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Abstract & Commentary
Is It Safe and Feasible to Limit Sedative Administration During the ICU Stay?
By Linda L. Chlan, RN, PhD, School of Nursing, University of Minnesota, is Associate Editor for Critical Care Alert.
Dr. Chlan reports that she receives grant/research support from the National Institutes of Health.
Synopsis: In an ICU where the routine practice consists of twice daily bedside discussions to evaluate sedative needs, patients can be safely managed with less continuous infusions of sedative agents, including those patients receiving mechanical ventilatory support.
Source: Salgado DR, et al. Toward less sedation in the intensive care unit: A prospective observational study. J Crit Care 2011;26:113-121.
The purpose of this prospective, observational study was to report on the feasibility and safety of limiting sedation throughout a patient's ICU stay. This single-center study was conducted in the 34-bed mixed ICU in Brussels, Belgium; 335 patients were observed over a 2-month period, and 46% were mechanically ventilated for a median time of 2 days. The practice on the ICU is to critically discuss during twice daily rounds the sedative needs for each individual patient. Sedation scales are not used in this ICU. Rather, sedation practice consists of titration of medication(s) to individual patient needs to achieve a calm, collaborative, and comfortable patient guided by the principles of Feeding, Analgesia, Sedation, Thromboembolic prophylaxis, Head of bed elevation, stress Ulcer prevention, and Glucose control (FASTHUG).1 Patients receive first a trial of acetaminophen or non-steroidal agent for pain management prior to the administration of opiates, usually morphine. Sedatives consist mainly of midazolam or propofol infusions; discontinuation of sedatives is encouraged whenever medically possible (for example, no seizure activity present or no scheduled invasive or surgical procedures), and is the focus of discussion during the twice daily patient rounds.
All sedatives and opiates were recorded daily for each patient along with numerous clinical data (illness severity, vasopressors, gender, age, etc.). Overall, 42% of patients received some sedation during their ICU stay, including 85% of those patients who received mechanical ventilation. Not surprisingly, patients with severe respiratory failure (20% of the sample) received sedatives for the longest period of time. Perhaps the most striking finding was that, overall, approximately 80% of the time period on mechanical ventilation was spent without receiving a continuous sedative infusion, regardless of illness severity. In total, there were six self-extubations, with only one requiring reintubation, demonstrating that the minimal-sedative approach to patient care was indeed safe. The authors concluded that minimal administration of sedative agents can be achieved to effectively manage critically ill patients, even those receiving mechanical ventilation, as long as there are scheduled, critical discussions with the entire multidisciplinary care team on strategies to meet each patient's individual care needs. The authors emphasize the importance of pain management and a personalized, patient-focused approach to care, including the use of non-pharmacologic interventions such as noise reduction and music.
This provocative article provides a viable alternative to sedation scales or sedation administration protocols to achieve the desired and sometimes elusive goal of minimizing sedative exposure while promoting patient comfort and meeting individual patient needs. Given the significant, frequently documented adverse side effects of oversedation, including prolonged immobility and prolonged ventilatory support, this study demonstrates that patients can be comfortable and safely managed in the ICU with little use of continuous sedative infusions, including those patients most critically ill and receiving mechanical ventilatory support. This article highlights the crucial aspects of tailored, personalized care guided by common sense care principles to achieve effective symptom management in critically ill patients. The authors point out that they deliberately chose not to adopt the use of a specific sedation scale or sedation protocol in their ICU, preferring instead to hold critical conversations twice daily to address each patient's individual needs guided by FASTHUG principles.1
The institution of a similar patient-care management approach focused on sedation administration in an ICU where the practice does not involve twice daily "patient/sedative needs rounds" would require a significant culture change. "Buy-in" from all critical care clinicians associated with the direct care of ICU patients would be essential for implementation of care based on FASTHUG principles.1 The authors stress that a highly dedicated multidisciplinary team is necessary to foster a minimal-sedation strategy in the care of ICU patients. Adequate staffing is paramount with concerted efforts to foster effective communication with patients to achieve the goal of a personalized, patient-focused approach to ICU care.