Despite its importance across a range of clinical contexts, sedation, if too prolonged, can lead to risks and undesired side-effects. These clinical risks are important to be aware of and minimize as much as possible in a patient-centric way.

First, a 2010 study found that critically ill patients receiving mechanical ventilation had more days without ventilation when receiving no sedation versus sedation.¹ Second, a 2015 study seeking to determine the short- and long-term outcomes of sedation on critically ill patients with acute respiratory insufficiency ² found that sedation was associated with longer hospital stays and even death. Compared with those who did not receive sedation, patients having received sedation were ventilated for longer, stayed in the intensive care unit and hospital longer, and experienced increased in-hospital mortality rates. Furthermore, compared to administering light sedation or interrupting a patient’s sedated state on a daily basis, deep sedation increased in-hospital mortality and decreased 60-month survival rates.

A 2004 study was one of the first to point out the risks of prolonged sedation in particular. It revealed that daily interruption of sedative infusions in critically ill patients receiving mechanical ventilation, by reducing intensive care unit length of stay, minimizes medical complications resulting from prolonged intubation or mechanical ventilation.³ Consistently, another study found that daily sedative interruption did not result in adverse psychological outcomes and could be linked to a reduction in post-traumatic stress disorder manifestations in critically ill patients.⁴

Most recently, a research study conducted at Vanderbilt University in 2013 further sought, a year post-discharge, to probe the cognitive skills of hospital patients with respiratory failure or septic shock who stayed in an intensive care unit for five days. Data confirmed that prolonged sedation may either trigger or exacerbate delirium, which may already affect patients experiencing septic shock to a certain degree.

As a result of the study, Vanderbilt implemented a system to wean intensive care unit patients off sedatives, waking them up regularly to assess whether they could breathe on their own, and getting them out of bed and moving as swiftly as possible.

In light of these results, it is not surprising that nearly 80% of patients who stay in the intensive care unit for a prolonged period – often heavily sedated and ventilated – experience cognitive problems a year or more following their discharge.⁵

A number of different factors and methods have been found to impact the need for sedatives while these continue to be researched on an ongoing basis. First, listening to music in the intensive care unit has been demonstrated to reduce the need for sedatives. Indeed, letting critically ill patients listen to their favorite music may reduce stress levels and sedative intake by more than one-third.⁶

Second, small modifications in hospital routines, such as in the timing of vital sign monitoring and routine medication administration, may also significantly reduce sedative use.⁷

Finally, in recent years, patient-targeted sedation protocols relying on structured assessments, to inform a strategically titrated drug escalation and withdrawal, have greatly enhanced patient outcomes. Furthermore, daily interruption of continuous sedative infusions may also improve outcomes.⁸

The effects and risks of prolonged sedation are important to consider for patient well-being, both clinically and post-clinically. In light of the fact that intensive care unit admissions have increased by 50% in the last decade,⁹ a better understanding and implementation of patient-tailored sedation protocols will remain critical into the future.

References

1. Strom, T., Martinussen, T., & Toft, P. A protocol of no sedation for critically ill patients receiving mechanical ventilation: a randomised trial. Lancet (2010), doi: 10.1016/S0140-6736(09)62072-9

2. Xing, X. et al. Effect of sedation on short-term and long-term outcomes of critically ill patients with acute respiratory insufficiency. World J. Emerg. Med. (2015). doi:10.5847/wjem.j.1920-8642.2015.02.011

3. Schweickert, W. D., Gehlbach, B. K., Pohlman, A. S., Hall, J. B. & Kress, J. P. Daily interruption of sedative infusions and complications of critical illness in mechanically ventilated patients. Critical Care Medicine (2004). doi:10.1097/01.CCM.0000127263.54807.79

4. Kress, J. P. et al. The Long-term Psychological Effects of Daily Sedative Interruption on Critically III Patients. Am. J. Respir. Crit. Care Med. (2003). doi:10.1164/rccm.200303-455OC

5. Pandharipande, P. P. et al. Long-Term Cognitive Impairment after Critical Illness. N. Engl. J. Med. (2013). doi:10.1056/nejmoa1301372

6. Chlan, L. L. et al. Effects of patient-directed music intervention on anxiety and sedative exposure in critically Ill patients receiving mechanical ventilatory support: A randomized clinical trial. JAMA – J. Am. Med. Assoc. (2013). doi:10.1001/jama.2013.5670

7. Bartick, M. C., Thai, X., Schmidt, T., Altaye, A. & Solet, J. M. Decrease in as-needed sedative use by limiting nighttime sleep disruptions from hospital staff. J. Hosp. Med. (2010). doi:10.1002/jhm.549

8. Schweickert, W. D. & Kress, J. P. Strategies to optimize analgesia and sedation. Critical Care (2008). doi:10.1186/cc6151

9. Mullins, P. M., Goyal, M. & Pines, J. M. National growth in intensive care unit admissions from emergency departments in the United States from 2002 to 2009. Acad. Emerg. Med. (2013). doi:10.1111/acem.12134