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Daily Sedation Interruption Versus Targeted Light Sedation Strategies in ICU Patients

Hughes, Christopher G. MD1; Girard, Timothy D. MD, MSCI2,3; Pandharipande, Pratik P. MD, MSCI1

Erratum

In the article in the September 2013 supplement issue, beginning on page S39, there was an error in one of the footnotes for Table 1.

The first footnote underneath Table 1 should have read:

aAll values converted to and expressed as midazolam equivalents. Mean daily exposure in patients who received benzodiazepines is reported for the studies by Kress et al (10), Girard et al (19), Treggiari et al (28), and Mehta et al (35). Median daily exposure in patients who received benzodiazepines is reported for the studies by Bucknall et al (41) and Strom et al (31).

Critical Care Medicine. 41(11):e400, November 2013.

doi: 10.1097/CCM.0b013e3182a168c5
Creating and Implementing the 2013 ICU Pain, Agitation, and Delirium Guidelines for Adult Icu Patients

Objective: The updated clinical practice guidelines for the management of pain, agitation, and delirium recommend either daily sedation interruption or maintaining light levels of sedation as methods to improve outcomes for patients who are sedated in the ICU. We review the evidence supporting both methods and discuss whether one method is preferable or if they should be used concurrently.

Data Source: Original research articles identified using the electronic PubMed database.

Study Selection and Data Extraction: Randomized controlled trials and large prospective cohort studies of mechanically ventilated ICU patients requiring sedation were selected.

Data Synthesis: The methods of daily sedation interruption and targeting light sedation levels (including avoidance of deep sedation) are safe in critically ill patients with no increase, and a potential decrease, in long-term psychiatric disturbances. Randomized trials comparing these methods with standard care, which has traditionally involved moderate to heavy sedation, found that both methods reduced duration of mechanical ventilation and ICU length of stay. Additionally, one trial noted that daily sedation interruption paired with spontaneous breathing trials improved 1-year survival, whereas a large observational study found that deep sedation was associated with decreased 180-day survival. Two common characteristics of these interventions in trials showing benefits were avoidance of deep levels of sedation and significant reductions in sedative doses, especially benzodiazepines. Thus, combining targeted light sedation with daily sedation interruption may be more beneficial than either method alone if sedative doses are reduced and arousal and mobility are facilitated during the ICU stay.

Conclusion: Daily sedation interruption and targeting light sedation levels are safe and proven to improve outcomes for sedated ICU patients when these approaches result in reduced sedative exposure and facilitate arousal. It remains unclear as to whether one approach is superior, and further studies are needed to evaluate which patients benefit most from either or both techniques.

1Department of Anesthesiology, Division of Critical Care, Vanderbilt University School of Medicine, Nashville, TN.

2Department of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine and Center for Health Services Research, Vanderbilt University School of Medicine, Nashville, TN.

3Geriatric Research, Education and Clinical Center Service, Department of Veterans Affairs Medical Center, Tennessee Valley Health Care System, Nashville, TN.

This work is attributed to Vanderbilt University Department of Anesthesiology.

Dr. Hughes received salary support from the Foundation for Anesthesia Education and Research (Rochester, MN) Mentored Research Training Grant and has received honoraria from Orion Pharma. Dr. Girard is supported by the National Institutes of Health (AG034257; Bethesda, MD) and the Veterans Affairs Tennessee Valley Geriatric Research, Education and Clinical Center (Nashville, TN). He has received honoraria from Hospira. Dr. Pandharipande is supported by the National Institutes of Health (HL111111-01A1; Bethesda, MD) and has received honoraria from Hospira and Orion Pharma, a grant from Hospira. He is a member of the France Foundation Speakers Bureau.

For information regarding this article, E-mail: christopher.hughes@vanderbilt.edu

© 2013 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins