Sedation Vacation in the ICU

Sandeep Sharma; Dominic J. Valentino III.

Last Update: October 27, 2018.

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Introduction
As the name implies, the intensive care unit (ICU) is where a hospital's
sickest patients who require accelerated and concentrated care are admitted.
Many of these patients, an estimated 33% of all admissions, are admitted for
respiratory failure of one etiology or another and subsequently are intubated
and placed on mechanical ventilatory control. Part of the standard of care for
intubation is to sedate the patient continuously to reduce pain and anxiety;
decrease oxygen consumption and the body’s stress response; prevent
patient-ventilator desynchrony; reduce adverse neurocognitive impacts such
as depression and post-traumatic stress disorder and ventilator-associated
events including pneumonia and tracheostomy, and reduce total nursing
requirements.
The medications used to initiate and maintain sedation within an intensive
care unit setting include benzodiazepines such as diazepam, lorazepam, and
midazolam; opioid analgesics such as fentanyl, hydromorphone, morphine,
remifentanil, propofol, dexmedetomidine, and ketamine; and antipsychotics
such as haloperidol, quetiapine, and ziprasidone. No sedative is found to be
superior in efficacy or mortality. However, The Society of Critical Care
Medicine guidelines state to avoid benzodiazepines due to evidence of longer
duration of intubation. The choice of which sedative is best lies in the
practitioner's clinical assessment of individual patient scenarios, weighing the
risk/benefit profile of the medicine to each patient.
Regardless of which sedative agent was utilized, total continuous sedation
was found to be associated with an extension of the total length of intubation
and increased length of the ICU stay and limited the ability to properly assess
the mental status of the patient, increased the risk for delirium, and
suppressed brainwave function seen on EEG, linking to increased 6-month
mortality. It was assessed that daily, short-term cessation of sedation, a
“sedation vacation,” led to improved outcomes in patient care.
Sedation vacations were first introduced in 2000 with a study by J.P. Kress et
al. that was published in the New England Journal of Medicine and
recognized as a medical necessity for standard practice within the ICU to
wean patients from mechanical ventilation. The study of spontaneous-
awakening trials showed that daily sedation interruptions improved the time
to extubation of 64 patients by approximately 2 days which reduced the total
admission time to the ICU by 3.5 days. This study was further reinforced by
two separate trials, the Awakening and Breathing Controlled Trial in 2008
titled the “wake up and breathe” protocol and the No Sedation in Intensive
Care Unit Patients trial in 2010. Both of these supporting trials investigated
the impacts of imposing a protocol to evaluate and reduce sedation in a
structured format and found that spontaneous-breathing trials along with
sedation vacations reduced ventilatory dependent days and ICU admission
days when compared to non-structured or no sedation vacation protocols.
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Issues of Concern
Sedation vacations can sometimes result in complications, and each one
should be addressed accordingly. When sedation is turned off, the patient
may not remember that they were intubated and may be unaware of all of the
tubes and lines going into their body. Upon awakening, they may be confused
and anxious and may pull out the endotracheal tube or other deep lines. This
may result in laryngeal injury/laryngeal edema, and if not addressed in a
timely fashion, can lead to respiratory failure and may result in death. If the
patient is very anxious after the sedation is turned off, this might make the
sympathetic drive very high, which can result in tachycardia and high blood
pressure. Very high blood pressure, especially in elderly persons, can cause a
stroke or myocardial infarction.
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Clinical Significance
Sedation vacations are a balancing act of tightly titrating the sedative dose to
provide agitation free, comfortable sedation on the lowest dosage possible.
They are patient-specific, as various disease processes and patient tolerances
necessitate different doses of medicine. There are two primary scale systems
utilized to assess the degree of sedation and agitation present during a
sedation vacation withdrawal period to determine success of the vacation
versus the need for continued sedation. These are the Sedation-Agitation
Scale (SAS) and the Richmond Agitation-Sedation Scale (RASS). Sedation-
Agitation Scale places a numerical value on the mental status of a patient,
where 1 is an unarousable state, 4 is a calm and cooperative patient, and 7 is a
dangerously agitated or combative patient. The Richmond Agitation-Sedation
Scale has a similar parameter of mental status assessment with -5 being
unarousable, 0 being alert and calm, and +4 being a dangerously agitated or
combative patient. These scales provide input when determining how
aggressively protocol is implemented. Baseline mental status is also assessed
by the ability to follow commands, including eye opening and tracking, hand
squeezing, or tongue protrusion.
