ArticlesA protocol of no sedation for critically ill patients receiving mechanical ventilation: a randomised trial
Introduction
…But what I see these days are paralyzed, sedated patients, lying without motion, appearing to be dead, except for the monitors that tell me otherwise…
Thomas Petty1
These lines were written in an editorial linked to a follow-up study of mechanically ventilated patients, in which Kollef and colleagues2 reported that continuous infusion of sedatives lengthened the duration of ventilation compared with bolus doses of sedatives. In 2000, Kress and colleagues3 showed that daily interruption of sedative infusions until patients were awake reduced the duration of mechanical ventilation. One major disadvantage of sedation for critically ill patients is that clinicians are unable to assess the patient's mental status; Kress and colleagues also recorded fewer CT scans of the brain in patients who were woken up daily than in the control group in which infusions were interrupted at the clinicians' discretion.
In a further study of daily sedative interruption, Kress and colleagues4 showed that daily interruption kept post-traumatic stress disorder to a minimum, although, at the follow-up interview, few patients recalled being woken up daily. Real memories of the intensive care stay have been shown to reduce the severity of post-traumatic stress disorder.5 Also the risk of several well known complications—ventilator-associated pneumonia, haemorrhage in the upper gastrointestinal tract, bacteraemia, barotraumas, venous thromboembolic disease, cholestasis, and sinusitis requiring surgical intervention—is reduced by daily interruption of sedation.6
Despite these findings, standard practice is to sedate critically ill patients needing intubation and mechanical ventilation.7, 8, 9 A natural development for sedation strategies would be to try to keep the amount and duration of sedation to a minimum, with the expectation that this strategy could further reduce the duration of mechanical ventilation.10 In the general intensive care unit in the Department of Anesthesia and Intensive Care Medicine at Odense University Hospital, Denmark, we have used the standard treatment of no sedation for intubated patients receiving mechanical ventilation since June, 1999. Patients receive intravenous morphine as bolus doses but no infusion of sedatives or analgesics. To our knowledge, this strategy has not been used in other departments or described in published reports. We undertook a prospective randomised study to establish whether no sedation versus sedation with daily interruption reduced the duration of mechanical ventilation.
Section snippets
Participants
We studied critically ill adult patients undergoing mechanical ventilation. Patients in Odense University Hospital, Denmark, were admitted to an 18-bed multidisciplinary, closed intensive care unit from both medical and surgical departments. The intensive care unit has at least two physicians present (one intensive care specialist and one specialist trainee) at all times. The patient to nurse ratio is 1:1, which allows the nurse to manage several tasks in addition to patient care (eg, renal
Results
428 patients were assessed for eligibility during April, 2007–December, 2008, of whom 140 were enrolled and randomly assigned to treatment (figure 1). Overall, a higher proportion of men (n=76 patients, 67%) than women (n=37, 33%) were included in the study, and the ratio of men to women was higher in the intervention group than in the control group (table 1). 27 patients were excluded from the statistical analysis because mechanical ventilation was stopped within 48 h (figure 1). An extra
Discussion
Findings from our study show that in critically ill patients receiving mechanical ventilation, a protocol of no sedation significantly increased the number of days without ventilation in a 28-day period compared with daily interruption of sedation. Use of no sedation was also associated with a significant reduction in the length of stay in the intensive care unit and in hospital. No difference in complications such as accidental removal of the endotracheal tube, ventilator-associated pneumonia,
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