What is the real impact of no sedation during mechanical ventilation?

EJRC ARTICLE REVIEW

For many years, standard therapy for patients undergoing mechanical ventilation included sedation. It was seen as a way to ease patients and help them to accept the procedure. In the last decade, randomised controlled trials (RCTs) have shown that utilising a sedation goal and daily wake-up reduced ventilation time, ICU length of stay of and hospitalisation (1) and even one-year mortality (2), but increased nursing workload (3).    

In a RCT published in 2000, the intervention group received bolus doses of morphine and the control group light sedation with a daily wake-up trial (4). They found a reduction of ventilation time, as well as a shorter LOS in the ICU and the hospital. However, concerns were raised that morphine was used as analgo-sedation, implying that there was no difference in the consciousness level.

The aim of this more recent study presented by Laerkner et al. was to replicate the design, but to focus on differences of consciousness in both groups and measure the objective and subjective nurses’ workload (5).

In this randomised trial, researchers reported data from 111 patients being ventilated more than 48 hours. Patients in both groups received bolus doses of morphine and only patients in the control group received sedation with propofol during the first 48 hours, and later midazolam. The nurse-patient ratio was 1:1 in both groups. Sedation was adjusted to RAMSEY 3-4 in the control group and consciousness was measured with the RASS scale (Richmond Agitation-Sedation Scale) (6). To measure the nurses’ workload, the Nursing Care Recording System (NCRS11) was used (7). Nurses’ self-assessed workload was measured on a Numeric Rating Scale from 1 (low) to 10 (high). Data was collected for the seven first days or until discharge. Cost per day and an average salary for an ICU and ward nurse was obtained for the whole hospital stay.

Patients from the intervention group were more awake through the first seven days compared to patients from the sedated control group, and had a median RASS score of -0,029 compared with -2 in the sedated control group (P<0⋅0000). The NCR11 scores were higher in the sedated control group: 19,054 versus 17⋅05 (P=0⋅00001). The nurse self-reported workload was the same in both groups. The use of no-sedation and a 1:1 nurse-patient ratio had a potential saving because of a shorter hospital stay in the no-sedation group.

This study supports the premise that working with a no-sedation strategy may be both possible and feasible in the ICU. It also stresses the fact that a 1:1 nurse-patient ratio allows for cost reduction when caring for conscious and awake mechanically ventilated patients. Future research should challenge experienced nurses to further develop their specific competences, and highlight the improvement in quality patient care and cost savings of this strategy.

Article review prepared and submitted by Madeleine Bruttin, member of the N&AHP section and the ESICM Journal Review Club.

References

1. Kress JP, Pohlman AS, O’Connor MF, & Hall JB (2000). Daily interruption of sedative infusions in critically ill patients undergoing mechanical ventilation. The New England Journal of Medicine; 342: 1471–1477.
2. Girard TD, Kress JP, Fuchs BD, Thomason JW, Schweickert WD, Pun BT, …& Ely EW. (2008). 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; 371, 126–134.
3. Tingsvik C, Bexell E, Andersson AC, & Henricson M. (2013). Meeting the challenge: ICU-nurses’ experiences of lightly sedated patients. Australian Critical Care, 26, 124–129.
4. Strom T, Martinussen T, & Toft P. (2010). A protocol of no sedation for critically ill patients receiving mechanical ventilation: a randomised trial. Lancet, 375, 475–480.
5. Laerkner E ,Stroem T, & Toft P. (2016). No sedation during mechanical ventilation: impact on patient’s consciousness, nursing workload and costs. Nursing in Critical Care, 21(1), 28–35. doi: 10.1111/nicc.12161
6. Sessler CN, Gosnell MS, Grap MJ, Brophy GM, O’Neal PV, Keane KA, ….& Elswick RK. (2002). The Richmond Agitation-Sedation Scale: validity and reliability in adult intensive care unit patients. American Journal of Respiratory and Critical Care Medicine, 166, 1338–1344.
7. Walther SM, Jonasson U, Karlsson S, Nordlund P, Johansson A, & Malstam J. (2004). Multicentre study of validity and inter-rater reliability of the modified Nursing Care Recording System (NCR11) for assessment of workload in the ICU. Acta Anaesthesiologica Scandinavica, 48, 690–696.