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

In a single-center, nested cohort study within the Awakening and Breathing Controlled (ABC)

randomized trial, Seymour et al. evaluated 140 patients for whom hourly doses of benzodiazepines

and propofol during the daytime (7 a.m. to 11 a.m.) and nighttime (11 p.m. to 7 a.m.) for 5 days were

measured. Greater daytime benzodiazepine doses were independently associated with failed SBT and

extubation and subsequent delirium in adjusted models (p<0.02 for all). A failed SBT (p<0.01) and

2012;40:2788-96).

SAT Paired with SBT: The daily coordination of an SAT completed before an SBT is a method of weaning

sedation before attempts at breathing trials in order to maximize a patient’s chances of weaning from

mechanical ventilation. This pairing of an SAT before an SBT is becoming recognized as an important

component to ICU care and management of sedation. Important safety screens are incorporated into the

daily SAT because studies have shown that the SAT is not appropriate for all ICU patients. If a patient does

not pass the safety screen and does not undergo the SAT, this should not preclude the appropriate titration

of sedatives to a goal level of sedation throughout the remainder of the day:

SAT safety screen (criteria may vary; published trial protocols have had variations): If any are present,

discontinue the protocol and repeat in 12–24 hours or according to hospital protocol:

Current RASS greater than 2; or goal for deeper sedation (e.g., RASS -3 to -5)

Active seizures requiring a continuous infusion of a sedative to control

Active alcohol withdrawal requiring a continuous infusion of a sedative to control

Neuromuscular blockade

Myocardial ischemia in previous 24 hours or ongoing myocardial ischemia

Intracranial pressure (ICP) greater than 20 mm Hg or need for control of ICP

are recommended for breakthrough pain. Continuous opioid infusions allowed to continue while

stopping sedatives if presence of active pain. If the patient “passes” the SAT, continue to the SBT safety

screen.

SAT failure (if any are present, discontinue the protocol, and repeat in 12–24 hours or according to

hospital protocol):

Anxiety/agitation/pain present (e.g., RASS greater than +1 for 5 minutes or more)

Respiratory rate greater than 35 breaths/minute for 5 minutes or more

Oxygen saturation less than 88% for 5 minutes or more

Acute cardiac ischemia or arrhythmia

Respiratory or cardiac distress (e.g., heart rate increase of 20 beats/minute or greater, heart rate

less than 55 beats/minute, use of accessory muscles, abdominal paradox, diaphoresis, or dyspnea)

If SAT fails: Consider giving patient bolus opioids first (up to three doses in 1 hour) before restarting

infusion. Reinitiate sedation infusion, if necessary, at half the previous dose and titrate to goal.

Determine the reasons for SAT failure. Repeat SAT steps in 12–24 hours or according to hospital

protocol.

SBT safety screen (if any are present, discontinue the protocol; repeat in 12–24 hours or according to

hospital protocol):

Agitation

Oxygen saturation less than 88%, Fio2 greater than 50%

PEEP (positive end-expiratory pressure) of 7 cm H2O or greater

Increasing vasopressor requirements

Lack of inspiratory efforts