Several guidelines have been proposed which offer guidance on how to
assess and address sedation vacations. One such protocol with proven benefit
is the Wake Up and Breathe protocol which combines spontaneous-
awakening trials where sedative medicine is withdrawn to awaken the patient
with spontaneous-breathing trials where the body’s readiness to extubate
from mechanical ventilation is assessed in stepwise fashion where ability to
undergo spontaneous awakening trial is assessed for safety specifically
monitoring for active seizures, active alcohol withdrawal, agitation, use of
paralytic agents, active myocardial ischemia, and elevated intracranial
pressure. If any are present, spontaneous awakening trials cannot be
attempted and should be reevaluated in 24 hours. If none are present, a
sedation vacation should be attempted. Markers of failure include agitation
per SAS or RASS scales, pain, respiration rate greater than 35 breaths per
minute, oxygen saturation less than 88%, respiratory distress, or an acute
cardiac arrhythmia. Any markers of failure should prompt the restarting of
sedatives at 50% the previous dosage with reassessment in 24 hours.
If spontaneous awakening is successful, a spontaneous-breathing trial should
be performed. Markers that it is safe to do so include no agitation, oxygen
saturation greater than 88%, FiO2 less than 50%, PEEP less than 8 cm H2O,
no active myocardial ischemia, minimal vasopressor requirements, and good
inspiratory efforts. If any are present, restart sedation and reevaluate in 24
hours. Signs of spontaneous-breathing trial failure include respiratory rate
greater than 35 or less than 8 breaths per minute, oxygen saturation less than
88%, signs of respiratory distress, mental status changes, or acute cardiac
arrhythmia. If none of these are present, it is appropriate to consider
extubation of the patient. If the patient has been intubated for more than 48
hours and has no cuff leak, then a dose of steroid can be given 4 to 5 hours
before extubation and another dose can be given 4 to 5 hours after extubation.
This has been shown to decrease the rate of reintubation and laryngeal
edema.
The reason for sedation vacation or breathing trial failing should be identified
and addressed accordingly. If the patient is getting agitated and is delirious,
antipsychotics can be tried; if anxious, anxiolytics can be tried; or if in pain,
low dose fentanyl drip/morphine drip or patch can be tried. Patient delirium
and agitation can be very well controlled on dexmedetomidine, and as the
medication does not suppress the respiratory center, the patient can be
extubated while on continuous infusion of dexmedetomidine. Attention
should be paid to home medications, and if clinically permitted, a patient who
is on any anxiolytics, antipsychotics, or on any chronic pain medications
should continue them while sedated or restart them in a timely fashion to
prevent withdrawal.
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Questions
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References
1.
Larrow V, Klich-Heartt EI. Prevention of Ventilator-Associated
Pneumonia in the Intensive Care Unit: Beyond the Basics. J Neurosci
Nurs. 2016 Jun;48(3):160-5. [PubMed]
2.
 Ackrivo J, Horbowicz KJ, Mordino J, El Kherba M, Ellingwood J, Sloan K,
Murphy J. Successful Implementation of an Automated Sedation
Vacation Process in Intensive Care Units. Am J Med Qual. 2016
Sep;31(5):463-9. [PubMed]
3.
Khan BA, Fadel WF, Tricker JL, Carlos WG, Farber MO, Hui SL, Campbell
NL, Ely EW, Boustani MA. Effectiveness of implementing a wake up
and breathe program on sedation and delirium in the ICU. Crit. Care
Med. 2014 Dec;42(12):e791-5. [PMC free article] [PubMed]
4.
Fan T, Wang G, Mao B, Xiong Z, Zhang Y, Liu X, Wang L, Yang S.
Prophylactic administration of parenteral steroids for preventing
airway complications after extubation in adults: meta-analysis of
randomised placebo controlled trials. BMJ. 2008 Oct
20;337:a1841. [PMC free article] [PubMed]
5.
Rotondi AJ, Chelluri L, Sirio C, Mendelsohn A, Schulz R, Belle S, Im K,
Donahoe M, Pinsky MR. Patients' recollections of stressful experiences
while receiving prolonged mechanical ventilation in an intensive care
unit. Crit. Care Med. 2002 Apr;30(4):746-52. [PubMed]
6.
Ely EW, Truman B, Shintani A, Thomason JW, Wheeler AP, Gordon S,
Francis J, Speroff T, Gautam S, Margolin R, Sessler CN, Dittus RS,
Bernard GR. Monitoring sedation status over time in ICU patients:
reliability and validity of the Richmond Agitation-Sedation Scale
(RASS). JAMA. 2003 Jun 11;289(22):2983-91. [PubMed]
7.
