Critical Care Medicine

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

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

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Abstract

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.

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

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