- Email: [email protected]
Rebuttal From Dr Vinayak
Rebuttal From Dr Kress offers important arguments regarding DrtheVinayak minimization of sedation, a trend that has 1
been present in the published literature for more than a decade. However, it is important to look at the practical options for this changing philosophy in sedation strategies. He cites the important study by Strøm et al,2 referred to as “no sedation.” A couple of aspects regarding this study deserve comment. First, patients in this trial who were randomized to the intervention group received morphine, rather than sedatives, as their foundational strategy. Morphine is an opiate analgesic drug. Although not in the category of pharmacologic sedatives, this drug certainly has a “calming” effect on patients who are mechanically ventilated. It is rare that a patient can be managed without any drug, at least not in the early stages of respiratory failure. Second, this study was performed in Denmark, where ICU nursing to patient ratios were universally 1:1. This luxury is very rare in the rest of the world and is certainly a practical limitation to the widespread institution of the “no sedation” strategy. Furthermore, a person who can be summoned to provide verbal reassurance in the event that a patient is agitated is not a reality in most busy ICUs around the world. Last, one of five patients in this study could not tolerate this “no sedation” strategy. Accordingly, this study, although impressive, has important practical limitations. Survival from critical illness is improving substantially. For these reasons, the reality is that sedatives will continue to be necessary for the foreseeable future for managing patients who are mechanically ventilated. Dr Vinayak1 mentions the importance of ICU delirium on patient outcomes. The study by Strøm et al2 did not measure ICU delirium, so no conclusions can be drawn. Indeed, the two large interventional studies reporting a reduction in ICU delirium both used a continuous infusion strategy with daily interruption as their foundation. The reality is that propofol and dexmedetomidine are the two agents that are most “forgiving” with regard to their propensity for accumulation over time.3-5 Benzodiazepines are falling out of favor based on accumulating evidence and strong recommendations from the upcoming ICU sedation guidelines from the Society of Critical Care Medicine.6 Propofol and dexmedetomidine must both be given by continuous infusion; indeed, it is for this very reason that they are attractive (they do not accumulate and they last for a relatively short period of time) and, thus, are not amenable to intermittent dosing. As Dr Vinayak1 correctly states, these newer drugs may have a lower propensity for delirium.
Dr Vinayak1 also reiterates the importance of early mobilization in his discussion. This is best accomplished using drugs given by continuous infusion, which can be stopped for therapy sessions. Benzodiazepines, with their propensity for accumulation and iatrogenic delirium, are the least desirable choices. Certainly, if an “opiates-only” strategy can be accomplished, this is a viable option; however, this has yet to be tested, at least outside of a single center with remarkable nursing staffing. The majority of published evidence shows clearly that the continuous infusion of sedatives (specifically propofol or dexmedetomidine) with the use of daily interruptions is the best strategy for managing ICU sedation in 2012. John P. Kress, MD Chicago, IL Affiliations: From the Department of Medicine, Section of Pulmonary and Critical Care, University of Chicago. Financial/nonfinancial disclosures: The author has reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article. Correspondence to: John P. Kress, MD, Department of Medicine, Section of Pulmonary and Critical Care, University of Chicago, 5841 South Maryland Ave, MC 6026, Chicago, IL 60637; e-mail: [email protected] © 2012 American College of Chest Physicians. Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details. DOI: 10.1378/chest.12-1996
References 1. Vinayak AG. Counterpoint: should all ICU patients receive continuous sedation? No. Chest. 2012;142(5):1092-1094. 2. Strøm T, Martinussen T, Toft P. A protocol of no sedation for critically ill patients receiving mechanical ventilation: a randomised trial. Lancet. 2010;375(9713):475-480. 3. Carson SS, Kress JP, Rodgers JE, et al. A randomized trial of intermittent lorazepam versus propofol with daily interruption in mechanically ventilated patients. Crit Care Med. 2006; 34(5):1326-1332. 4. Riker RR, Shehabi Y, Bokesch PM, et al; SEDCOM (Safety and Efficacy of Dexmedetomidine Compared With Midazolam) Study Group. Dexmedetomidine vs midazolam for sedation of critically ill patients: a randomized trial. JAMA. 2009;301(5):489-499. 5. Jakob SM, Ruokonen E, Grounds RM, et al; Dexmedetomidine for Long-Term Sedation Investigators. Dexmedetomidine vs midazolam or propofol for sedation during prolonged mechanical ventilation: two randomized controlled trials. JAMA. 2012;307(11):1151-1160. 6. Coursin D. Sedation and Delirium in the ICU: What Do the New Guidelines Say? Houston, TX: Society of Critical Care Medicine; 2012.
