COCHRANE CORNER
By Chen Xiaojuan, BSN, RN
Editor’s note: This is a summary of a nursing care–related systematic review from the Cochrane Library.
Daily Sedation Interruption in Critically Ill Patients on Mechanical Ventilation REVIEW QUESTION
Does daily sedation interruption reduce the duration of mechanical ventilation in critically ill patients compared with no daily sedation interruption?
TYPE OF REVIEW
This review included nine randomized controlled trials, for a total of 1,282 mechanically ventilated patients. Five studies were from North America, two were from Europe, one was from Australia, and one was from Brazil. Meta-analysis was undertaken where possible.
RELEVANCE FOR NURSING
Sedatives are commonly administered to critically ill patients on mechanical ventilation, even though too much sedation in this population can cause adverse effects such as increased time on ventilation and pneumonia. One strategy for minimizing these effects is to stop the continuous infusion of sedation for a period of time each day. This interruption of sedation may reduce drug bioaccumulation in these patients, thereby making them more alert and providing an opportunity to evaluate weaning of sedation and extubation readiness. However, some clinicians are reluctant to interrupt sedation because of concerns that patients’ alertness may lead to accidental removal of the endotracheal tube or result in more pain or discomfort.
CHARACTERISTICS OF THE EVIDENCE
All 1,282 patients were adults (at least 16 years of age), were medical or surgical patients, and had been admitted to the ICU. The intervention compared daily sedation interruption with no daily sedation interruption (either usual sedation practice or protocol-based sedation practice). The primary outcome was duration of mechanical ventilation. Secondary outcomes included mortality, length of ICU or hospital stay, adverse event rates, total drug doses, and quality of life. There was no strong evidence in the nine trials that daily sedation interruption alters duration of mechanical ventilation when compared with no daily interruption. Among the secondary outcomes, a pooled analysis of seven trials demonstrated no difference in overall [email protected]
mortality or in ICU or hospital mortality between the daily sedation interruption and control groups. A pooled analysis of the nine trials also found no difference in length of ICU stay. A pooled analysis of six trials indicated no difference between groups in the adverse event rate of accidental endotracheal tube removal. However, tracheostomy was performed less frequently in the daily sedation interruption group than in the no daily sedation interruption group, which was considered moderate quality evidence. There was also no difference between groups in drug consumption in eight trials. Finally, a pooled analysis of three trials revealed no difference between study groups in quality of life.
BEST PRACTICE RECOMMENDATIONS
Daily sedation interruption is more or less as effective as other sedation strategies for reducing the duration of mechanical ventilation in critically ill patients. Maintaining a patient with a light level of sedation that enables participation in care activities should be the goal of care. This may be achieved by ongoing assessment of sedation using a validated tool and by titration of sedatives toward achieving this target via either the usual practice on the unit or a protocol. Daily interruption of sedation may not add further benefit if this goal is achieved.
RESEARCH RECOMMENDATIONS
Future research should consider strategies to blind outcome assessment and, if possible, the intervention as well, since clinician decision making can influence the duration of mechanical ventilation and the assessment of readiness for weaning and extubation. ▼ Chen Xiaojuan is senior staff nurse at the National University Cancer Institute, Singapore, and a member of the Cochrane Nursing Care Field.
SOURCE DOCUMENT Burry L, et al. Daily sedation interruption versus no daily sedation interruption for critically ill adult patients requiring invasive mechanical ventilation. Cochrane Database Syst Rev 2014;7:CD009176.
AJN ▼ May 2015
▼
Vol. 115, No. 5
21
By Chen Xiaojuan, BSN, RN
Editor’s note: This is a summary of a nursing care–related systematic review from the Cochrane Library.
Daily Sedation Interruption in Critically Ill Patients on Mechanical Ventilation REVIEW QUESTION
Does daily sedation interruption reduce the duration of mechanical ventilation in critically ill patients compared with no daily sedation interruption?
TYPE OF REVIEW
This review included nine randomized controlled trials, for a total of 1,282 mechanically ventilated patients. Five studies were from North America, two were from Europe, one was from Australia, and one was from Brazil. Meta-analysis was undertaken where possible.
RELEVANCE FOR NURSING
Sedatives are commonly administered to critically ill patients on mechanical ventilation, even though too much sedation in this population can cause adverse effects such as increased time on ventilation and pneumonia. One strategy for minimizing these effects is to stop the continuous infusion of sedation for a period of time each day. This interruption of sedation may reduce drug bioaccumulation in these patients, thereby making them more alert and providing an opportunity to evaluate weaning of sedation and extubation readiness. However, some clinicians are reluctant to interrupt sedation because of concerns that patients’ alertness may lead to accidental removal of the endotracheal tube or result in more pain or discomfort.
CHARACTERISTICS OF THE EVIDENCE
All 1,282 patients were adults (at least 16 years of age), were medical or surgical patients, and had been admitted to the ICU. The intervention compared daily sedation interruption with no daily sedation interruption (either usual sedation practice or protocol-based sedation practice). The primary outcome was duration of mechanical ventilation. Secondary outcomes included mortality, length of ICU or hospital stay, adverse event rates, total drug doses, and quality of life. There was no strong evidence in the nine trials that daily sedation interruption alters duration of mechanical ventilation when compared with no daily interruption. Among the secondary outcomes, a pooled analysis of seven trials demonstrated no difference in overall [email protected]
mortality or in ICU or hospital mortality between the daily sedation interruption and control groups. A pooled analysis of the nine trials also found no difference in length of ICU stay. A pooled analysis of six trials indicated no difference between groups in the adverse event rate of accidental endotracheal tube removal. However, tracheostomy was performed less frequently in the daily sedation interruption group than in the no daily sedation interruption group, which was considered moderate quality evidence. There was also no difference between groups in drug consumption in eight trials. Finally, a pooled analysis of three trials revealed no difference between study groups in quality of life.
BEST PRACTICE RECOMMENDATIONS
Daily sedation interruption is more or less as effective as other sedation strategies for reducing the duration of mechanical ventilation in critically ill patients. Maintaining a patient with a light level of sedation that enables participation in care activities should be the goal of care. This may be achieved by ongoing assessment of sedation using a validated tool and by titration of sedatives toward achieving this target via either the usual practice on the unit or a protocol. Daily interruption of sedation may not add further benefit if this goal is achieved.
RESEARCH RECOMMENDATIONS
Future research should consider strategies to blind outcome assessment and, if possible, the intervention as well, since clinician decision making can influence the duration of mechanical ventilation and the assessment of readiness for weaning and extubation. ▼ Chen Xiaojuan is senior staff nurse at the National University Cancer Institute, Singapore, and a member of the Cochrane Nursing Care Field.
SOURCE DOCUMENT Burry L, et al. Daily sedation interruption versus no daily sedation interruption for critically ill adult patients requiring invasive mechanical ventilation. Cochrane Database Syst Rev 2014;7:CD009176.
AJN ▼ May 2015
▼
Vol. 115, No. 5
21
