"Daily Interruption of Sedative Infusions in Critically Ill Patients Undergoing Mechanical Ventilation".
The New England Journal of Medicine.
PubMed • Full text • PDF

Contents

1. Clinical Question
2. Bottom Line
3. Major Points
4. Guidelines
5. Design
6. Population
6.1 Inclusion Criteria
6.2 Exclusion Criteria
6.3 Baseline Characteristics
7. Interventions
8. Outcomes
8.1 Primary Outcomes
8.2 Secondary Outcomes
9. Criticisms
10. Funding
11. Further Reading

Clinical Question

Does the daily interruption of sedative-drug infusions in patients receiving mechanical ventilation decrease the duration of mechanical ventilation and length of stay in the intensive care unit?

Bottom Line

Daily interruption of sedative-drug infusions in critically ill patients undergoing mechanical ventilation decreases the duration of mechanical ventilation and the length of stay in the intensive care unit.

Major Points

Continuous sedative infusions in the intensive care unit are associated with prolonged mechanical ventilation, extended ICU stays, and increased difficulty in performing and interpreting daily neurological exams, which may lead to additional diagnostic tests. The routine daily interruption of sedative-drug infusions may mitigate these issues by providing a consistent level of comfort while allowing periodic patient assessment.

Guidelines

Current guidelines for ICU management of mechanically ventilated patients and sedative use are not reported in this article.

Design

- Multicenter, randomized, controlled trial
- N=128 adult patients
- Intervention: Daily interruption of sedative-drug infusions until patients were awake
- Control: Interruption of sedation at clinician discretion
- Setting: Medical intensive care unit
- Enrollment: Data not specified
- Mean follow-up: Duration of ICU stay
- Primary efficacy outcome: Duration of mechanical ventilation, ICU stay, and hospital stay
- Analysis: Intention-to-treat

Population

Inclusion Criteria

- Intubated and receiving mechanical ventilation
- Requiring sedation with continuous intravenous infusion

Exclusion Criteria

- Pregnancy
- Transfer from outside institution where sedation already administered
- Admission after resuscitation from cardiac arrest

Baseline Characteristics

- The groups were similar regarding demographics, APACHE II scores, reason for ICU admission, and type of respiratory failure.

Interventions

- Interruption of sedative-drug infusions (midazolam or propofol) and morphine simultaneously until patients were awake or uncomfortable/agitated, requiring sedation resumption (intervention group).
- Control group received continuous infusions with the interruption at clinicians' discretion.

Outcomes

Primary Outcomes

- Shorter median duration of mechanical ventilation in the intervention group (4.9 vs. 7.3 days, P=0.004)
- Shorter median length of ICU stay in the intervention group (6.4 vs. 9.9 days, P=0.02)

Secondary Outcomes

- Fewer patients in the intervention group required diagnostic tests to assess the change in mental status (P=0.02).
- No significant difference in adverse events such as self-extubation or other complications between groups.
- No significant difference in overall hospital length of stay between groups.

Criticisms

- The awareness of study-group assignments may have affected care provider decisions, although this was minimized by not disclosing study endpoints.
- Study results are specific to medical ICU patients; applicability to surgical or trauma ICU patients is not established.
- Monitoring subjective discomfort may not reflect less obvious types of discomfort or psychological distress.

Funding

The article does not disclose funding sources or any potential conflicts of interest.

Further Reading

The article mentions potential further reading or references for additional related studies but does not specify titles or authors.