Rebuttal From Dr Vinayak concluding comments regarding sedaDrtionKress’s management with continuous agents are irre1
futable: (1) The evidence strongly supports a practice
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that interrupts sedation daily when continuous sedation is used. (2) As to choice of agent, the upcoming consensus sedative guideline revisions will significantly downsize the role of benzodiazepines compared with agents with more rapid offset pharmacology. Yet it remains unclear whether all ventilated patients need a continuous sedative drug as part of their management. One approach to the ventilated patient includes involving a multidisciplinary group of bedside practitioners in the development of a sedation practice plan. The study by Mehta et al2 referred to by Dr Kress outlines one such nurse-guided “protocolized sedation” attempt. Despite the use of a continuous sedation infusion strategy with a benzodiazepine agent, there were no significant outcome differences compared with a practice of continuous sedation with daily interruption. The protocol used a sedations scale, the Sedation Agitation Scale, to initiate and maintain sedation. As mentioned, a multicenter follow-up study is anticipated. Other tailored sedation practices formulated by the multidisciplinary group have shown improvement in ventilator outcomes and length of stay. de Wit et al3 showed that an intermittent bolus sedation practice using the Richmond Agitation Sedation Scale achieved improved outcomes compared with a strategy of continuous sedation and daily interruption. Historically, this ICU has a large proportion of patients with substance abuse issues. This highlights the usefulness of a local protocol meeting the needs of the patient population served. Similarly, Robinson et al4 used a tailored approach in the management of trauma patients. The investigators’ goal was to avoid daily interruption of analgesia given the nature of the injuries and the associated continuous pain. The local group developed a tiered approach to care, the analgesia-delirium-sedation protocol. Continuous analgesic therapy was provided with opiate agents. Next, anxiety was addressed initially with nonpharmacologic intervention before haloperidol and then sedative agents were needed. Propofol was the continuous sedative agent, but if sedation was needed for . 48 h, intermittent midazolam was then the preferred agent. Implementation of this analgesiadelirium-sedation approach led to improvements in outcomes. The protocol used not only the Richmond Agitation Sedation Scale but also the delirium scale, Confusion Assessment Method for the ICU. Although the patient populations served by de Wit et al3 and
Robinson et al4 may have been specialized, it should be noted that the Strøm et al’s5 no-sedation protocol enrolled a general population with a significant level of illness as measured by severity of illness scores (APACHE [Acute Physiology and Chronic Health Evaluation] II and SAPS [Simplified Acute Physiology Score]). When approaching sedative practice, incorporating sedation and delirium scores in a protocolized manner as developed by a select multidisciplinary group seems to improve ventilator and ICU outcomes. This strategy appears to decrease the need for continuous sedative agents and promote the goal of the animated ICU. As Dr Kress1 has pointed out, interruption of sedation seems to induce no psychiatric or coronary harm. When continuous sedation is required, not only is drug choice important, but scale-based targeting along with daily interruption may become even more important to avoid oversedation. Ajeet G. Vinayak, MD Washington, DC Affiliations: From Georgetown University Hospital. Financial/nonfinancial disclosures: The author has reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article. Correspondence to: Ajeet G. Vinayak, MD, Georgetown University Hospital, 4th Floor Main Bldg, 3800 Reservoir Rd NW, Washington, DC 20007; e-mail: [email protected] © 2012 American College of Chest Physicians. Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details. DOI: 10.1378/chest.12-1998
References 1. Kress JP. Point: should all ICU patients receive continuous sedation? Yes. Chest. 2012;142(5):1090-1092. 2. Mehta S, Burry L, Martinez-Motta JC, et al; Canadian Critical Care Trials Group. A randomized trial of daily awakening in critically ill patients managed with a sedation protocol: a pilot trial. Crit Care Med. 2008;36(7):2092-2099. 3. de Wit M, Gennings C, Jenvey WI, Epstein SK. Randomized trial comparing daily interruption of sedation and nursingimplemented sedation algorithm in medical intensive care unit patients. Crit Care. 2008;12(3):R70. 4. Robinson BR, Mueller EW, Henson K, Branson RD, Barsoum S, Tsuei BJ. An analgesia-delirium-sedation protocol for critically ill trauma patients reduces ventilator days and hospital length of stay. J Trauma. 2008;65(3):517-526. 5. Strøm T, Martinussen T, Toft P. A protocol of no sedation for critically ill patients receiving mechanical ventilation: a randomised trial. Lancet. 2010;375(9713):475-480.
