The authors give advice on developing a nurse-implemented sedation protocol.

Nurses who care for patients on mechanical ventilators must walk a tightrope, ensuring patients get the precise amount of sedation they need. Oversedation can lengthen ventilator time, which raises the risk of ventilator-associated complications and may lengthen intensive-care unit (ICU) stays. Undersedation, on the other hand, may lead patients to try to self-extubate or remove monitoring and treatment lines, which can compromise their medical condition and harm themselves or others.

One of the first studies of nurse-implemented sedation protocols (1999) showed ventilator time decreased with the use of a nurse-implemented sedation protocol that allowed nurses to adjust sedation to achieve level 3 on the Ramsay sedation scale, meaning the patient responds only to verbal commands. Nurses were permitted to titrate sedative doses to achieve this goal without waiting for a physician’s order. The protocol also guided sedative weaning and withdrawal as the patient’s status improved. The study found protocol use led to shorter ICU and hospital stays, a reduced need for tracheostomy, and shorter durations of continuous I.V. sedation.

In 2000, the first study of daily sedation cessation (also called spontaneous awakening trials, or SATs) found dramatic benefits. Compared to patients who didn’t have daily sedation breaks, patients in the group with daily breaks experienced decreased ventilator and ICU times and needed fewer diagnostic tests to assess neurologic function. Sedation was stopped daily so they could “wake up.” If the patient became agitated or uncomfortable, sedation was restarted at half the previous dosage and titrated as needed. What’s more, researchers found no increase in complications or mortality. At 6-month follow-up, these patients showed a better psychological adjustment to illness and a lower incidence and fewer symptoms of posttraumatic stress disorder.

In 2002, these and similar studies prompted the Society of Critical Care Medicine (SCCM) to issue guidelines that include daily sedation breaks for critically ill patients.

ABC Trial

In 2008, the Awakening and Breathing Controlled (ABC) Trial reported results similar to the 2000 study. In this multisite study involving 336 patients, medical ICU patients were randomly assigned to one of two groups:

• The control group received the standard management normally used on the unit, which didn’t include daily SATs but did include daily ventilator weaning with use of spontaneous breathing trials (SBTs), with pressure support of 7 cm or lower.
• The intervention group received both SATs and SBTs daily. Sedation administration was stopped until the patient opened the eyes to voice, at which time the SBT began. Patients had to pass safety screens before each intervention. If a patient could open the eyes to voice, didn’t meet the failure criteria, and passed the SBT safety screen, the SBT was instituted. (See Safety screen for SBTs by clicking the PDF icon above) If the patient became agitated or uncomfortable, sedation was restarted at half the previous dosage and titrated as needed. Patients were placed on a T-piece or on the ventilator’s spontaneous breathing mode with 7-cm pressure support or lower; they passed the SBT after 2 hours if they met none of the SBT failure criteria. (See SBT failure criteria.by clicking the PDF icon above)

The intervention group had 3 fewer ventilator days, 4 fewer ICU days, and 4 fewer hospital days. Remarkably, 56% of patients in this group were alive by the end of 1 year, compared to 42% in the control group. Thus, for every seven patients treated, one life was saved by the end of a year. Also, follow-up at 3 months and 12 months showed no adverse long-term cognitive or psychological outcomes in the SAT + SBT group.

Strong evidence, poor use

Despite strong evidence that daily sedation breaks not only save lives but reduce ventilator, ICU, and hospital days, these breaks are used infrequently. In a 2006 study, 273 Canadian physicians reported just 40% of their patients got daily sedation breaks. Similarly, 904 polled SCCM members reported only 40% implementation of SATs in the United States.

Why aren’t these procedures widespread?

Perhaps caregivers’ fear of patient self-extubation exceeds their desire to expedite weaning from sedation. The ABC Trial showed a larger number of patients in the SAT + SBT group (16 patients) self-extubated than in the SBT-only group (6 patients). Yet essentially the same number of patients in both groups required reintubation, meaning some patients in the SAT + SBT group who self-extubated were ready for extubation and knew it sooner than the healthcare team. What’s more, the SBT-only group had a significantly higher tracheot­-omy incidence, further suggesting that sedation breaks promote ventilator weaning.

