Interruption of Sedation in Patients Treated With Mechanical Ventilation
Interruption of Sedation in Patients Treated With Mechanical Ventilation
Purpose. 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.
Summary. 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.
Conclusion. 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.
Pain and anxiety are frequently observed in patients requiring mechanical ventilation, and the administration of analgesics and sedatives is often medically necessary. Inadequate sedation may lead to patients removing invasive devices or to ventilator dysynchrony, increased oxygen consumption, or unpleasant memories. While it is important to make patients comfortable and provide relief from distress, oversedation should be avoided, as it is associated with an increased duration of mechanical ventilation and intensive care unit (ICU) length of stay. The Society of Critical Care Medicine's pain and sedation guidelines published in 2002 recommend that a sedation goal should be set for every patient, and this is usually a calm patient who can be easily aroused.
Recent epidemiologic studies, however, have identified a high prevalence of oversedation in the ICU. One recent observational study revealed that only 43% of patients on day 2 of their ICU stay and 31% of patients on ICU day 6 had their level of sedation measured with a standardized assessment tool. Of these patients, a deep state of sedation (i.e., a Sedation–Agitation Scale score of 1 or 2) was observed in 57% of patients on ICU day 2 and 41% of patients on ICU day 6. Furthermore, a cohort study found that patients were unarousable or minimally arousable in 32% of sedation assessments, but only 2.6% of the nursing assessments considered patients to be oversedated.
Various strategies can help limit excessive sedation and have been shown to reduce the duration of mechanical ventilation in critically ill patients. Examples include the use of protocol-directed sedation, direct i.v. "push" (or bolus doses) of benzodiazepines instead of a continuous infusion, sedatives with a short duration of action (e.g., propofol, dexmedetomidine), and daily interruption of sedation (DIS), also referred to as spontaneous awakening trials, where all sedative and analgesic medications are stopped until patients are awake on a daily basis. This review describes the literature evaluating DIS and identifies the benefits of this intervention and barriers to its incorporation into clinical practice.
Abstract and Introduction
Abstract
Purpose. 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.
Summary. 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.
Conclusion. 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.
Introduction
Pain and anxiety are frequently observed in patients requiring mechanical ventilation, and the administration of analgesics and sedatives is often medically necessary. Inadequate sedation may lead to patients removing invasive devices or to ventilator dysynchrony, increased oxygen consumption, or unpleasant memories. While it is important to make patients comfortable and provide relief from distress, oversedation should be avoided, as it is associated with an increased duration of mechanical ventilation and intensive care unit (ICU) length of stay. The Society of Critical Care Medicine's pain and sedation guidelines published in 2002 recommend that a sedation goal should be set for every patient, and this is usually a calm patient who can be easily aroused.
Recent epidemiologic studies, however, have identified a high prevalence of oversedation in the ICU. One recent observational study revealed that only 43% of patients on day 2 of their ICU stay and 31% of patients on ICU day 6 had their level of sedation measured with a standardized assessment tool. Of these patients, a deep state of sedation (i.e., a Sedation–Agitation Scale score of 1 or 2) was observed in 57% of patients on ICU day 2 and 41% of patients on ICU day 6. Furthermore, a cohort study found that patients were unarousable or minimally arousable in 32% of sedation assessments, but only 2.6% of the nursing assessments considered patients to be oversedated.
Various strategies can help limit excessive sedation and have been shown to reduce the duration of mechanical ventilation in critically ill patients. Examples include the use of protocol-directed sedation, direct i.v. "push" (or bolus doses) of benzodiazepines instead of a continuous infusion, sedatives with a short duration of action (e.g., propofol, dexmedetomidine), and daily interruption of sedation (DIS), also referred to as spontaneous awakening trials, where all sedative and analgesic medications are stopped until patients are awake on a daily basis. This review describes the literature evaluating DIS and identifies the benefits of this intervention and barriers to its incorporation into clinical practice.
