Daily Interruption of Sedation versus Continuous Sedation and Length of Mechanical Ventilation

Monday, 9 November 2015

Crystal Nicole Weise, BSN, RN
Medical Intensive Care Unit, Greater Baltimore Medical Center, Baltimore, MD, USA

Hundreds of thousands of critical care patients are intubated every year. Many of these patients are sedated for comfort. However, continuous moderate to deep sedation can lead to increased ventilator days and other morbitities, including delirium. Every intensive care unit uses a variety of sedation practices. Furthermore, there are barriers to the healthcare team using daily sedation interruptions. These include the concern that the patient will self extubate and that it will worsen the patient’s respiratory status. This leads to practitioners not implementing the practice.

Objective: The objective of the systematic review is to determine if conducting daily sedation interruptions for ventilated adult intensive care patients will decrease the length of mechanical ventilation. The secondary objective is to determine if the sedation interruptions are safe and feasible.

Method: A literature search was conducted using CINHAL, Ovid/Medline and Embase databases. Eleven primary studies and one systematic review was kept after using key words and limiting the articles to articles no older than 2008, English and adult patients. These articles were critiqued based on their methods, number of participants and results. Then they were assigned a SORT level of evidence. There were seven level 2 articles and 3 level 1 articles. The main limitation of the studies were the inability of the studies to be blinded.

Results: The data provided by the studies were inconclusive. However, based on the findings of the studies it is safe and feasible to conduct the daily sedation interruptions in mechanically ventilated patients in the intensive care unit. Many barriers still exist, including the fear of self extubation, patient agitation and worsened respiratory status.

Recommendation: It is recommended that in patients that have been intubated for more than 48 hours that a sedation interruption and when the patient’s RASS is zero a spontaneous breathing trial should be conducted. If the patient passes the spontaneous breathing trial the patient can be extubated per physician order. If the patient becomes agitated or has worsening respiratory status during the sedation interruption, the patient fails and will be put back on the sedative medication at half the current rate. This process will be conducted daily as long as the patient is intubated and hemodynamically stable. Starting this practice in the intensive care unit will better patient outcomes, decrease ventilator days and decrease health care costs.

Change Model: To implement this change the Kotter and Cohen change model is to be used. The key stake holders that need to be involved in the process are the mechanically ventilated patients and their families, the nurse manager, nursing and physician staff. The leaders of change are the nurse manager, lead intensive care attending and senior nursing staff. When the change is implemented it will be evaluated by using staff questionnaires and tracking individual patient’s outcomes, any adverse events and the average number of mechanical ventilation days before and after the intervention.