Critical Care Societies Collaborative – Critical Care

View all recommendations from this society

Released January 28, 2014

Don’t deeply sedate mechanically ventilated patients without a specific indication and without daily attempts to lighten sedation.

Many mechanically ventilated ICU patients are deeply sedated as a routine practice despite evidence that using less sedation reduces the duration of mechanical ventilation and ICU and hospital length of stay. Several protocol-based approaches can safely limit deep sedation, including the explicit titration of sedation to the lightest effective level, the preferential administration of analgesic medications prior to initiating anxiolytics and the performance of daily interruptions of sedation in appropriately selected patients receiving continuous sedative infusions. Although combining these approaches may not improve outcomes compared to one approach alone, each has been shown to improve patient outcomes compared with approaches that provide deeper sedation for ventilated patients.


These items are provided solely for informational purposes and are not intended as a substitute for consultation with a medical professional. Patients with any specific questions about the items on this list or their individual situation should consult their physician.

How The List Was Created

This document was prepared as an initiative of the Critical Care Societies Collaborative, which includes the American Association of Critical-Care Nurses, the American College of Chest Physicians, the American Thoracic Society and the Society of Critical Care Medicine. Each of these four societies was invited to nominate up to three members to join the taskforce. The final taskforce included 10 members representing all four societies and the disciplines of internal medicine, surgery, anesthesiology, emergency medicine and critical care nursing. Taskforce members initially proposed 58 items for consideration. The taskforce evaluated each item on five criteria (evidence, prevalence, cost, relevance, innovation), and agreed to narrow the list to 16 items. The taskforce debated the conceptual merits of these 16, and selected nine in which to pursue in-depth evidence reviews and consultations with external content experts. Taskforce members then independently scored each item on a scale from 1-9, rating each item on its overall impact as well as on each of the five criteria. The five items with the best mean overall scores were retained in the “penultimate” list. The taskforce then reviewed and edited the wording of items on the penultimate list, and submitted it to the 4 societies’ executive committees. The executive committees sought feedback from additional experts in the field, debated the items, and provided written comments to the taskforce. The taskforce deliberated and incorporated these suggestions where appropriate to create the final list, resolving any conflicts through discussion. All four societies endorsed the final list.

Members of the taskforce were: Scott D. Halpern, MD, PhD (Chair), Deborah Becker, PhD, RN, J. Randall Curtis, MD, MPH, Robert Fowler, MD, Robert Hyzy, MD, Jeremy M. Kahn, MD, MSc, Lewis Kaplan, MD, Nishi Rawat, MD, Curtis Sessler, MD and Hannah Wunsch, MD, MSc.

The disclosure and conflict of interest policies for the American Association of Critical Care Nurses, American College of Chest Physicians, the American Thoracic Society and the Society of Critical Care Medicine can be found at www.accn.org, www.chestnet.org,www.thoracic.org and www.sccm.org respectively.

Sources

Brook AD, Ahrens TS, Schaiff R, Prentice D, Sherman G, Shannon W, Kollef MH. Effect of a nursing-implemented sedation protocol on the duration of mechanical ventilation. Crit Care Med. 1999;27:2609–15.

Girard TD, Kress JP, Fuchs BD, Thomason JW, Schweickert WD, Pun BT, Taichman DB, Dunn JG, Pohlman AS, Kinniry PA, Jackson JC, Canonico AE, Light RW, Shintani AK, Thompson JL, Gordon SM, Hall JB, Dittus RS, Bernard GR, Ely EW. Efficacy and safety of a paired sedation and ventilator weaning protocol for mechanically ventilated patients in intensive care (awakening and breathing controlled trial): a randomized controlled trial. Lancet. 2008;371(9607):126–34.

Jacobi J, Fraser GL, Coursin DB, Riker RR, Fontaine D, Wittbrodt ET, Chalfin DB, Masica MF, Bjerke HS, Coplin WM, Crippen DW, Fuchs BD, Kelleher RM, Marik PE, Nasraway SA Jr, Murray MJ, Peruzzi WT, Lumb PD;Task Force of the American College of Critical Care Medicine (ACCM) of the Society of Critical Care Medicine (SCCM), American Society of Health-System Pharmacists (ASHP), American College of Chest Physicians. Clinical practice guidelines for the sustained use of sedatives and analgesics in the critically ill adult. Crit Care Med. 2002;30(1):119–41.

Kress JP, Pohlman AS, O’Connor MF, Hall JB. Daily interruption of sedative infusions in critically ill patients undergoing mechanical ventilation. N Eng J Med. 2000;342:1471–7.

Mehta S, Burry L, Cook D, Fergusson D, Steinberg M, Granton J, Herridge M, Ferguson N, Devlin J, Tanios M, Dodek P, Fowler R, Burns K, Jacka M, Olafson K, Skrobik Y, Hébert P, Sabri E, Meade M; SLEAP Investigators; Canadian Critical Care Trials Group. Daily sedation interruption in mechanically ventilated critically ill patients cared for with a sedation protocol: a randomized controlled trial. JAMA. 2012;308(19):1985–92.