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Downloaded From: http://journal.publications.chestnet.org/ by David Kinnison on 11/19/2012
Point/Counterpoint Editorials
been present in the published literature for more than a decade. However, it is important to look at the practical options for this changing philosophy in sedation strategies. He cites the important study by Strøm et al,2 referred to as “no sedation.” A couple of aspects regarding this study deserve comment. First, patients in this trial who were randomized to the intervention group received morphine, rather than sedatives, as their foundational strategy. Morphine is an opiate analgesic drug. Although not in the category of pharmacologic sedatives, this drug certainly has a “calming” effect on patients who are mechanically ventilated. It is rare that a patient can be managed without any drug, at least not in the early stages of respiratory failure. Second, this study was performed in Denmark, where ICU nursing to patient ratios were universally 1:1. This luxury is very rare in the rest of the world and is certainly a practical limitation to the widespread institution of the “no sedation” strategy. Furthermore, a person who can be summoned to provide verbal reassurance in the event that a patient is agitated is not a reality in most busy ICUs around the world. Last, one of five patients in this study could not tolerate this “no sedation” strategy. Accordingly, this study, although impressive, has important practical limitations. Survival from critical illness is improving substantially. For these reasons, the reality is that sedatives will continue to be necessary for the foreseeable future for managing patients who are mechanically ventilated. Dr Vinayak1 mentions the importance of ICU delirium on patient outcomes. The study by Strøm et al2 did not measure ICU delirium, so no conclusions can be drawn. Indeed, the two large interventional studies reporting a reduction in ICU delirium both used a continuous infusion strategy with daily interruption as their foundation. The reality is that propofol and dexmedetomidine are the two agents that are most “forgiving” with regard to their propensity for accumulation over time.3-5 Benzodiazepines are falling out of favor based on accumulating evidence and strong recommendations from the upcoming ICU sedation guidelines from the Society of Critical Care Medicine.6 Propofol and dexmedetomidine must both be given by continuous infusion; indeed, it is for this very reason that they are attractive (they do not accumulate and they last for a relatively short period of time) and, thus, are not amenable to intermittent dosing. As Dr Vinayak1 correctly states, these newer drugs may have a lower propensity for delirium.
Dr Vinayak1 also reiterates the importance of early mobilization in his discussion. This is best accomplished using drugs given by continuous infusion, which can be stopped for therapy sessions. Benzodiazepines, with their propensity for accumulation and iatrogenic delirium, are the least desirable choices. Certainly, if an “opiates-only” strategy can be accomplished, this is a viable option; however, this has yet to be tested, at least outside of a single center with remarkable nursing staffing. The majority of published evidence shows clearly that the continuous infusion of sedatives (specifically propofol or dexmedetomidine) with the use of daily interruptions is the best strategy for managing ICU sedation in 2012. John P. Kress, MD Chicago, IL Affiliations: From the Department of Medicine, Section of Pulmonary and Critical Care, University of Chicago. Financial/nonfinancial disclosures: The author has reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article. Correspondence to: John P. Kress, MD, Department of Medicine, Section of Pulmonary and Critical Care, University of Chicago, 5841 South Maryland Ave, MC 6026, Chicago, IL 60637; e-mail: [email protected] © 2012 American College of Chest Physicians. Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details. DOI: 10.1378/chest.12-1996
References 1. Vinayak AG. Counterpoint: should all ICU patients receive continuous sedation? No. Chest. 2012;142(5):1092-1094. 2. Strøm T, Martinussen T, Toft P. A protocol of no sedation for critically ill patients receiving mechanical ventilation: a randomised trial. Lancet. 2010;375(9713):475-480. 3. Carson SS, Kress JP, Rodgers JE, et al. A randomized trial of intermittent lorazepam versus propofol with daily interruption in mechanically ventilated patients. Crit Care Med. 2006; 34(5):1326-1332. 4. Riker RR, Shehabi Y, Bokesch PM, et al; SEDCOM (Safety and Efficacy of Dexmedetomidine Compared With Midazolam) Study Group. Dexmedetomidine vs midazolam for sedation of critically ill patients: a randomized trial. JAMA. 2009;301(5):489-499. 5. Jakob SM, Ruokonen E, Grounds RM, et al; Dexmedetomidine for Long-Term Sedation Investigators. Dexmedetomidine vs midazolam or propofol for sedation during prolonged mechanical ventilation: two randomized controlled trials. JAMA. 2012;307(11):1151-1160. 6. Coursin D. Sedation and Delirium in the ICU: What Do the New Guidelines Say? Houston, TX: Society of Critical Care Medicine; 2012.
