Pain, Agitation/Sedation, Delirium, Immobility, Sleep Disruption, and Neuromuscular Blockade

A randomized trial (FAST) using a 2×2 factorial design included patients that had been on the ventilator

for at least 24 hours who could initiate spontaneous breaths and were on an FIo2 of 70% or less and

a PEEP of 12 or less. Patients were randomized to more frequent or once-daily trials using a T piece

or an SBT lasting 30–120 minutes. There were 198 patients in the once-daily screening and pressure-

supported SBT group, 204 in the the once-daily screening and T-piece SBT, 195 in the more frequent

screening and pressure-supported SBT, and 200 in the more frequent screening and T-piece. SBT.

The median time to successful extubation was 2 days (95% CI, 1.7–2.7) for once-daily screening and

pressure-supported SBT, 3.1 days (95% CI, 2.7–4.8) for once-daily screening and T-piece SBT, 3.9 (95%

CI, 2.9–4.7) for more frequent screening and pressure-supported SBT, and 2.9 (95% CI, 2.0–3.1) for

more frequent screening and T-piece SBT. An interaction was found between screening frequency

and SBT technique, which showed that more frequent screening and pressure-supported SBT increased

the time to successful extubation (HR, 0.70 [95% CI, 0.50–0.96]; P = .02. Screening once-daily and

pressure-supported SBT did not reduce the time to successful extubation (HR 1.3 [95% CI, 0.98–1.70];

P = .08).

Patients who have been receiving high doses of continuous infusion sedation and/or analgesia in the

ICU for an extended period may be at risk of sedative or analgesia withdrawal as dose tapering begins.

In a retrospective review of adult trauma/surgical ICU patients, 32% of patients experienced either

sedative or opiate withdrawal soon after discontinuing these medications. The patients in this study

had been in the ICU for 20 days or more and were receiving higher mean daily analgesic and sedative

doses than were the non-withdrawal patients (fentanyl 6.4 mg vs. 1.4 mg; lorazepam 38 mg vs. 11 mg).

1998;26:676-84).

that a small number of ICUs have policies or protocols for opioid or sedative weaning or iatrogenic

withdrawal syndrome. Even when these protocols exist, they are rarely used.

The risk factors and incidence of sedation or analgesia withdrawal in adult ICU patients have not been

well characterized; however, these are important considerations in the long-term ICU patient receiving

high doses of these medications. Use of longer-acting agents given orally or by feeding tube has been

described to assist in the transition off long-term continuous infusions. The medical indication and

dosing plan for using oral medications to taper off continuous infusions should be clearly documented

in the medical chart on patient discharge from the ICU. Clonidine is a potential consideration in patients

to aid in dexmedetomidine withdrawal.