Better outcomes with quick interruption of sedation in surgical ICU

Last Updated: 2017-10-02

By Will Boggs MD

NEW YORK (Reuters Health) - Critically ill postoperative patients fare better when sedation is interrupted as soon as possible after admission to the ICU, compared with usual sedation care, according to results from the SOS-Ventilation trial.

"The most interesting and surprising result is that interrupting sedation as early as in the intervention group (2 hours after the transfer from the operating room, and 15 minutes after randomization) was so easy to do in these critically ill postoperative patients: in 71% of the cases, no sedation was necessary anymore until day 28 follow-up," Dr. Gerald Chanques from Montpellier University Saint Eloi Hospital, in France, told Reuters Health by email. "This is a major point because unnecessary sedation can be associated with bad outcomes: longer duration of mechanical ventilation, ICU and hospital lengths of stay, as well as ICU complications."

Dr. Chanques and colleagues evaluated whether immediate cessation of sedation could improve postoperative outcomes compared with usual sedation care in a randomized trial of 137 patients admitted to one of three ICUs in France after abdominal surgery.

All patients were expected to require at least 12 hours of mechanical ventilation for critical illness, defined by a Sequential Organ Failure Assessment score >1 for any organ, but without severe acute respiratory distress syndrome or brain injury.

Continuous sedation was stopped a median 15 minutes after randomization in the immediate-interruption group, versus 33 hours in the control group. Fewer than 30% of patients in both groups required resumption of sedation.

Median time between randomization and successful extubation for at least 48 hours, the primary outcome, was significantly shorter with immediate interruption (8 hours) than usual care (50 hours), according to the September 18 Lancet Respiratory Medicine online report.

Fewer patients in the immediate-interruption group than the usual-care group developed coma (15 vs. 34) or delirium (28 vs. 48), and the intervention group had significantly more delirium-free days (median, 28 vs. 26 days).

Patients in the immediate-interruption group also had more ventilator-free days, fewer days on high-dose vasopressors, and a higher probability of being discharged by day 28, compared with patients in the usual sedation group.

"In all, our results should encourage intensivists to immediately stop sedation in postoperative ICU patients to prevent any potential iatrogeny related to 'unnecessary use of sedation,' even in case of septic shock, as soon as possible," Dr. Chanques said.

"However, this strategy should not be done without strict adherence to recommended guidelines on Pain Agitation and Delirium, such as the 2013 PAD guidelines made by the Society of Critical Care Medicine (http://bit.ly/2xM7xe7)," he cautioned. "These guidelines recommend assessing and detecting agitation, pain, and delirium in all ICU patients, whether they are sedated or not, mechanically ventilated or not. Without implementing these guidelines, an early stop of sedation will be as 'going skydiving without a parachute.'"

"This strategy needs further studies to assess its feasibility and its impact in other patient populations, such as (those) undergoing different surgical interventions than abdominal surgery, medical patients just after intubation and achievement of invasive procedures, patients with a more severe acute lung injury, and so on," Dr. Chanques said.

"We have become successful in ensuring that patients admitted to hospital survive after undergoing major abdominal surgery," write Dr. Matthias Eikermann and Dr. Todd W. Sarge from Beth Israel Deaconness Medical Center, Boston, Massachusetts in a related editorial. "It is time to eliminate unnecessary treatments that predictably immobilize patients without improving the value of the care we provide."

The editorial concludes, "Interruption of sedation on arrival in the surgical ICU after abdominal surgery should become a new standard of care."

SOURCES: http://bit.ly/2yK8hyN and http://bit.ly/2hBUx4V

Lancet Respir Med 2017.