Clinical question: Does sedation by protocol, in combination with daily sedative interruption, reduce the duration of mechanical ventilation and ICU stay?
Background: Limiting excessive sedation in mechanically ventilated adults is associated with shorter duration of mechanical ventilation and lower risk of delirium. Two strategies to minimize sedation are daily sedation interruptions and protocolized sedation. These strategies have not been evaluated in combination.
Study design: Randomized controlled trial.
Setting: Tertiary-care medical and surgical ICUs in Canada and the U.S.
Synopsis: This randomized controlled trial conducted in 430 critically ill, mechanically ventilated adults at 16 tertiary-care ICUs showed no difference in time to extubation (mean seven days in each group) or ICU length of stay (mean 10 days in each group) in protocolized sedation and sedation interruption compared with protocolized sedation alone. The daily interruption group received higher mean daily doses of midazolam and fentanyl, increased number of boluses of benzodiazepines and opiates, and required increased nurse workload. There was no difference in unintentional endotracheal tube removal or rate of delirium.
A limitation of this study was the use of continuous opioid and/or benzodiazepine infusions instead of bolus dosing. Hospitalists involved in critical care should be careful about changing their practice based on this study alone.
Bottom line: The addition of daily sedation interruptions in mechanically ventilated patients treated with protocolized sedation does not reduce duration of ventilation or ICU stay.
Citation: Mehta S, Burry L, Cook D, et al. Daily sedation interruption in mechanically ventilated critically ill patients cared for with a sedation protocol. JAMA. 2012;308:1985-1992.