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LESS is MORE - ..

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The use of continuous sedation therapy in patients undergoing mechanical ventilation in the intensive care unit (ICU) has been the standard of practice for decades1. Despite the fact that this strategy has been associated with an increase in the duration of mechanical ventilation, it has been shown to reduce the severity of posttraumatic stress disorder (PTSD) and stress related to critical illness2. Critically ill patients are also at an increased risk for developing neurocognitive disorders post ICU discharge; whether or not sedation therapy resolves or precipitates those neurocognitive disorders is unknown2,3

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Strom and colleagues conducted a single-center, un-blinded, randomized trial in critically ill patients requiring mechanical ventilation for longer than 24 hours. Patients were assigned to a no sedation protocol or to sedation with daily interruption. Both groups received bolus doses of morphine as needed for pain. Continuous sedation was achieved with propofol, followed by a transition to midazolam after 48 hours. A protocol of no sedation reduced the time patients received mechanical ventilation, reduced the intensive care and total hospital length of stay. Agitated delirium however was more common in the no sedation group compared to the sedation group4. This raised concerns surrounding the no sedation approach and the risks of psychological trauma as well as other neurocognitive disorders.

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Therefore, to evaluate the psychological long-term effect after intensive care stay, a follow-up prospective study by the same investigators was conducted interviewing all available patients from their original study. A total of 26 patients were interviewed (13 from each group). Very few patients suffered from PTSD and no significant difference was found between the two groups. A very low rate of depression was found in both groups with no significant difference. The modified ICU memory tool showed that two-thirds of patients from both groups had experienced nightmares during their ICU stay. Very few patients remembered pain or breathing difficulties in the ICU with no significant difference.

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The authors concluded that a strategy of no sedation did not worsen long-term psychological and functional outcomes compared to a standard strategy of sedation5. A larger sample size might have yielded a statistically significant beneficial effect favoring the no sedation therapy group.

1. Jacobi J, Fraser GL, Coursin DB, et al. Clinical practice guidelines for the sustained use of sedatives and analgesics in the critically ill adult. Crit Care Med. 2002;30:119-141.   [PubMed: 11902253]
2. Kress JP, Gehlbach B, Lacy M, et al. The long-term psychological effects of daily sedative interruption on critically ill patients. Am J Respir Crit Care Med. 2003;168:1457-1461.   [PubMed: 14525802]
3. Hopkins RO, Jackson JC. Long-term neurocognitive function after critical illness. Chest 2006,130:869-878.   [PubMed: 16963688]
4. Strom T, Martinussen T, Toft P. A protocol of no sedation for critically ill patients receiving mechanical ventilation: A randomized trial. Lancet 2010,375:475-480.   [PubMed: 20116842]
5. Strom T, ...

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