No sedation for mechanical ventilation

The standard practice for mechanical ventilation on an intensive care unit (ICU) is to sedate the patient. Studies of daily interruption of sedation have shown that it reduces the duration of mechanical ventilation, possibly reduces the risk of post-traumatic stress disorder, and reduces the risks of ventilator-associated pneumonia, upper gastrointestinal bleeding, bacteraemia, barotraumas, venous thromboembolism, cholestasis, and severe sinusitis.

In Odense, Denmark, the practice since 1999 has been to give intravenous morphine but no sedatives or analgesics. Now, researchers there have compared no sedation (NS) with daily interrupted sedation (DIS).

A total of 140 patients on mechanical ventilation were randomized to NS or DIS with propofol for 48 hours and then midazolam. Bolus doses of morphine were given in both groups. The analysis included 113 patients. In the first 28 days the mean number of days without ventilation was 13.8 days (NS) vs 9.6 days (DIS), a significant difference. NS was also significantly associated with a shorter stay in ICU and in hospital. Agitated delirium was more frequent in the NS group (20% vs 7%). The groups did not differ significantly in the frequency of accidental extubation, ventilator-associated pneumonia, or requests for CT o MRI brain scans.

The NS policy appeared to be advantageous. A multicentre study is called for.

Strøm T et al. A protocol of no sedation for critically ill patients receiving mechanical ventilation: a randomized trial. Lancet 2010; 375:475–480; Brochard L. Less sedation in intensive care: the pendulum swings back. Ibid: 436–438 (comment).