To Sedate or Not to Sedate? A New Question in Critical Care Medicine

Summary and Comment |
March 1, 2010

To Sedate or Not to Sedate? A New Question in Critical Care Medicine

  1. Matthew Hoffman, MD

A sedation protocol that included morphine only as needed was associated with fewer ventilator and intensive care unit days and no excess complications in critically ill patients.

  1. Matthew Hoffman, MD

Daily interruptions of continuous sedation in mechanically ventilated patients shorten duration of mechanical ventilation, lower number of days in the ICU, and prevent complications of critical illness. Can outcomes be improved further by minimizing sedation in the ICU? Researchers enrolled 140 critically ill patients who were expected to require mechanical ventilation for >24 hours; patients were randomized either to traditional sedation with daily awakenings (control arm) or to a protocol of “no sedation” (intervention arm). The control group received continuous infusions of propofol followed by midazolam, along with as-needed morphine boluses (≤5 mg), and were awakened daily. Intervention patients received as-needed morphine boluses only.

Patients in the intervention arm averaged significantly fewer days of mechanical ventilation (14 vs. 10), fewer ICU days (13 vs. 22), and shorter mean total hospital stays (34 vs. 58 days) compared with patients in the control arm. Researchers found no difference in rates of complications (accidental extubation, additional neuroimaging, ventilator-associated pneumonias, need for reintubation, and mortality) between the groups. Intervention patients were significantly more likely to suffer agitated delirium than were control patients (20% vs. 7%), and a significantly larger percentage required haloperidol (35% vs. 14%; although total doses were low). Intervention patients also required more attention from nurses and other caregivers, and about 15% received one-on-one comfort from dedicated caregivers.

Comment

Several weaknesses of this study should be noted. (1) About 18% of intervention patients were persistently uncomfortable and required episodes of continuous sedation (although such patients were evaluated with the intervention group in the intent-to-treat analysis). (2) The study was small and unblinded. (3) Patients were all from a single Danish center with relatively high resources (i.e., a 1:1 nurse-to-patient ratio, available assigned dedicated caregivers for comforting patients) and with many years of experience in managing lightly sedated patients.

Continuous sedation with daily interruption is standard therapy for most mechanically ventilated patients. This small study challenges that paradigm, suggesting that as-needed morphine could shorten ventilator and ICU time significantly without excess medical complications. A larger study that includes less resource-rich ICUs is required to confirm the safety and efficacy of this promising approach and should include follow-up to ensure that these nonsedated patients do not incur psychological sequelae such as post-traumatic stress disorder.

Dr. Hoffman is a Fellow in Pulmonary and Critical Care Medicine at Emory University School of Medicine in Atlanta, Georgia.

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