Review, Sep/20: Sedation Vacation in the ICU

"Sedation Vacation in the ICU"

https://pubmed.ncbi.nlm.nih.gov/30020699/

Excerpt

As the name implies, the intensive care unit (ICU) is where a hospital's sickest patients who require accelerated and concentrated care are admitted. Many of these patients, an estimated 33% of all admissions, are admitted for respiratory failure of one etiology or another and subsequently are intubated and placed on mechanical ventilatory control. Part of the standard of care for intubation is to sedate the patient continuously to reduce pain and anxiety; decrease oxygen consumption and the body’s stress response; prevent patient-ventilator desynchrony; reduce adverse neurocognitive impacts such as depression and post-traumatic stress disorder and ventilator-associated events including pneumonia and tracheostomy, and reduce total nursing requirements. The medications used to initiate and maintain sedation within an intensive care unit setting include benzodiazepines such as diazepam, lorazepam, and midazolam; opioid analgesics such as fentanyl, hydromorphone, morphine, remifentanil, propofol, dexmedetomidine, and ketamine; and antipsychotics such as haloperidol, quetiapine, and ziprasidone. No sedative is found to be superior in efficacy or mortality. However, The Society of Critical Care Medicine guidelines state to avoid benzodiazepines due to evidence of longer duration of intubation. The choice of which sedative is best lies in the practitioner's clinical assessment of individual patient scenarios, weighing the risk/benefit profile of the medicine to each patient. Regardless of which sedative agent was utilized, total continuous sedation was found to be associated with an extension of the total length of intubation and increased length of the ICU stay and limited the ability to properly assess the mental status of the patient, increased the risk for delirium, and suppressed brainwave function seen on EEG, linking to increased 6-month mortality. It was assessed that daily, short-term cessation of sedation, a “sedation vacation,” led to improved outcomes in patient care. Sedation vacations were first introduced in 2000 with a study by J.P. Kress et al. that was published in the New England Journal of Medicine and recognized as a medical necessity for standard practice within the ICU to wean patients from mechanical ventilation. The study of spontaneous-awakening trials showed that daily sedation interruptions improved the time to extubation of 64 patients by approximately 2 days which reduced the total admission time to the ICU by 3.5 days. This study was further reinforced by two separate trials, the Awakening and Breathing Controlled Trial in 2008 titled the “wake up and breathe” protocol and the No Sedation in Intensive Care Unit Patients trial in 2010. Both of these supporting trials investigated the impacts of imposing a protocol to evaluate and reduce sedation in a structured format and found that spontaneous-breathing trials along with sedation vacations reduced ventilatory dependent days and ICU admission days when compared to non-structured or no sedation vacation protocols.

Thanks Lapis...

-Though I think it was more “Wake up and Code out”..  -or flip out.. 

In more stable patients I can see the “vacations” making a huge difference (so long as no one mentions “kindling”, as best I remember it took several weeks to wean me off the vent, but the Pneumonia forced the issue..

Such a juggle, but I bet they are getting pretty good at it this year..! 

I do wonder how many people on Vents with Covid are getting Trachies for access to the lungs for suction or whatevs.??

Hi Cantfly,

I don't have any personal experience with this -- and it sounds like you do -- but I can see that sedation in the ICU requires careful thought in order to get the balance right. Clearly, it's not easy. Lots of issues to balance. And yes, unfortunately, there might be increased use of ventilators this year due to COVID-19. 

Oh sorry Lapis, just the “Thanks” was specifically for you.. -Bad layout of my post indeed..

The rest was my early morning pondering/blurt for the thread in general, fwiw..