undergoing mechanical ventilation and were expected to need ventilation for more than 24 h. Patients were randomly assigned in a 1:1 ratio (unblinded) to receive: no sedation (n = 70 patients); or sedation (20 mg/mL propofol for 48 h, 1 mg/mL midazolam thereafter) with daily interruption until awake (n = 70, control group). Both groups were treated with bolus doses of morphine (2.5 or 5 mg). The primary outcome was the number of days without mechanical ventilation in a 28-day period, and we also recorded the length of stay in the intensive care unit (from admission to 28 days) and in hospital (from admission to 90 days). Analysis was by intention to treat. This study is registered with ClinicalTrials.gov, number NCT00466492.Findings27 patients died or were successfully extubated within 48 h, and, as per our study design, were excluded from the study and statistical analysis. Patients receiving no sedation had significantly more days without ventilation (n = 55; mean 13.8 days, SD 11.0) than did those receiving interrupted sedation (n = 58; mean 9.6 days, SD 10.0; mean difference 4.2 days, 95% CI 0.3-8.1; p = 0.0191). No sedation was also associated with a shorter stay in the intensive care unit (HR 1.86, 95% CI 1.05-3.23; p = 0.0316), and, for the first 30 days studied, in hospital (3.57, 1.52-9.09; p = 0.0039), than was interrupted sedation. No difference was recorded in the occurrences of accidental extubations, the need for CT or MRI brain scans, or ventilator-associated pneumonia. Agitated delirium was more frequent in the intervention group than in the control group (n = 11, 20% vs. n = 4, 7%; p = 0.0400).InterpretationNo sedation of critically ill patients receiving mechanical ventilation is associated with an increase in days without ventilation. A multicentre study is needed to establish whether this effect can be reproduced in other facilities.

Effect of an analgo-sedation protocol for neurointensive patients: a two-phase interventional non-randomized pilot study

IntroductionSedation protocols are needed for neurointensive patients. The aim of this pilot study was to describe sedation practice at a neurointensive care unit and to assess the feasibility and efficacy of a new sedation protocol. The primary outcomes were a shift from sedation-based to analgesia-based sedation and improved pain management. The secondary outcomes were a reduction in unplanned extubations and duration of sedation.MethodsThis was a two-phase (before-after), prospective controlled study at a university-affiliated, 14-bed neurointensive care unit in Denmark. The sample included patients requiring mechanical ventilation for at least 48 hours treated with continuous sedative and analgesic infusions or both. During the observation phase the participants (n = 106) were sedated as usual (non-protocolized), and during the intervention phase the participants (n = 109) were managed according to a new sedation protocol.ResultsOur study showed a shift toward analgo-sedation, suggesting feasibility of the protocol. We found a significant reduction in the use of propofol (P < .001) and midazolam (P = .001) and an increase in fentanyl (P < .001) and remifentanil (P = .003). Patients selected for daily sedation interruption woke up faster, and estimates of pain free patients increased from 56.8% to 82.7% (P < .001), suggesting efficacy of the protocol. The duration of sedation and unplanned extubations were unchanged.ConclusionsOur pilot study showed feasibility and partial efficacy of our protocol. Some neurointensive patients might not benefit from protocolized practice. We recommend an interdisciplinary effort to target patients requiring less sedation, as issues of oversedation and inadequate pain management still need more attention.Trial registrationISRCTN80999859.

Is Daily Awakening Always Safe in Severely Brain Injured Patients?

