Correspondence
Daily Interruption of Sedative Infusions in Critically Ill Patients
N Engl J Med 2000; 343:814-815September 14, 2000
- Article
To the Editor:
Kress et al. (May 18 issue)1 report that daily interruption of sedative infusions in patients requiring mechanical ventilation resulted in a decreased duration of mechanical ventilation and a decreased length of stay in the intensive care unit. They note that patients in the intervention group were awake 85.5 percent of the days during which they were receiving an infusion, as compared with 9.0 percent of days for the patients in the control group, but did not comment on this important finding. Presumably, patients in the intervention group were weaned from mechanical ventilation and extubated sooner because they were more awake, having received smaller doses of sedatives, and not specifically because of the daily interruption of the sedative infusion. This may be implicit in the authors' conclusion but should be stated explicitly.
Moreover, we suggest that the patients in the control group were overly sedated. Whether oversedation results from continuous infusion, continuous infusion with daily interruption, or intermittent bolus dosing, the end results are the same: increased requirements for mechanical ventilation and increased lengths of stay in the intensive care unit. We postulate that if patients received an initial loading dose of sedative and analgesic medication to control pain and agitation and then received a continuous infusion at lower doses, with a goal of a score of 2 or 3 (rather than 3 or 4) on the Ramsay sedation scale, decreases in the total dose of sedatives could be achieved, with resultant decreases in ventilator requirements similar to those the authors report with daily interruption of sedative infusion.
Kress et al. confirm that excessive use of sedatives results in longer requirements for mechanical ventilation and longer lengths of stay in the intensive care unit.2,3 The specific means by which sedation is achieved — continuous infusion, continuous infusion interrupted daily, or intermittent bolus dosing — is less important than achievement of the appropriate level of sedation.
3 ReferencesJohn J. Hong, M.D.
John E. Mazuski, M.D., Ph.D.
Marc J. Shapiro, M.D.
St. Louis University, St. Louis, MO 63110-02501
Kress JP ,Pohlman AS ,O'Connor MF ,Hall JB . Daily interruption of sedative infusions in critically ill patients undergoing mechanical ventilation. N Engl J Med 2000;342:1471-1477
Full Text | Web of Science | Medline2
Kollef MH ,Levy NT ,Ahrens TS ,Schaiff R ,Prentice D ,Sherman G . The use of continuous i.v. sedation is associated with prolongation of mechanical ventilation. Chest 1998;114:541-548
CrossRef | Web of Science | Medline3
Brook AD ,Ahrens TS ,Schaiff R , et al. Effect of a nursing-implemented sedation protocol on the duration of mechanical ventilation. Crit Care Med 1999;27:2609-2615
CrossRef | Web of Science | Medline
To the Editor:
Kress et al. are to be commended for their provocative study. However, their study design and conclusions raise important questions.1 The authors did not assess the effects of the daily cessation of sedative infusions on the patients in terms of comfort, removal of medical devices, and recall (and the associated potential for long-lasting psychological sequelae) or on the patients' families or the intensive care unit nurses. Without such information, it is difficult to evaluate the potential negative effects of the decreased sedation in these patients. In addition, experienced intensive care unit researchers managed sedation in the intervention group and presumably paid close attention to the provision of comfort, whereas house staff and general intensive care unit teams managed sedation in the control group. This difference may help explain the improved results in the intervention group. Finally, the criteria used to decide whether to restart sedation and the length of time patients were kept awake are not provided.
1 ReferencesRichard R. Riker, M.D.
Gilles L. Fraser, Pharm.D.
Maine Medical Center, Portland, ME 041021
Heffner JE . A wake-up call in the intensive care unit. N Engl J Med 2000;342:1520-1522
Full Text | Web of Science | Medline
Author/Editor Response
The authors reply:
To the Editor: Hong et al. suggest that the patients in our intervention group were extubated sooner because they were more awake. We agree with this statement but disagree with the statement that their being more awake was “not specifically because of the daily interruption of the sedative infusion.” Indeed, the very reason they were more awake and received smaller doses of sedatives (at least in the patients who received midazolam) was because their sedative infusions were interrupted daily. Although we did not include these results in our report, there were no differences between the two groups in the scores on the Ramsay sedation scale while the patients were receiving the sedative infusions. Daily interruption of the sedative infusions allowed patients to awaken more quickly, presumably by reducing the accumulation of sedatives. We agree completely that the means by which sedation is achieved is less important than the avoidance of oversedation. However, the suggestion to provide less sedation is impractical and unrealistic, because this approach may not be adequate to meet the needs of many critically ill patients with respiratory failure. In our experience, many of these patients require deeper levels of sedation to ensure adequate levels of comfort. Daily interruption of sedative infusions allows both goals — deep sedation to ensure comfort and avoidance of oversedation — to be achieved.
Riker and Fraser's statement that we did not assess the effect of daily interruption of sedative infusions on the removal of medical devices is incorrect. We found no difference between the intervention group and the control group in complications of interruption such as extubation or catheter removal by the patient. Daily interruption and resumption of sedative infusions were the only management decisions made by the research team. All other decisions regarding the patients' care, including other decisions regarding the administration of sedative infusions, were made by the house staff and attending physicians in the intensive care unit. Patients were kept awake only long enough to assess their wakefulness. The resumption of sedative administration was performed according to protocol, on the basis of the score on the Ramsay sedation scale. Because of this, we do not believe the improved results in the intervention group are a result of a greater level of attention paid to this group.
John P. Kress, M.D.
Jesse B. Hall, M.D.
University of Chicago, Chicago, IL 60637- Citing Articles (7)
Citing Articles
1
T. Muñoz-Martínez. (2012) Interrupción diaria de la sedación; ¿siempre es un indicador de calidad?. Medicina Intensiva
CrossRef2
Michael H. Hooper, Timothy D. Girard. (2011) Sedation and Weaning from Mechanical Ventilation: Linking Spontaneous Awakening Trials and Spontaneous Breathing Trials to Improve Patient Outcomes. Anesthesiology Clinics 29:4, 651-661
CrossRef3
Michael H. Hooper, Timothy D. Girard. (2009) Sedation and Weaning from Mechanical Ventilation: Linking Spontaneous Awakening Trials and Spontaneous Breathing Trials to Improve Patient Outcomes. Critical Care Clinics 25:3, 515-525
CrossRef4
Mark O’Connor, Tracey Bucknall, Elizabeth Manias. (2009) A critical review of daily sedation interruption in the intensive care unit. Journal of Clinical Nursing 18:9, 1239-1249
CrossRef5
Timothy D Girard, John P Kress, Barry D Fuchs, Jason WW Thomason, William D Schweickert, Brenda T Pun, Darren B Taichman, Jan G Dunn, Anne S Pohlman, Paul A Kinniry, James C Jackson, Angelo E Canonico, Richard W Light, Ayumi K Shintani, Jennifer L Thompson, Sharon M Gordon, Jesse B Hall, Robert S Dittus, Gordon R Bernard, E Wesley Ely. (2008) Efficacy and safety of a paired sedation and ventilator weaning protocol for mechanically ventilated patients in intensive care (Awakening and Breathing Controlled trial): a randomised controlled trial. The Lancet 371:9607, 126-134
CrossRef6
John W. Devlin, Jeffrey J. Fong, Greg L. Schumaker. (2006) Identifying factors that could account for differences in duration of mechanical ventilation between intermittent lorazepam- and propofol-treated patients. Critical Care Medicine 34:12, 3063-3064
CrossRef7
J KRESS, J HALL. (2004) Delirium and sedation. Critical Care Clinics 20:3, 419-433
CrossRef
