Limiting sedation for patients with acute respiratory distress syndrome – time to wake up

Abstract

Purpose of Review Critically ill patients with acute respiratory distress syndrome (ARDS) may require sedation in their clinical care. The goals of sedation in ARDS patients are to improve patient comfort and tolerance of supportive and therapeutic measures without contributing to adverse outcomes. This review discusses the current evidence for sedation management in patients with ARDS. Recent Findings Deep sedation strategies should be avoided in the care of patients with ARDS because deep sedation has been associated with increased time on mechanical ventilation, longer ICU and hospital length of stay, and higher mortality in critically ill patients. Adoption of protocol-based, light-sedation strategies are preferred and improve patient outcomes. Although the optimal sedative agent for ARDS patients is unclear, benzodiazepines should be avoided due to associations with oversedation, delirium, prolonged intensive care unit and hospital length of stay, and increased mortality. Minimizing sedation in patients with ARDS facilitates early mobilization and early discharge from the intensive care unit, potentially aiding in recovery from critical illness. Strategies to optimize ventilation in ARDS patients, such as low-tidal volume ventilation and high positive end-expiratory pressure (PEEP) can be employed without deep sedation; however, deep sedation is required if patients receive neuromuscular blockade, which may benefit some ARDS patients. Knowledge gaps persist as to whether or not prone positioning and extracorporeal membrane oxygenation (ECMO) can be tolerated with light sedation. Summary Current evidence supports the use of protocol-based, light-sedation strategies in critically ill patients with ARDS. Further research into sedation management specifically in ARDS populations is needed.

Safety of psychotropic medications in people with COVID-19: evidence review and practical recommendations

“…The risk of respiratory distress is probably higher for highly sedative agents, particularly at higher doses, in combination, and when they are prescribed in Low patients with pre-existing respiratory impairment [39,90]. In case of psychomotor agitation requiring rapid tranquilization with antipsychotics (e.g., hyperkinetic delirium), the risk for acute extrapyramidal symptoms (e.g., dystonia, with possible impaired swallowing and consequent risk of aspiration) and reduced mobility can notably worsen respiratory distress [80,107]. Mood stabilizers have mild-to-moderate sedative profiles, and there is no evidence of a relevant risk for excessive sedation and related respiratory distress [24,66].…”

Patients’ lived experience of intensive care when being on mechanical ventilation during the weaning process: A hermeneutic phenomenological study

“…Ventilators have been developed to optimise the treatment and make it more comfortable (Boles et al, 2007, Karcz et al, 2012. Strategies for sedation and pain treatment have also improved (Barr et al, 2013, Egerod et al, 2013, Shah et al, 2017. Today, the benefits of less sedation during MV are well accepted.…”

Role of Neuromuscular Blocking Agents in Acute Respiratory Distress Syndrome: An Updated Meta-Analysis of Randomized Controlled Trials

“…Sedation is frequently prescribed in patients with ARDS, which facilitates tolerance of the intubation tube, reduces discomfort, and in some cases can improve patient-ventilator synchrony (Bourenne et al, 2017). Previous studies have indicated that early deep sedation can predispose a patient to double triggering and VILI, in addition to delirium, a longer time on mechanical ventilation or longer stay in the ICU, and an increased risk of ventilator-associated pneumonia (Balzer et al, 2015;Shah et al, 2017). However, minimizing sedation had beneficial effects in critically ill patients, improving the ability to participate in early exercise and rehabilitation in patients with ARDS (Kayambu et al, 2013).…”