Sliding-scale intermittent sedation and analgesia regimens in surgical patients significantly reduced both mechanical ventilation time and the total amount of medication administered, compared with continuous infusions, according to a new study.
A preliminary analysis of the first yea r of data from this two-year study also found that the number of adverse events was not increased and the duration at target levels of sedation with midazolam and the analgesic fentanyl were equivalent, according to lead author Nicholas Sich, MD, a general surgeon at Abington Hospital, in Pennsylvania. The study was presented at the 2018 annual meeting of the Society of Critical Care Medicine (abstract 18).
It was the sliding-scale regimen that made the difference, Dr. Sich said. “Midazolam has been used in a continuous fashion for mechanical ventilation for decades. This is a new way to use classic drugs that adds to the armamentarium of medications available to intensivists to keep patients comfortable while intubated, with fewer side effects,” he said.
Both groups were targeted to a Richmond Agitation-Sedation Scale score of –1 and a Critical Care Pain Observation Tool target of 0, according to the researchers. From September 2016 to January 2018, data for intermittent versus continuous groups, respectively, showed that:
- mean ventilation times were 65.3 versus 111.9 hours (P<0.03);
- mean total doses of midazolam were 18.0 versus 73.1 mg (P=0.06); and
- mean total doses of fentanyl were 942 versus 5,848 mcg (P<0.01).
Benefits of Intermittent Sedation
“This new method of administering it does not have that effect,” he said. “Rather, it behaves more like propofol in that when you stop giving the medication, patients wake up within an hour or two, regardless of how many days they have been sedated.”
Dr. Sich said sliding-scale intermittent sedation “also trended toward significance in having less delirium” among patients, at 33% in the continuous group and 17% in the intermittent group.
The new method also reduced the amount of drugs needed in the first place. “Our data has already reached significance and we have not finished accruing patients,” Dr. Sich said. The data showed that by using these medications in a sliding scale, as-needed fashion, one-fourth of the sedative midazolam, and one-sixth of the narcotic fentanyl, were administered, while the same levels of sedation and comfort during mechanical ventilation were achieved.
Less time under sedation can have other benefits for patients, Dr. Sich added. “Perhaps, more importantly, these patients are extubated on average 24 hours or greater sooner than those using traditional continuous infusions, which will lead to less pulmonary complications, which is the most feared risk of prolonged mechanical intubation.”
The protocol is nurse driven, Dr. Sich said, praising the ICU nursing staff at Abington Hospital for their participation in the study. “It does not require a physician to put in as-needed orders for every hour, and also allows nurses to titrate the amount of medication that a patient needs,” he said. “It recognizes and solves the fact that there is not a ‘one size fits all’ as-needed dosing to keep patients sedated and comfortable with their pain control.”
Dr. Sich’s study drew praise from clinicians at the presentation. Tina L. Palmieri, MD, FACS, FCCM, the director of the burn ICU and a professor in the Department of Surgery, University of California Davis Health System, said the study provides important data on intermittent sedation dosing in the ICU.
“Continuous sedation has long been the culture for many ICUs, and this study challenges that culture,” said Dr. Palmieri, who was not associated with the study. “The reduction in days of ventilation and narcotic use without an increase in adverse events represents a significant improvement in patient outcomes as well as cost reduction.
“I encourage the authors to continue this study to completion, as it could represent a landmark study that changes the culture of sedation in the ICU,” Dr. Palmieri said. She also noted that the researchers and the ICU staff at the institution should be commended for incorporating the nurse-driven protocol, “as intermittent dosing is much more labor-intensive.”
“The results speak for themselves in providing better and safer care to one of the sickest patient populations in the hospital,” Dr. Sich said. It also works better for patients requiring more than three days of ventilator support, because patients intubated for a longer period must be switched off propofol to avoid propofol infusion syndrome, according to Dr. Sich.
The researchers would like to set up “a head-to-head trial with propofol infusions versus intermittent midazolam,” he said. “We believe that midazolam has less hemodynamic instability than propofol when used in this fashion, which is one of the worst side effects of propofol.”
Dr. Sich said, “Even if we can only show noninferiority to propofol in patient comfort and time to extubation, we believe that it would still be a significant finding.”