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Most good medical intensive care units have incorporated interruptions in sedation (so-called ‘sedation vacations’) into standard care for patients receiving mechanical ventilation. Avoiding excessive sedation in general is believed to reduce prolonged mechanical ventilation in ICUs.
However, there is surprisingly little data about effects of sedation (or over-sedation) on critically ill postoperative patients in the ICU.
The SOS-Ventilation trial, published in Lancet Respiratory Medicine, suggests that the benefits of reducing sedation could be even greater in postoperative critically ill patients than in medical patients -- at least in France.
Investigators enrolled 137 patients who were expected to require at least 12 hours of ventilation after abdominal surgery and who had some degree of organ failure. Patients were randomized to usual care or to immediate sedation interruptions (15 minutes after randomization, two hours after transfer from the operating room to the PACU). The study was done at three ICUs in France.
Strikingly, 70% of patients whose sedation was quickly interrupted were able to go without any further sedation for the full 28-day follow-up period.
The usual care patients received sedation for another ~33 hours on average. Less than a third of patients in either group required resumption of sedation.
Patients whose sedation was interrupted quickly were extubated in 8 hours, instead of more than two days later (50 hours) with usual care. They also had fewer days on high-dose vasopressors and were more likely to be discharged at 28 days.
Editorialists Dr. Matthias Eikermann and Dr. Todd W. Sarge from the anesthesia department at Beth Israel Deaconness Medical Center in Boston, Massachusetts concluded,
We have become successful in ensuring that patients admitted to hospital survive after undergoing major abdominal surgery. It is time to eliminate unnecessary treatments that predictably immobilize patients without improving the value of the care we provide. Interruption of sedation on arrival in the surgical ICU after abdominal surgery should become a new standard of care."
It's unknown how often oversedation occurs postoperatively in mechanically ventilated patients in U.S. ICUs. Numerous trials testing sedation interruptions are underway, but none specifically in surgical patients.