Sedation is a central component of critical care to prevent sleep deprivation, pain, anxiety, agitation, and delirium. Daily interruption of sedation (DIS) decreases the duration of mechanical ventilation, shortens hospital stay and may, in combination with spontaneous breathing trials, improve outcome in medical intensive care patients [1, 2]. Moreover, the amount of sedatives and opioids administered, which is directly associated with morbidity (nosocomial infections and thromboembolic events), can be reduced by DIS [1, 2]. Therefore, sedative drugs should be titrated to a lower level when sedation is restarted, which is, in our mind, the major factor contributing to decrease ventilation and ICU days. An estimated 30–40% of intensive care units worldwide have implemented daily interruption of sedation as a routine protocol [3–5]. Even if daily interruption of sedation could be a cornerstone for medical intensive care patients, it has not extensively been studied so far in acutely brain injured patients. So, can these results be translated to patients with subarachnoidal hemorrhage (SAH), intracerebral hemorrhage (ICH), or traumatic brain injury (TBI)? In fact, in a recent randomized control trial, the subgroup of acutely head injured patients did not show decreased ventilation or ICU days when sedation was interrupted on a daily basis (n = 21) compared to controls (n = 17) [6]. The major reason for neurointensivists to prescribe sedative drugs is to decrease oxygen consumption and prevent metabolic distress in the severely injured brain. Unfortunately, continuous sedation can mask important changes that can only be elucidated by clinical exam, which remains so far the gold standard. Therefore, several NICUs in the USA have already implemented the strategy of daily or even twice daily awakening for reliable assessment. Immediate detection of early (brain edema, rebleeding) and late (e.g., delayed cerebral ischemia secondary to cerebral vasospasm) complications in the course of SAH, ICH, and TBI may improve outcome. Modern advances in neurocritical care has led to the implementation of multimodal neuromonitoring, which includes monitoring of ICP (intraparenchymal or with EVD), cerebral metabolism (microdialysis), brain tissue oxygen (PbtO2), and cerebral blood flow (CBF). This may help to early detect complications, however, so far, we are still on the way to introduce these data in the daily care of our patients. So, relying on clinical evaluation by stopping sedatives, do we know whether this is safe for NICU patients or may the risk of metabolic derangement overweigh the benefit of an appropriate exam? The study by Skoglund and coworkers in this issue of the Journal is the first effort to prove safety of daily interruption of sedation in NICU patients. A total of 127 awakening trials with interruption of continuous propofol infusion were studied in 12 TBI and 9 SAH patients. In the majority of patients (13/21) the authors observed an increase in ICP (to mean 22 ± 7 mmHg) and CPP (to mean 79 ± 21 mmHg). In 23 awakening trials (8 patients) a decrease in CPP was observed as ICP increased (C25 mmHg). No other adverse events were reported, and R. Helbok (&) N. Badjatia Division of Critical Care Neurology, Department of Neurology, Milstein Hospital 8 Center, Columbia University, 177 Fort Washington Ave, New York, NY 10032, USA e-mail: raimund.helbok@uki.at

Head CT is of limited diagnostic value in critically ill patients who remain unresponsive after discontinuation of sedation

BackgroundProlonged sedation is common in mechanically ventilated patients and is associated with increased morbidity and mortality. We sought to determine the diagnostic value of head computed tomography (CT) in mechanically ventilated patients who remain unresponsive after discontinuation of sedation.MethodsA retrospective review of adult (age >18 years of age) patients consecutively admitted to the medical intensive care unit of a tertiary care medical center. Patients requiring mechanical ventilation for management of respiratory failure for longer than 72 hours were included in the study group. A group that did not have difficulty with awakening was included as a control.ResultsThe median time after sedation was discontinued until a head CT was performed was 2 days (interquartile range 1.375–2 days). Majority (80%) of patients underwent head CT evaluation within the first 48 hours after discontinuation of sedation. Head CT was non-diagnostic in all but one patient who had a small subarachnoid hemorrhage. Twenty-five patients (60%) had a normal head CT. Head CT findings did not alter the management of any of the patients. The control group was similar to the experimental group with respect to demographics, etiology of respiratory failure and type of sedation used. However, while 37% of subjects in the control group had daily interruption of sedation, only 19% in the patient group had daily interruption of sedation (p < 0.05).ConclusionIn patients on mechanical ventilation for at least 72 hours and who remain unresponsive after sedative discontinuation and with a non-focal neurologic examination, head CT is performed early and is of very limited diagnostic utility. Routine use of daily interruption of sedation is used in a minority of patients outside of a clinical trial setting though it may decrease the frequency of unresponsiveness from prolonged sedation and the need for head CT in patients mechanically ventilated for a prolonged period.

Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomised controlled trial

Long-term complications of critical illness include intensive care unit (ICU)-acquired weakness and neuropsychiatric disease. Immobilisation secondary to sedation might potentiate these problems. We assessed the efficacy of combining daily interruption of sedation with physical and occupational therapy on functional outcomes in patients receiving mechanical ventilation in intensive care. Sedated adults (>/=18 years of age) in the ICU who had been on mechanical ventilation for less than 72 h, were expected to continue for at least 24 h, and who met criteria for baseline functional independence were eligible for enrolment in this randomised controlled trial at two university hospitals. We randomly assigned 104 patients by computer-generated, permuted block randomisation to early exercise and mobilisation (physical and occupational therapy) during periods of daily interruption of sedation (intervention; n=49) or to daily interruption of sedation with therapy as ordered by the primary care team (control; n=55). The primary endpoint-the number of patients returning to independent functional status at hospital discharge-was defined as the ability to perform six activities of daily living and the ability to walk independently. Therapists who undertook patient assessments were blinded to treatment assignment. Secondary endpoints included duration of delirium and ventilator-free days during the first 28 days of hospital stay. Analysis was by intention to treat. This trial is registered with ClinicalTrials.gov, number NCT00322010. All 104 patients were included in the analysis. Return to independent functional status at hospital discharge occurred in 29 (59%) patients in the intervention group compared with 19 (35%) patients in the control group (p=0.02; odds ratio 2.7 [95% CI 1.2-6.1]). Patients in the intervention group had shorter duration of delirium (median 2.0 days, IQR 0.0-6.0 vs 4.0 days, 2.0-8.0; p=0.02), and more ventilator-free days (23.5 days, 7.4-25.6 vs 21.1 days, 0.0-23.8; p=0.05) during the 28-day follow-up period than did controls. There was one serious adverse event in 498 therapy sessions (desaturation less than 80%). Discontinuation of therapy as a result of patient instability occurred in 19 (4%) of all sessions, most commonly for perceived patient-ventilator asynchrony. A strategy for whole-body rehabilitation-consisting of interruption of sedation and physical and occupational therapy in the earliest days of critical illness-was safe and well tolerated, and resulted in better functional outcomes at hospital discharge, a shorter duration of delirium, and more ventilator-free days compared with standard care. None.

A critical review of daily sedation interruption in the intensive care unit

Daily sedation interruption (DSI) has been proposed as a method of improving sedation management of critically ill patients by reducing the adverse effects of continuous sedation infusions. To critique the research regarding daily sedation interruption, to inform education, research and practice in this area of intensive care practice. Literature review. Medline, CINAHL and Web of Science were searched for relevant key terms. Eight research-based studies, published in the English language between 1995-December 2006 and three conference abstracts were retrieved. Of the eight articles and three conference abstracts reviewed, five originated from one intensive care unit (ICU) in the USA. The research indicates that DSI reduces ventilation time, length of stay in ICU, complications of critical illness, incidence of post-traumatic stress disorder and is reportedly used by 15-62% of ICU clinicians in Australia, Europe, USA and Canada. DSI improves patients' physiological and psychological outcomes when compared with routine sedation management. However, research relating to these findings has methodological limitations, such as the use of homogenous samples, single-centre trials and retrospective design, thus limiting their generalisability. DSI may provide clinicians with a simple, cost-effective method of reducing some adverse effects of sedation on ICU patients. However, the evidence supporting DSI is limited and cannot be generalised to heterogeneous ICU populations internationally. More robust research is required to assess the potential impact of DSI on the physical and mental health of ICU survivors.

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.