Thursday, August 22, 2013

Whither sedation interruption?

A lot of folks are no doubt rethinking the notion of daily sedation interruption in view of last November's JAMA paper which at first glance goes against the teaching of the past few years:

Intervention Continuous opioid and/or benzodiazepine infusions and random allocation to protocolized sedation (n = 209) (control) or to protocolized sedation plus daily sedation interruption (n = 214). Using validated scales, nurses titrated infusions to achieve light sedation...
Results Median time to successful extubation was 7 days in both the interruption and control groups...
Conclusion For mechanically ventilated adults managed with protocolized sedation, the addition of daily sedation interruption did not reduce the duration of mechanical ventilation or ICU stay.

So what does it mean and how might it change practice? To put the study in perspective it's helpful to listen to the interview with one of the authors available at the link above.

Can we say now that sedation interruption is of dubious benefit? No. Can we say that the evidence in support of sedation interruption is mixed? No. Prior research has established the benefits of sedation interruption. What is important to understand about this study is the comparison group which was treated with a protocol designed to sedate as lightly as possible. This is in contrast to conventional sedation in which patients definitely benefit from daily interruption.

If there is a practice changing message form this study it is that sedation, protocol driven to be as light as possible is better than conventional continuous sedation and so is sedation interruption and you need to do one or the other but not necessarily both. The study is not a license to ignore the need to use protocols to limit sedation and it is my suspicion that both approaches are about equally onerous to the ICU staff.

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