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Update on ICU sedation - Mayo Clinic

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April 03, 2020. The state of pharmacological sedation in the ICU is ever changing. Traditionally, patients who were mechanically ventilated in the ICU were ... COVID-19:Advice,updatesandvaccineoptions Weareopenforsafein-personcare. Learnmore: MayoClinicfactsaboutcoronavirusdisease2019(COVID-19) OurCOVID-19patientandvisitorguidelines,plustrustedhealthinformation Lateston COVID-19vaccination bysite: Arizonapatientvaccinationupdates Arizona, Floridapatientvaccinationupdates Florida, Rochesterpatientvaccinationupdates Rochesterand MayoClinicHealthSystempatientvaccinationupdates MCHS Skiptositenavigation SkiptoContent ThiscontentdoesnothaveanEnglishversion.ThiscontentdoesnothaveanArabicversion. ReferralsNewsVideosPhysiciansContinuingEducationExternalLinkClinicalTrials UpdateonICUsedation April03,2020 ThestateofpharmacologicalsedationintheICUiseverchanging.Traditionally,patientswhoweremechanicallyventilatedintheICUwerekeptdeeplysedatedwithcontinuousdepressantinfusionstomaximizeventilatorsynchronyanddecreasediscomfortthatmayariseduringcriticalillness."Thisconventionofheavydepressantusecontributedtoareflexfamiliartomanyintensivists,"saysDanteN.Schiavo,M.D.,PulmonaryandCriticalCareMedicineatMayoClinicinRochester,Minnesota."AfterintubationofapatientintheICU,thecareteammightask,'Whatarewegoingtouseforsedation?'" Datafromtheturnofthiscenturysuggestedthatcontinuousinfusionsofsedativemedicationswereassociatedwithworseclinicaloutcomesandmoreuntowardeffectscomparedwithintermittentdosing. AnotherpracticeinICUsedationthatdevelopedinthiscenturywasdailysedationinterruption(DSI),or"sedationholidays,"asdatasuggestedthatuseofDSIimprovedoutcomesandfurtherreduceduntowardeffectsofdepressantmedications. SubsequentdataonDSIinpatientsalreadyonsedationalgorithms(asopposedtocontinuousinfusions)withfrequentassessmentsofnecessitybuiltindidnotshowasrobustfindingstosupportDSI.AsreportedinCriticalCarein2016,ahead-to-headtrialofDSIcomparedwithsedationalgorithmswasevenstoppedearlybecauseofworseoutcomesintheDSIgroup."Thesedatasuggestthatwhatismostcriticalissomecompulsorytooltofrequentlyassesswhethersedationisneeded,asopposedtotheDSIitself,"saysDr.Schiavo. AlsocontributingtodecreasedenthusiasmforaggressiveuseofsedativemedicationintheICUisastudypublishedin2020inTheNewEnglandJournalofMedicinethatexaminedastrategyofnoplannedsedationversusastrategyoflightsedation.Inthiswell-designed,multicenter,randomizedclinicaltrial,710adultpatientsinICUswhowerenotseverelyhypoxemicandwereexpectedtoreceivemechanicalventilationformorethan24hourswererandomizedintoastrategyofnosedationversuslightsedation,definedaspursuitofaRichmondAgitationandSedationScale(RASS)scoreof-2to-3. ThelightsedationarmfeaturedmanyofthetenetsofICUsedationlearnedfromtheprior20yearsofdata: Patientswerenotkeptdeeplysedated. DSIwasused. AprotocolwasfollowedforsedationuseandresumptionafterDSI. BothgroupswerewellbalancedexceptforahigherAcutePhysiologyandChronicHealthEvaluation(APACHE)IIscoreindicatingagreaterpredictedmortalityinthenonsedationgroup,andbothgroupsofpatientswerepermittedopioidnarcoticsforanalgesia.Betweenthegroups,therewasnosignificantdifferenceinmortality,lengthofhospitalorICUstay,ventilator-freedays,oracutekidneyinjury. Dr.Schiavoconcludes:"AtMayoClinic,themechanicalventilationordersetnolongerincludesmandatoryuseofsedativemedications.Whenpharmacologicalsedationisrequired,thestandardislightsedationwithaprotocolizedgoalRASSscoreof0to-2withDSIordocumentationofwhyitwasforewent.Weencourageourteamtousetheterm"sedation-analgesia-anxiolysis,"orSAA,ratherthanICUsedation,tobetteremphasizethatuseofdepressantmedicationsshouldbeinresponsetoaspecifictypeofdiscomfortratherthanaroutineICUtherapy. "Furthermore,aclinicaltrialcurrentlyunderwayisexaminingwhetherastrategyofpatient-controlledSAAversususualprotocolizedSAAaffectsshort-term(anxiety,delirium,durationofmechanicalventilation)andlong-term(functionalstatus,psychologicalwell-being,health-relatedqualityoflife)outcomes.Thecorrectanswerto'Whatarewegoingtouseforsedation?'shouldbe'Onlywhatthepatientneeds'.Andforsomepatientsthatmaybenothingatall." FormoreinformationdeWitM,etal.Randomizedtrialcomparingdailyinterruptionofsedationandnursing-implementedsedationalgorithminmedicalintensivecareunitpatients.CriticalCare.2008;12:R70. OlsenHT,etal.Nonsedationorlightsedationincriticallyill,mechanicallyventilatedpatients.TheNewEnglandJournalofMedicine,2020.Inpress. MayoClinic.Self-ManagementofSedativeTherapybyVentilatedPatients.ClinicalTrials.gov. ReceiveMayoClinicnewsinyourinbox. Signup RelatedContentArticleRoboticsystemscanperformsimpleICUcaretasksArticleSurgeryandICU:CollaboratingforthebestoutcomesArticleImprovingaccesstorehabilitationservicesforICUpatients MAC-20483374 MedicalProfessionals UpdateonICUsedation

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