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

Data: In a multicenter European trial (MIDEX), Jakob et al. compared midazolam (n=251) with

dexmedetomidine (n=249) for sedation in prolonged mechanical ventilation. Patients in both groups

were treated with daily sedation interruption trials and SBTs, and pain was treated with fentanyl

boluses. There was no difference in the primary outcome: proportion of time in target RASS (0, -3)

without rescue therapy in the midazolam group (56%) versus the dexmedetomidine group (60%).

Median time on mechanical ventilation was lower in the dexmedetomidine group (5 days) than in the

midazolam group (6.8 days), p=0.03. Patients in the dexmedetomidine group were more arousable,

more cooperative, and better able to communicate discomfort or pain to clinical staff than were patients

in the midazolam group. Hypotension occurred more often in the dexmedetomidine group (20.6%) than

in the midazolam group (11.6%; p=0.007); and bradycardia was more common in the dexmedetomidine

group (14.2%) than in the midazolam group (5.2%; p<0.001). The two treatment groups showed no

difference in neurocognitive adverse events after 48 hours of follow-up, including agitation, anxiety,

Adverse effects: Paradoxical agitation and prolonged duration of sedative action, respiratory depression,

hypotension, bradycardia

Titration of Sedation in the ICU

Titration of medications using a sedation protocol to a goal level of sedation is arguably one of the

most salient clinical practice standards within ICU care. This titration practice has consistently been

shown to decrease time on mechanical ventilation, decrease ICU length of stay, and decrease rates of

tracheostomy, which may all result in faster physical and cognitive rehabilitation time.

The goal level of sedation should be reassessed daily, documented, and communicated clearly to

the nursing and medical staff because the goal may change throughout a patient’s ICU stay.

Level of sedation should be assessed every 2–4 hours throughout the day and evening. Consider

assessing every 4 hours during nighttime sleeping hours to minimize sleep interruption.

The two validated sedation scales currently recommended by the PADIS guidelines are the RASS

(Table 5) and the Riker Sedation-Agitation Scale (Table 6).

level of sedation, unless clinically contraindicated, or (2) daily SAT. The PADIS guidelines suggest

using light sedation (vs. deep sedation) in critically ill, mechanically ventilated adults. Light sedation

is defined as a RASS of –2 to +1 or an SAS of 3 or 4, per the PADIS Guidelines. However, a pilot study

from 2022 suggested that a RASS of –1 and an SAS of 4 indicate light sedation.

Patients should receive sedation only if required.

Sedatives should be titrated to allow patient responsiveness and awareness, as shown by patients’

ability to purposefully respond to a combination of any three of the following actions on request:

open eyes, maintain eye contact, squeeze hand, stick out tongue, and wiggle toes. A numerical

score on a sedation scale may not fully represent a patient’s ability to follow purposeful commands.

Data: In a multicenter, prospective, longitudinal Australian and New Zealand Study, Shehabi et al.

evaluated 251 medical/surgical patients who were ventilated and sedated for 24 hours or more. Within 4

hours of initiating ventilation, deep sedation occurred in 191 patients (76.1%) and in 171 patients (68%)

at 48 hours. Early deep sedation was an independent predictor of time to extubation (HR 0.90; 95% CI,

0.87–0.94; p<0.001), hospital death (HR 1.11, 95% CI, 1.02–1.20; p=0.01), and 180-day mortality (HR