Promoting daily sedation breaks

One strategy for encouraging daily sedation breaks is to focus on the safety screens used to identify candidates for SATs and SBTs. In the ABC Trial, patients who met any of the safety screening criteria did not undergo a SAT that day and were reevaluated the next day. (See SAT safety screen by clicking the PDF icon above.) Of the 1,140 safety screens done, 82% passed and 18% failed. The main reason for failure was the patient’s need for escalating sedative doses. If the patient already seemed agitated, a sedation break wasn’t needed. When a patient met SAT failure criteria, sedatives were restarted at half the previous dosage and titrated as needed. (See SAT failure criteria. by clicking the PDF icon above)

Keep in mind that the goal is to titrate sedation to the patient’s need, not simply withdraw it. In the safe, controlled environment of a trial, daily sedation breaks can establish if the patient still needs sedation and, if so, at what dosage.

Writing a protocol

If you have an opportunity to write a protocol for SATs or SBTs, closely examine the patient population and work with the multidisciplinary team to determine if the criteria you’re proposing will meet all your patients’ needs. For instance, you may find you need to add more criteria to cover patients with anxiety-induced bronchospasm or impending aneurysm dissection. Be sure to consider each patient individually.

In the ABC Trial, if a patient was in pain or suspected of being in pain, analgesics were continued during the SAT. The ABC Trial involved only medical patients, but that doesn’t mean the same protocol can’t be used for other patients—
for instance, postsurgical or posttrauma patients, patients with acute pancreatitis, and those with chronic pain syndromes who may need to have analgesics continued during weaning from sedation and ventilator use. Be sure to differentiate pain from anxiety, agitation, and delirium.

When developing a protocol, plan for SATs at times when the
patient can be monitored closely. Emphasize the need for continual patient reassurance as well as explanation and reexplanation as necessary. To accomplish a calm awakening, you may find the family’s presence helpful.

Celebrate protocol success

Developing and implementing a new protocol are challenging. To build consensus for the protocol, involve the multidisciplinary team and identify champions from the medical and respiratory staffs. As leaders emerge, involve them in crafting the protocol, developing guidelines, and educating other staff members. As the new protocol rolls out, have support resources readily available, such as printed guidelines for each caregiver and a support person to aid decision making.

Recognize and celebrate successes. Recognition and appreciation during the early stages of protocol implementation build confidence and commitment. Using these strategies helps caregivers institute and sustain successful daily sedation breaks and a daily breathing trial protocol.

Selected references

Brook AD, Ahrens TS, Schaiff R, et al. Effect of a nursing-implemented sedation protocol on the duration of mechanical ventilation. Crit Care Med. 1999;27(12):2609-2615.

Devlin JW, Tanios MA, Epstein SK. Intensive care unit sedation: waking up clinicians to the gap between research and practice. Crit Care Med. 2006;34(2):556-557.

Girard TD, Kress JP, Fuchs BD, et al. Efficacy and safety of a paired sedation and ventilator weaning protocol for mechanically ventilated patients in intensive care (Awakening and Breathing Controlled Trial): a randomized controlled trial. http://rtjournalonline.com/Sedation%20and%20Weaning%20protocols%20combined%20Lancet%202008.pdf. Accessed January 21, 2011.

Jackson JC, Girard TD, Gordon SM, et al. Long-term cognitive and psychological outcomes in the awakening and breathing controlled trial. Am J Respir Crit Care Med. 2010;182(2):183-191.

Jacobi J, Fraser GL, Coursin DB, et al. Clinical practice guidelines for sustained use of sedatives and analgesics in the critically ill adult. 2002;30(1):119-141.

Kress JP, Gehlbach B, Lacy M, Pliskin N, Pohlman AS, Hall JB. The long-term psychological effects of daily sedative interruption on critically ill patients. Am J Respir Crit Care Med. 2003;168(12):1457-1461.

Kress JP, Pohlman AS, O’Connor MF, Hall JB. Daily interruption of sedative infusions in critically ill patients undergoing mechanical ventilation. N Engl J Med. 2000;342(20):1471-1477.

Mehta S, Burry L, Fischer S, et al. Canadian survey of the use of sedatives, analgesics, and neuromuscular blocking agents in critically ill patients. Crit Care Med. 2006;34(2):374-380.

Both authors work at Saint Thomas Hospital in Nashville, Tennessee. Jan Dunn is a coordinator in the patient relations department. Mitzi Wilder Baker is a staff nurse and research nurse coordinator.