Sedation Vacation in the ICU

Excerpt

As the name implies, the intensive care unit (ICU) is where a hospital's sickest patients who require accelerated and concentrated care are admitted. Many of these patients, an estimated 33% of all admissions, are admitted for respiratory failure of one etiology or another and subsequently are intubated and placed on mechanical ventilatory control. Part of the standard of care for intubation is to sedate the patient continuously to reduce pain and anxiety; decrease oxygen consumption and the body's stress response; prevent patient-ventilator desynchrony; reduce adverse neurocognitive impacts such as depression and post-traumatic stress disorder and ventilator-associated events including pneumonia and tracheostomy, and reduce total nursing requirements.

Mechanically ventilated patients frequently experience pain from mechanical ventilation, endotracheal suctioning, indwelling catheters, surgical incisions, and repositioning in bed. The medications used to initiate and maintain sedation in an intensive care unit include benzodiazepines (eg, diazepam, lorazepam, and midazolam), opioid analgesics (eg, fentanyl, hydromorphone, morphine, remifentanil), propofol, dexmedetomidine, ketamine, and antipsychotics (eg, haloperidol, quetiapine, and ziprasidone). No sedative is found to be superior in efficacy or mortality. However, The Society of Critical Care Medicine guidelines recommend avoiding benzodiazepines due to evidence of a longer duration of intubation. The choice of which sedative is best lies in the practitioner's clinical assessment of individual patient scenarios, weighing the risk/benefit profile of the medicine for each patient.

Regardless of which sedative agent was utilized, total continuous sedation was found to be associated with an extension of the total length of intubation and increased length of the ICU stay and limited the ability to assess the mental status of the patient properly, increasing the risk of delirium, and suppressed brainwave function seen on EEG, linking to increased 6-month mortality. It was assessed that daily, short-term cessation of sedation, a "sedation vacation," improved patient care outcomes. As per the evidence-based practice, sedation should be interrupted at least every day in mechanically ventilated patients to evaluate the patient's need to remain on intravenous continuous sedation. Benefits of this approach include the ability to appropriately titrate sedation, which reduces the length of ICU stay, time on mechanical ventilation, risk of ventilator-associated lung infections, and need for neurological diagnostic tests related to oversedation.

A study conducted on 80 patients revealed that a daily sedation vacation protocol in patients with intravenous sedation reduced the incidence of ventilator-associated pneumonia (VAP). Therefore, nurses are recommended to use the daily sedation vacation protocol to prevent VAP.

Sedation vacations were first introduced in 2000 with a study by J.P. Kress et al. published in the New England Journal of Medicine and recognized as a medical necessity for standard practice within the ICU to wean patients from mechanical ventilation. The study of spontaneous-awakening trials showed that daily sedation interruptions improved the time to extubation of 64 patients by approximately 2 days, which reduced the total admission time in the ICU by 3.5 days. Two separate trials further reinforced this study: the Awakening and Breathing Controlled trial in 2008, titled the "wake up and breathe" protocol, and the No Sedation in Intensive Care Unit Patients trial in 2010. Both supporting trials investigated the impacts of imposing a protocol to evaluate and reduce sedation in a structured format and found that spontaneous breathing trials and sedation vacations reduced ventilatory-dependent days and ICU admission days compared to nonstructured or no-sedation vacation protocols.