Daily ‘Sedation Holiday’ Reduces Ventilation Time and ICU Stay
Daily Sedation Holiday’ Reduces Ventilation Time and ICU Stay
Abstract & Commentary
Synopsis: Daily interruption of continuous intravenous sedation in mechanically ventilated ICU patients decreases the duration of mechanical ventilation and the length of stay in the ICU.
Source: Kress JP, et al. N Engl J Med 2000;342:1471-1477.
Mechanically ventilated patients requiring continuous intravenous sedation were randomized 48 hours after enrollment to one of two management strategies: 1) daily interruption of the sedative (and morphine) until the patient became awake and could answer questions or was agitated and required renewed sedation, or 2) continuous sedation per standard management practices. Patients were further randomized in each group to sedation with either midazolam or propofol, and all patients received morphine for analgesia. In both patient groups, sedative administration was titrated in order to achieve a score of 3 to 4 on the 6-point Ramsay sedation scale. On this scale, a score of 1 indicates that the patient is agitated, anxious, or restless, while a score of 6 means that the patient is asleep without response to glabellar tap or loud sound. Patients requiring a paralytic agent were given cisatracurium and sedation was not discontinued when this agent was being administered.
A total of 75 patients were entered into each group, and their baseline characteristics were similar. The daily interruption of sedation was associated with significant reductions in the median duration of mechanical ventilation (4.9 vs 7.3 days in the intervention and control groups, respectively) and length of stay in the ICU (6.4 vs 9.9 days), and there was also a trend toward a reduced duration of hospitalization (P = 0.19). Furthermore, fewer diagnostic imaging tests were performed to assess mental status changes in the intervention group. Among the patients receiving midazolam there was a significant reduction in the amount of sedative received in the daily interruption group. Interestingly, this reduction in drug use was not observed in the groups receiving propofol. Self-extubation rates were unaffected by the intervention and there were no differences within groups between those receiving propofol or midazolam.
COMMENT BY MARK T. GLADWIN, MD
Continuous intravenous infusions of sedative/hypnotic agents, coupled with continuous infusions of analgesics, are increasingly used in managing mechanically ventilated patients in order to alleviate patient pain and anxiety, reduce oxygen consumption, facilitate nursing care, and reduce the swings in blood pressure and agitation experienced with intermittent dosing regimens. Possible drawbacks of this practice are failure to appreciate excessive sedation and, more important, failure to recognize the moment when the patient has improved sufficiently to warrant weaning. Numerous trials now prove that daily trials of spontaneous breathing (either via T-piece or continuous positive airway pressure [CPAP]) result in more rapid identification of "weanable" patients and more rapid extubation (Ely EW, et al. N Engl J Med 1996;335:1864-1869). Such data reinforce the notion that the busy clinician often fails to appreciate the exact timing of recovery in patients who require mechanical ventilation for acute respiratory failure.
The elegance of the present study lies in its simplicity and solid results. A simple protocol will reduce ICU length of stay, ventilator time, and trips to the CT scanner (one of the banes of the ICU nurse’s existence). Based on these data, Kress and colleagues believe that the use of nursing- and respiratory therapy-directed protocols for the daily withdrawal of sedation and a daily trial of T-piece or CPAP breathing trials, at least for patients off sedation and vasopressors who require a low inspired oxygen concentration and positive end-expiratory pressure, should be routine in ICUs.
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