Rebuttal From Dr Vinayak concluding comments regarding sedaDrtionKress’s management with continuous agents are irre1
futable: (1) The evidence strongly supports a practice
journal.publications.chestnet.org
Downloaded From: http://journal.publications.chestnet.org/ by David Kinnison on 11/19/2012
CHEST / 142 / 5 / NOVEMBER 2012
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that interrupts sedation daily when continuous sedation is used. (2) As to choice of agent, the upcoming consensus sedative guideline revisions will significantly downsize the role of benzodiazepines compared with agents with more rapid offset pharmacology. Yet it remains unclear whether all ventilated patients need a continuous sedative drug as part of their management. One approach to the ventilated patient includes involving a multidisciplinary group of bedside practitioners in the development of a sedation practice plan. The study by Mehta et al2 referred to by Dr Kress outlines one such nurse-guided “protocolized sedation” attempt. Despite the use of a continuous sedation infusion strategy with a benzodiazepine agent, there were no significant outcome differences compared with a practice of continuous sedation with daily interruption. The protocol used a sedations scale, the Sedation Agitation Scale, to initiate and maintain sedation. As mentioned, a multicenter follow-up study is anticipated. Other tailored sedation practices formulated by the multidisciplinary group have shown improvement in ventilator outcomes and length of stay. de Wit et al3 showed that an intermittent bolus sedation practice using the Richmond Agitation Sedation Scale achieved improved outcomes compared with a strategy of continuous sedation and daily interruption. Historically, this ICU has a large proportion of patients with substance abuse issues. This highlights the usefulness of a local protocol meeting the needs of the patient population served. Similarly, Robinson et al4 used a tailored approach in the management of trauma patients. The investigators’ goal was to avoid daily interruption of analgesia given the nature of the injuries and the associated continuous pain. The local group developed a tiered approach to care, the analgesia-delirium-sedation protocol. Continuous analgesic therapy was provided with opiate agents. Next, anxiety was addressed initially with nonpharmacologic intervention before haloperidol and then sedative agents were needed. Propofol was the continuous sedative agent, but if sedation was needed for . 48 h, intermittent midazolam was then the preferred agent. Implementation of this analgesiadelirium-sedation approach led to improvements in outcomes. The protocol used not only the Richmond Agitation Sedation Scale but also the delirium scale, Confusion Assessment Method for the ICU. Although the patient populations served by de Wit et al3 and
Robinson et al4 may have been specialized, it should be noted that the Strøm et al’s5 no-sedation protocol enrolled a general population with a significant level of illness as measured by severity of illness scores (APACHE [Acute Physiology and Chronic Health Evaluation] II and SAPS [Simplified Acute Physiology Score]). When approaching sedative practice, incorporating sedation and delirium scores in a protocolized manner as developed by a select multidisciplinary group seems to improve ventilator and ICU outcomes. This strategy appears to decrease the need for continuous sedative agents and promote the goal of the animated ICU. As Dr Kress1 has pointed out, interruption of sedation seems to induce no psychiatric or coronary harm. When continuous sedation is required, not only is drug choice important, but scale-based targeting along with daily interruption may become even more important to avoid oversedation. Ajeet G. Vinayak, MD Washington, DC Affiliations: From Georgetown University Hospital. Financial/nonfinancial disclosures: The author has reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article. Correspondence to: Ajeet G. Vinayak, MD, Georgetown University Hospital, 4th Floor Main Bldg, 3800 Reservoir Rd NW, Washington, DC 20007; e-mail: [email protected] © 2012 American College of Chest Physicians. Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details. DOI: 10.1378/chest.12-1998
References 1. Kress JP. Point: should all ICU patients receive continuous sedation? Yes. Chest. 2012;142(5):1090-1092. 2. Mehta S, Burry L, Martinez-Motta JC, et al; Canadian Critical Care Trials Group. A randomized trial of daily awakening in critically ill patients managed with a sedation protocol: a pilot trial. Crit Care Med. 2008;36(7):2092-2099. 3. de Wit M, Gennings C, Jenvey WI, Epstein SK. Randomized trial comparing daily interruption of sedation and nursingimplemented sedation algorithm in medical intensive care unit patients. Crit Care. 2008;12(3):R70. 4. Robinson BR, Mueller EW, Henson K, Branson RD, Barsoum S, Tsuei BJ. An analgesia-delirium-sedation protocol for critically ill trauma patients reduces ventilator days and hospital length of stay. J Trauma. 2008;65(3):517-526. 5. Strøm T, Martinussen T, Toft P. A protocol of no sedation for critically ill patients receiving mechanical ventilation: a randomised trial. Lancet. 2010;375(9713):475-480.
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Downloaded From: http://journal.publications.chestnet.org/ by David Kinnison on 11/19/2012
Point/Counterpoint Editorials