Variation in diurnal sedation in mechanically ventilated patients who are managed with a sedation protocol alone or a sedation protocol and daily interruptionReport as inadecuate

Variation in diurnal sedation in mechanically ventilated patients who are managed with a sedation protocol alone or a sedation protocol and daily interruption - Download this document for free, or read online. Document in PDF available to download.

Critical Care

, 20:233

First Online: 01 August 2016Received: 09 May 2016Accepted: 12 July 2016


BackgroundMechanically ventilated patients may receive more sedation during the night than during the day, potentially delaying extubation. We compared nighttime and daytime benzodiazepine and opioid administration in adult patients enrolled in a multicenter sedation trial comparing protocolized sedation alone or protocolized sedation combined with daily sedation interruption; and we evaluated whether nighttime and daytime doses were associated with liberation from mechanical ventilation.

MethodsThis is a secondary analysis of a randomized trial which was conducted in 16 North American medical-surgical ICUs. In all 423 patients, nurses applied a validated sedation scale hourly to titrate benzodiazepine and opioid infusions to achieve a light level of sedation. Using fentanyl equivalents and midazolam equivalents, we compared dosages administered during night 19:00 to 07:00 and day 07:00 to 19:00 shifts. Using multivariable logistic regression we evaluated the association between nighttime and daytime opioid and sedative doses, and spontaneous breathing trial SBT conduct, SBT success, and extubation.

ResultsNighttime benzodiazepine and opioid doses were significantly higher than daytime doses mean difference midazolam equivalents 23.3 mg, 95 % CI 12.9, 33.8, p < 0.0001; mean difference fentanyl equivalents 356 mcg, 95 % CI 130, 582, p = 0.0021. Mean Sedation Agitation Scale score was similar between night and day, and was at target 3.2 vs 3.3, 95 % CI −0.05, 0.02, p = 0.35. Self-reported nurse workload was similar during the night and day. Patients were more often restrained during day shifts 76.3 % vs 73.7 %, p < 0.0001, and there were more unintentional device removals during the day compared with night 15.9 % vs 9.1 %, p < 0.0001. Increases in nighttime drug doses were independently associated with failure to meet SBT screening criteria, SBT failure, and the decision not to extubate the patient despite successful SBT.

ConclusionPatients received higher doses of opioids and benzodiazepines at night. Higher nighttime doses were associated with SBT failure and delayed extubation.

Trial NCT00675363. Registered 7 May 2008.

KeywordsSedation Opioids Mechanical ventilation Protocols Weaning Diurnal rhythm Intensive care unit Electronic supplementary materialThe online version of this article doi:10.1186-s13054-016-1405-3 contains supplementary material, which is available to authorized users.

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Author: Sangeeta Mehta - Maureen Meade - Lisa Burry - Ranjeeta Mallick - Christina Katsios - Dean Fergusson - Peter Dodek - Karen 


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