Interruptions of Sedation

Daily Interruptions of Sedation in Mechanically Ventilated Patients

OVERVIEW

A daily interruption of sedation is a strategy designed to:

• reduce exposure to sedative agents
• allow assessment of neurological status
• assess readiness for extubation, and
• reduce duration of mechanical ventilation

aka ‘sedation holiday’

EVIDENCE

Initial trials showed a marked reduction in duration of mechanical ventilation, and decreased ICU LOS (e.g. Kress et al, NEJM 2000) but subsequent studies have been conflicting. Strom et al, 2012 even found that no sedation was better!

• Kress et al 2000
  — SCRCT, daily interrupted sedation vs usual care, n = 128
  — no sedation target nor protocol was used in the control group, thus this group may have been oversedated (possibly an example of Practice Misalignment)
  -> duration of mechanical ventilation decreased by 2 days
  -> length of ICU stay decreased by 3-5 days
• Girard et al 2008 (Awakening and Breathing Controlled trial aka ABC trial)
  — unblinded RCT with allocation concealment and intention to treat analysis
  — daily sedation interruption paired with a spontaneous breathing trial vs usual care
  -> reduced ventilator days, ICU LOS and 1 year mortality
• Augustes et al 2011
  — meta-analysis of 5 RCTs of sedation holidays vs usual care, n = 699
  -> no difference in ventilator-days, but was safe (no excess self-extubations) and led to fewer tracheostomies
• Mehta 2012 (SLEAP study)
  — MCRCT, 16 ICUs using protocolised sedation, sedation holiday vs usual care
  -> no difference in time to extubation, ICU LOS, hospital LOS
  -> no difference in self extubations or delirium
  —> nurses perceived themselves as working harder and higher total doses of fentanyl and midazolam were needed in the ‘sedation holiday’ arm
• Strom 2012
  — SCRCT, n = 140, interrupted sedation vs no sedation (analgesia only)
  -> no sedation led to shorter ICU LOS and shorter duration of mechanical ventilation

POTENTIAL PROBLEMS

Adverse effects

• Patient discomfort (e.g. burns, trauma) and risk of PTSD and other long term psychological issues
• Possible increase in self extubations and emergency re-intubations (this has not been shown to increase mortality or morbidity)
• Dislodgment of CVC, arterial lines etc.
• Increased nursing workload
• Cessation of sedation could lead to agitation which can be associated with physiological instability, hypertension, tachycardia, ventilator dysynchrony and hypoxaemia
• risk of  exacerbation of primary disease in certain conditions where interruption of sedation is contra-indicated
  — e.g. myocardial ischaemia (MI), brain injury (high ICPs), severe ARDS requiring controlled ventilation

Note that most of data from US where ICUs are more likely to be open

SUMMARY

• Daily interruption of sedation may have a role in physiologically stable patients in ICUs that do not routinely use protocolised sedation.
• There are risks and the use of a protocol needs to be adapted to local circumstances
• Routine daily interruptions may not be required in closed ICUs with protocolised sedation and the level of sedation is assessed by skilled staff.

References and Links

LITFL

• CCC — Sedation in ICU
• CCC — Practice Misalignment

FOAM and web resources

• PulmCCM.org — Sedation vacations don’t improve outcomes in large trial (RCT, JAMA) (2013)

Journal articles and textbooks

• Augustes R, Ho KM. Meta-analysis of randomised controlled trials on daily sedation interruption for critically ill adult patients. Anaesth Intensive Care. 2011 May;39(3):401-9. PubMed PMID: 21675059.
• Girard TD, et al. Efficacy and safety of a paired sedation and ventilator weaning protocol for mechanically ventilated patients in intensive care (Awakening and Breathing Controlled trial): a randomised controlled trial. Lancet. 2008 Jan 12;371(9607):126-34. PubMed PMID: 18191684.
• Kress JP, Pohlman AS, O’Connor MF, Hall JB. Daily interruption of sedative infusions in critically ill patients undergoing mechanical ventilation. N Engl J Med. 2000 May 18;342(20):1471-7. PubMed PMID: 10816184. [Free Full Text]
• Mehta S, et al; SLEAP Investigators; Canadian Critical Care Trials Group. Daily sedation interruption in mechanically ventilated critically ill patients cared for with a sedation protocol: a randomized controlled trial. JAMA. 2012 Nov 21;308(19):1985-92. Erratum in: JAMA. 2013 Jan 16;309(3):237. PubMed PMID: 23180503.
• Strøm T, Martinussen T, Toft P. A protocol of no sedation for critically ill patients receiving mechanical ventilation: a randomised trial. Lancet. 2010 Feb 6;375(9713):475-80. Epub 2010 Jan 29. PubMed PMID: 20116842.