Simmons LE, Riker RR, Prato BS, Fraser GL. Assessing sedation during
intensive care unit mechanical ventilation with the Bispectral Index
and the Sedation-Agitation Scale. Crit. Care Med. 1999
Aug;27(8):1499-504. [PubMed]
8.
Riker RR, Picard JT, Fraser GL. Prospective evaluation of the Sedation-
Agitation Scale for adult critically ill patients. Crit. Care Med. 1999
Jul;27(7):1325-9. [PubMed]
9.
Jablonski J, Gray J, Miano T, Redline G, Teufel H, Collins T, Pascual-
Lopez J, Sylvia M, Martin ND. Pain, Agitation, and Delirium Guidelines:
Interprofessional Perspectives to Translate the Evidence. Dimens Crit
Care Nurs. 2017 May/Jun;36(3):164-173. [PubMed]
10.
Kanji S, MacPhee H, Singh A, Johanson C, Fairbairn J, Lloyd T, MacLean
R, Rosenberg E. Validation of the Critical Care Pain Observation Tool in
Critically Ill Patients With Delirium: A Prospective Cohort Study. Crit.
Care Med. 2016 May;44(5):943-7. [PubMed]
11.
Davidson JE, Winkelman C, Gélinas C, Dermenchyan A. Pain, agitation,
and delirium guidelines: nurses' involvement in development and
implementation. Crit Care Nurse. 2015 Jun;35(3):17-31; quiz
32. [PubMed]
12.
Lee JM, Lee HB. Clinical year in review 2014: critical care
medicine. Tuberc Respir Dis (Seoul). 2014 Jul;77(1):6-12. [PMC free
article] [PubMed]
13.
Girard TD, Kress JP, Fuchs BD, Thomason JW, Schweickert WD, Pun BT,
Taichman DB, Dunn JG, Pohlman AS, Kinniry PA, Jackson JC, Canonico
AE, Light RW, Shintani AK, Thompson JL, Gordon SM, Hall JB, Dittus RS,
Bernard GR, Ely EW. Efficacy and safety of a paired sedation and
ventilator weaning protocol for mechanically ventilated patients in
intensive care (Awakening and Breathing Controlled trial): a
randomised controlled trial. Lancet. 2008 Jan 12;371(9607):126-
34. [PubMed]
14.
Toft P, Olsen HT, Jørgensen HK, Strøm T, Nibro HL, Oxlund J, Wian KA,
Ytrebø LM, Kroken BA, Chew M. Non-sedation versus sedation with a
daily wake-up trial in critically ill patients receiving mechanical
ventilation (NONSEDA Trial): study protocol for a randomised
controlled trial. Trials. 2014 Dec 20;15:499. [PMC free article]
[PubMed]
15.
Strøm T, Martinussen T, Toft P. A protocol of no sedation for critically
ill patients receiving mechanical ventilation: a randomised
trial. Lancet. 2010 Feb 06;375(9713):475-80. [PubMed]
16.
Youngquist P, Carroll M, Farber M, Macy D, Madrid P, Ronning J, Susag
A. Implementing a ventilator bundle in a community hospital. Jt Comm
J Qual Patient Saf. 2007 Apr;33(4):219-25. [PubMed]
17.
Plevin R, Callcut R. Update in sepsis guidelines: what is really
new? Trauma Surg Acute Care Open. 2017;2(1):e000088. [PMC free
article] [PubMed]
18.
 Rhodes A, Evans LE, Alhazzani W, Levy MM, Antonelli M, Ferrer R,
Kumar A, Sevransky JE, Sprung CL, Nunnally ME, Rochwerg B,
Rubenfeld GD, Angus DC, Annane D, Beale RJ, Bellinghan GJ, Bernard
GR, Chiche JD, Coopersmith C, De Backer DP, French CJ, Fujishima S,
Gerlach H, Hidalgo JL, Hollenberg SM, Jones AE, Karnad DR, Kleinpell
RM, Koh Y, Lisboa TC, Machado FR, Marini JJ, Marshall JC, Mazuski JE,
McIntyre LA, McLean AS, Mehta S, Moreno RP, Myburgh J, Navalesi P,
Nishida O, Osborn TM, Perner A, Plunkett CM, Ranieri M, Schorr CA,
Seckel MA, Seymour CW, Shieh L, Shukri KA, Simpson SQ, Singer M,
Thompson BT, Townsend SR, Van der Poll T, Vincent JL, Wiersinga WJ,
Zimmerman JL, Dellinger RP. Surviving Sepsis Campaign: International
Guidelines for Management of Sepsis and Septic Shock: 2016. Crit.
Care Med. 2017 Mar;45(3):486-552. [PubMed]
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