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    Sedative Interruption Strategy Results in Better ICU Outcomes

    By Jennifer Huddleston, staff writer     

    A protocol for weaning patients from daily sedation and ventilation—called daily sedative interruption—can reduce a patient’s time spent in an intensive care unit (ICU), reduce the likelihood of negative cognitive results and even save a patient’s life, according to researchers who studied the strategy.

    Despite these findings, a similar approach is used in less than half of all U.S. hospitals, according to Timothy Girard, M.D., lead researcher of the study.

    Girard, a critical care physician at Vanderbilt University School of Medicine in Nashville, Tennessee, presented data about the protocol at the Society of Critical Care Medicine’s (SCCM) annual meeting. An article in the April 2009 edition of Anesthesiology News detailed Girard’s presentation, which focused on additional evidence about the effectiveness of the strategy.

    The new information complements the findings of a previous study conducted by Girard and his colleagues, the Awakening and Breathing Controlled (ABC) Trial, which was published in The Lancet in 2008.

    During the ABC Trial, 336 patients were randomly assigned to one of two groups: an intervention group in which patients were placed on the protocol that combined spontaneous awakening trials (SAT) and spontaneous breathing trials (SBT), and a control group in which participants were given patient-targeted sedation.

    “We found that the protocol significantly reduced the duration of septic delirium and the likelihood of poor long-term cognitive outcomes, without an increase in post-traumatic stress disorder symptoms three and 12 months after discharge,” Girard said.

    Further, patients in the intervention group spent about three more ventilator-free days in the ICU, were discharged from the ICU and hospital approximately four days earlier than the control group and spent fewer days in comas. The patients in the intervention group also had fewer deaths one year later compared to the control group.

    “The mortality results were particularly striking,” said Girard.
    [2] Compared to the control group, patients in the intervention group were 32 percent less likely to die during the year after the trial.

    “For every seven patients whom we placed on the wake-up-and-breathe protocol, one life was saved,” Girard said.

    Before being enrolled in trial, patients were subjected to strict safety screens to ensure that altering their sedation or ventilation routines would not pose great risk. Girard cited these safety screens as one reason it should be easy for hospitals to repeat the researchers’ process and achieve the same results.

    While the daily sedative interruption strategy was added to the SCCM’s sedation practice guidelines in 2002, it is now up to hospitals to implement the protocol, which has been a challenge for many critical care specialists.

    “We haven’t been able to implement this consistently to save our lives,” said Judith Jacobi, PharmD, FCCM, BCPS, a critical care pharmacist at Clarian Health Partners in Indianapolis, Indiana, and one of the co-authors of the SCCM’s 2002 Clinical Practice Guidelines for the Sustained Use of Sedatives and Analgesics in the Critically Ill Adult. “We’ve tried a number of times, and our main problem was logistics: You have to get the respiratory therapists, pharmacists and the nurses all working together, and you have to have someone pushing them to do it. Then it has to be slotted into the workflow at the right time for it to work. It’s very difficult.”

    Despite the challenges of implementation faced by some physicians, Girard contends that the sedative interruption strategy should be standard practice in hospital ICUs.

    [1] Bronstein, David. “Waking Up to the Benefits of Less Sedation in the ICU.” Anesthesiology News. Volume 35:4. April 2009.
    [2]  Ibid.
    [3]  Ibid.
    [4]  Ibid.

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