Highlights from AAST - an alternative to the "sedation vacation"

This interesting paper asks the questions - "why start continuous sedation"? As opposed to "when can we stop continuous sedation"?

SEDATION IN THE INTENSIVE CARE UNIT: MOVING BEYOND SEDATION INTERRUPTION Brenton LaRiccia, Megan Battin, Theodophilus Ugheghe, Tara Sacco, Paul E. Bankey*, M.D., Ph.D., Jignesh Patel, Mark L. Gestring*, M.D., Julius D. Cheng*, M.D. M.P.H., Ayodele Sangosanya, Nicole Stassen*, MD, University of Rochester Invited Discussant: Heidi L. Frankel Introduction: Over sedation of mechanically ventilated patients contributes to worse ICU outcomes. While sedation interruption (SI) regimens have been shown to reduce sedation in medical ICUs, their utility in trauma ICUs is variable. In 2011 our trauma ICU (BTICU) implemented a regimen using aggressive up front bolus dosing of drugs, only utilizing continuous infusions if bolus dosing was ineffective over time, followed by regimented weaning of all medications. This study evaluates the efficacy of this regimen compared to our previous continuous drip/SI based practice. Average Ventilator days Total Sedation Days CLASBI Rate VAP rate Press Ganey Pain Score PRE N=743 8.4 1784 4.5 12 93.7 POST N=749 6.2 344 2.7 1 94.9 Methods: Intubated patients >18 years old, admitted to the BTICU over two time periods, pre-protocol (PRE) and post-protocol (POST), were identified. Records were reviewed concurrently and retrospectively for demographics, APACHE II score, LOS, ventilator days, sedation use, complications, and outcome. Exclusion criteria included chemical paralysis, hourly neuro checks and burns. Results: PRE(2009) and POST(2011) groups had similar demographics, APACHE II scores, and GCS. The POST group had a significant decrease in average ventilator days, total sedation days and infectious complications. (Table) In the POST group >50% of patients required <48 hours of continuous sedation and 23% never required continuous sedation. The total fall/self extubation rates and press ganey pain scores were unchanged. Conclusion: This study shows that a protocol that preferentially utilizes intermittent pain and sedation medications, instead of continuous infusions with SI greatly decreases ICU sedation use and improves ICU infection rates, decreases ventilator days, without significant complications.