- Classic sedation is using benzos, and then benzos, add some opioids, and more benzos!
- We know that early deep sedation is associated with longer duration of vent support, higher need for tracheostomy, and increased mortality (SPICE I/II Trials).
- Larsen et al. Systematic Review in 2013 showed that compared to a benzo sedative strategy, a non-benzo strategy was associated with a shortened ICU LOS (1.62 d) and duration of mechanical ventilation (1.9 d), but similar short-term mortality.
What non-benzos can be used for sedation??
- Selective alpha-2 agonist
- Causes sedation and analgesia
- Decreases sympathetic tone - watch for bradycardia
- Allows psychomotor function while patient rests comfortably
- 2015 Cochrane Review showed 22% reduction in ventilator time and 14% reduction in ICU LOS compared to traditional sedative agents
- Potentiates GABA-A receptor activity
- Quick acting sedative with short half-life, easily titratable
What about no sedation?
- Analgesia first is a viable and preferred option
- Fentanyl, Morphine, Remifentanyl
- Des Brown et al., 105 patients Multicenter study compared Remifentanyl only analgesia vs standard sedatives in ICU patients
- Remifentanyl patients received midazolam as needed
- Remifentanyl-based sedation reduced duration of mechanical ventilation by > 2 days
- 26% did not require any midazolam, the remainder received less than the control group
Take Home Points
- Early deep sedation is an independent predictor of increased on the ventilator, time in the ICU, and risk of death. This is one factor we can potentially modify in the ED.
- Focus on analgesia before adding sedative hypnotics
- Attempt bolus dose anxiolytics before resorting to a continuous infusion
- Ideally the patient should appear alert and calm, or be able to open his/her eyes to voice and make eye contact (RASS 0 to -1)
- Dexmedetomidine and proposal are viable alternatives to benzodiazepines and are associated with reduced time on the ventilator and in the ICU
- Fraser G, et al. Benzodiazepine versus nonbenzodiazepine-based sedation for mechanically ventilated, critically ill adults: a systematic review and meta-analysis of randomized trials. CCM Journal 2013;41(9):S30-38.
- Wood S, Winters M. Care of the intubated emergency department patient. JEM 2011;40(4):419-427.
- Shehabi Y, et al. Early intensive care sedation predicts long-term mortality in ventilated critically ill patients. Am J Respire Crit Care Med 2012;186(8):724-731.
- Shehabi Y, et al. Sedation depth and long-term mortality in mechanically ventilated critically ill adults: a prospective longitudinal multi center cohort study. Intensive Care Med 2013;39:910-918.
- Strom T, Martinussen T, Toft P. A protocol for critically ill patients receiving mechanical ventilation: a randomized trial. Lancet 2010;375:475-80.
- Chen K, Lu Z, Xin YC, Cai Y, Chen Y, Pan SM. Alpha-2 agonists for long-term sedation during mechanical ventilation in critically ill patients. Cochrane Database of Systemic Reviews 2015, Issue 1. Art. No.: CD010269. DOI: 10.1002/14651858.CD010269.pub2.
- Breen D, et al. Decreased duration of mechanical ventilation when comparing analgesia-based sedation using remifentanyl with standard hypnotic-based sedation for up to 10 days in intensive care until patients: a randomized trial. Critical Care 2005;9:R200-210.
- Tanaka LM, Azevedo LC, Park M, Schettino G, Nassar AP Jr, Rea-Neto A, Tannous L, de Souza-Dantas VC, Torelly A, Lisboa T, Piras C, Carvalho FB, Maia MD, Gianini FP, Machado FR, Dal-Pizzol F, de Carvalho AG, Dos Santos RB, Tierno PF, Soares M, Salluh JI. Early sedation and clinical outcomes of mechanically ventilated patients: a prospective multicenter cohort study. Crit Care 2014, 18:R156.
- Gertler R, et al. Dexmedetomidine: a novel sedative-analgesic agent. Proc (Bayl Univ Med Cent). 2001 Jan; 14(1):13-21.