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

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.