Eliminating ICU Sedation and Its Negative Consequences Is the Aim of a Multidisciplinary Pilot Effort to Advance the Concept of a Patient-Centered ICU

Intensive care unit (ICU) patients requiring mechanical ventilation commonly are sedated to reduce agitation and traumatic memories of their critical care experience. However, long-term sedation can have negative consequences and impede recovery.

In a new commentary in The Lancet Respiratory Medicine, Matthias Eikermann, MD, PhD, Chair, Anesthesiology, Montefiore Einstein, and Francis F. Foldes Professor, Anesthesiology, Albert Einstein College of Medicine, argues that ICU sedation could be safely eliminated with a multidisciplinary, patient-centric approach that targets the underlying causes of agitation or discomfort.

Studies show that among ICU patients, sedation is the most common modifiable risk factor for delirium, which is associated with long-lasting impairments in cognitive function.

“We know that early mobilization is a predictor of enhanced recovery, but patients who are sedated cannot get out of bed and walk,” said Dr. Eikermann. “What’s more, sedation prevents patients from participating in their medical care or interacting with family members.”

Common causes of distress in mechanically ventilated adults include pain, shortness of breath, a full bladder, constipation, anxiety and drug withdrawal—each of which can be addressed.

“In my experience, ICU patients generally appreciate knowing that they can participate in their care and that they have an option other than sedation,” said Dr. Eikermann.

Even patients on mechanical ventilation who are intubated can be managed without sedation. While they are unable to speak, they can effectively communicate with the help of experts in nonverbal communication, such as speech-language pathologists.

While some ICU physicians say that it’s unsafe for patients on mechanical ventilation not to be sedated, Dr. Eikermann believes adopting a patient-centric approach can prevent patients from removing medical devices and suffering from psychological trauma.

Montefiore Einstein already has successfully implemented many of his recommendations for eliminating sedation, such as relaxation techniques for pain, endotracheal tube comfort measures, gastric drainage for nausea, sleep protocols to minimize insomnia and elimination or reduction of medications associated with urinary retention.

Dr. Eikermann currently is leading a multidisciplinary pilot effort to better understand the steps needed to advance the concept of a patient-centered ICU.

His commentary, published May 12, is titled, “Multimodal, Patient-centered Symptom Control: A Strategy to Replace Sedation in the ICU.” The other contributors include Dale M. Needham, MD, PhD, Johns Hopkins University, Baltimore, and John W. Devlin, PharmD, Brigham and Women’s Hospital, Boston.