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| |  Not Sedating Critically Ill Patients Reduces Days on Mechanical Ventilation, Less Time in ICU NEW YORK -- January 28, 2010 -- Not sedating critically ill patients in intensive care means they need fewer days on mechanical ventilation and spend less time in intensive care, according to a study published early online and appearing in an upcoming edition of The Lancet. Standard treatment of critically ill patients undergoing mechanical ventilation is continuous sedation, with daily interruption of sedation having a beneficial effect. In Odense University Hospital, Odense, Denmark, standard practice is a protocol of no sedation. In the study, t Thomas Strøm, MD, Department of Anaesthesia and Intensive Care Medicine, Odense University Hospital, University of Southern Denmark, and colleagues aimed to establish whether duration of mechanical ventilation could be reduced with a protocol of no sedation versus daily interruption of sedation. The study enrolled 140 critically ill adult patients who were undergoing mechanical ventilation and were expected to need ventilation for more than 24 hours. Patients were randomly assigned in a 1:1 ratio to receive no sedation (n = 70) or sedation with propofol 20 mg/mL for 48 hours followed by midazolam 1 mg/mL with daily interruption until awake (n = 70 patients, control group). Both groups could be treated with bolus doses of morphine (2.5 or 5 mg) for pain management. The primary outcome was the number of days without mechanical ventilation in a 28-day period, and the researchers also recorded the length of stay in the intensive care unit (ICU) from admission to 28 days. The researchers found that 27 patients died or were successfully extubated within 48 hours, and as such were excluded from the study and statistical analysis. Patients receiving no sedation had significantly more days without ventilation (55 patients; mean 13.8 days) than did those receiving interrupted sedation (58 patients; mean 9.6 days-mean difference between groups 4.2 days). No sedation was also associated with a shorter stay in the ICU (13.1 days vs 22.8 days), than was interrupted sedation. No difference was recorded in the occurrences of accidental extubations, the need for computed tomography or magnetic resonance imaging brain scans, or ventilator-associated pneumonia. Agitated delirium was more frequent in the no sedation group than in the control group (20% vs 7%). “Findings from our study show that in critically ill patients receiving mechanical ventilation, a protocol of no sedation significantly increased the number of days without ventilation in a 28-day period compared with daily interruption of sedation,” the authors wrote. “Use of no sedation was also associated with a significant reduction in the length of stay in the intensive care unit and in hospital... Results from this single-centre study suggest that a strategy of no sedation is promising, but a multicentre trial is needed to show that the benefits of this strategy can be reproduced in other facilities.” In an accompanying comment, Laurent Brochard, MD, Medical Intensive Care Unit, Centre Hospitalier Albert Chenevier-Henri Mondor, France, said the study shows that no sedation has major benefits (reduced days on ventilation and in intensive care) and describes the overall results as impressive and promising. However, in asking what the price is for these major benefits, Dr. Brochard concluded: “Boluses of morphine as needed provide some sedation, and although the total dose in today’s study was low, initial doses can be higher and need careful clinical monitoring. The study also suggested that patients receiving no sedation might need appropriate supplemental drugs because they had an increased probability of developing delirium, and they might need an extra person for reassurance. Long-term follow-up of these patients will be important to assess the occurrence of post-traumatic stress disorder or painful recollections. Therefore the protocol of no sedation seems to be associated with a need for more frequent individual assessment of the patient’s pain, fear, anxiety, agitation or confusion, and adaption to the ventilator. Moreover, early and frequent mobilisation of patients could have contributed to improved outcome, but such a strategy might have increased the workload for personnel.”
SOURCE: The Lancet
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