Document Detail

Daily sedation interruption in mechanically ventilated critically ill patients cared for with a sedation protocol: a randomized controlled trial.
MedLine Citation:
PMID:  23180503     Owner:  NLM     Status:  MEDLINE    
CONTEXT: Protocolized sedation and daily sedation interruption are 2 strategies to minimize sedation and reduce the duration of mechanical ventilation and intensive care unit (ICU) stay. We hypothesized that combining these strategies would augment the benefits.
OBJECTIVE: To compare protocolized sedation with protocolized sedation plus daily sedation interruption in critically ill patients.
DESIGN, SETTING, AND PATIENTS: Randomized controlled trial of 430 critically ill, mechanically ventilated adults conducted in 16 tertiary care medical and surgical ICUs in Canada and the United States between January 2008 and July 2011.
INTERVENTION: Continuous opioid and/or benzodiazepine infusions and random allocation to protocolized sedation (n = 209) (control) or to protocolized sedation plus daily sedation interruption (n = 214). Using validated scales, nurses titrated infusions to achieve light sedation. For patients receiving daily interruption, nurses resumed infusions, if indicated, at half of previous doses. Patients were assessed for delirium and for readiness for unassisted breathing.
MAIN OUTCOME MEASURE: Time to successful extubation. Secondary outcomes included duration of stay, doses of sedatives and opioids, unintentional device removal, delirium, and nurse and respiratory therapist clinical workload (on a 10-point visual analog scale [VAS]).
RESULTS: Median time to successful extubation was 7 days in both the interruption and control groups (median [IQR], 7 [4-13] vs 7 [3-12]; interruption group hazard ratio, 1.08; 95% CI, 0.86-1.35; P = .52). Duration of ICU stay (median [IQR], 10 [5-17] days vs 10 [6-20] days; P = .36) and hospital stay (median [IQR], 20 [10-36] days vs 20 [10-48] days; P = .42) did not differ between the daily interruption and control groups, respectively. Daily interruption was associated with higher mean daily doses of midazolam (102 mg/d vs 82 mg/d; P = .04) and fentanyl (median [IQR], 550 [50-1850] vs 260 [0-1400]; P < .001) and more daily boluses of benzodiazepines (mean, 0.253 vs 0.177; P = .007) and opiates (mean, 2.18 vs 1.79; P < .001). Unintentional endotracheal tube removal occurred in 10 of 214 (4.7%) vs 12 of 207 patients (5.8%) in the interruption and control groups, respectively (relative risk, 0.82; 95% CI, 0.36-1.84; P = .64). Rates of delirium were not significantly different between groups (53.3% vs 54.1%; relative risk, 0.98; 95% CI, 0.82-1.17; P = .83). Nurse workload was greater in the interruption group (VAS score, 4.22 vs 3.80; mean difference, 0.41; 95% CI, 0.17-0.66; P = .001).
CONCLUSION: For mechanically ventilated adults managed with protocolized sedation, the addition of daily sedation interruption did not reduce the duration of mechanical ventilation or ICU stay.
TRIAL REGISTRATION: Identifier: NCT00675363.
Sangeeta Mehta; Lisa Burry; Deborah Cook; Dean Fergusson; Marilyn Steinberg; John Granton; Margaret Herridge; Niall Ferguson; John Devlin; Maged Tanios; Peter Dodek; Robert Fowler; Karen Burns; Michael Jacka; Kendiss Olafson; Yoanna Skrobik; Paul Hébert; Elham Sabri; Maureen Meade; ;
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Publication Detail:
Type:  Comparative Study; Journal Article; Multicenter Study; Randomized Controlled Trial; Research Support, Non-U.S. Gov't    
Journal Detail:
Title:  JAMA     Volume:  308     ISSN:  1538-3598     ISO Abbreviation:  JAMA     Publication Date:  2012 Nov 
Date Detail:
Created Date:  2012-11-23     Completed Date:  2012-11-26     Revised Date:  2014-09-17    
Medline Journal Info:
Nlm Unique ID:  7501160     Medline TA:  JAMA     Country:  United States    
Other Details:
Languages:  eng     Pagination:  1985-92     Citation Subset:  AIM; IM    
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MeSH Terms
Airway Extubation
Analgesics, Opioid / administration & dosage*
Benzodiazepines / administration & dosage*
Clinical Protocols
Conscious Sedation / methods*
Critical Illness*
Drug Administration Schedule
Intensive Care Units
Middle Aged
Respiration, Artificial / methods*
Time Factors
Treatment Outcome
Grant Support
//Canadian Institutes of Health Research
Reg. No./Substance:
0/Analgesics, Opioid; 12794-10-4/Benzodiazepines
Comment In:
Med Klin Intensivmed Notfmed. 2013 Mar;108(2):153-5   [PMID:  23455442 ]
JAMA. 2012 Nov 21;308(19):2030-1   [PMID:  23168826 ]
JAMA. 2013 Mar 13;309(10):981   [PMID:  23483161 ]
JAMA. 2013 Mar 13;309(10):981-2   [PMID:  23483162 ]
JAMA. 2013 Mar 13;309(10):982-3   [PMID:  23483163 ]
JAMA. 2013 Mar 13;309(10):982-3   [PMID:  23483164 ]
Erratum In:
JAMA. 2013 Jan 16;309(3):237

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