Tools Are Needed to Promote Sedation Practices for Mechanically Ventilated Patients

Abstract

Suboptimal sedation practices continue to be frequent, although the updated guidelines for management of pain, agitation, and delirium in mechanically ventilated (MV) patients have been published for several years. Causes of low adherence to the recommended minimal sedation protocol are multifactorial. However, the barriers to translation of these protocols into standard care for MV patients have yet to be analyzed. In our view, it is necessary to develop fresh insights into the interaction between the patients' responses to nociceptive stimuli and individualized regulation of patients' tolerance when using analgesics and sedatives. By better understanding this interaction, development of novel tools to assess patient pain tolerance and to define and predict oversedation or delirium may promote better sedation practices in the future.

Factors Associated With Deep Sedation Practice in Mechanically Ventilated Patients: A Post hoc Analysis of a Cross–Sectional Survey Combined With a Questionnaire for Physicians on Sedation Practices

“…Based on the opinions of experts, deep sedation was recommended only for managing a few specific situations in MV patients, such as severe acute respiratory distress syndrome (ARDS) with ventilator–patient asynchrony or use of neuromuscular blocking agents, severe brain injury with severe intracranial hypertension, and status epilepticus ( 26 – 29 ). Meanwhile, indications for deep sedation or contraindications for maintaining MV patients at light levels of sedation remain unexplained ( 30 ). One of the important barriers is how to define the intensity of stimuli–induced discomfort requiring deep levels of sedation.…”

“…However, the result of the RASS assessment is the transient tolerability of MV patients regulated by the infused analgesics and sedatives. While the intensity of nociceptive stimuli changes because of the occurrence or disappearance of fever, thirst, drainage tube pain, andintestinal colic as well as upregulation or downregulation of supportive therapies such as changes in ventilator settings, significantly, MV patients would become over—or under–sedated as the dosages of sedatives and analgesics were unchanged ( 30 ). This partially at least accounts for the frequent and unpredictable agitation as well as oversedation in the real practice.…”

“…Some limitations to our study should be addressed. First, this is a post hoc analysis of a study aimed at developing a model for the prediction of agitation in MV patients maintained under light sedation ( 30 ). Some important measurements such as anxiety score and pain score were not collected in this study.…”