Intensive care unit (ICU) patients who require mechanical ventilation are commonly sedated for lengthy periods, with the goal of reducing agitation and traumatizing memories of the critical care experience. However, sedation can have negative consequences and impede recovery. 

In a new commentary in Lancet Respiratory Medicine, Matthias Eikermann, M.D., Ph.D., chair of anesthesiology at Montefiore Health System and 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 also know that early mobilization is a predictor of enhanced recovery. But patients who are sedated cannot get out of bed and walk,” says Dr. Eikermann. What’s more, sedation prevents patients from participating in their medical care or interacting with family members. 

By focusing on the underlying causes of a patient’s symptoms, ICU staff can safely avoid the need for sedation, Dr. Eikermann contends. 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. “For instance,” he says, “patients in pain can be helped with measures such as massage therapy or analgesics. Anxiety can be reduced by visits with family members, music therapy, or anti-anxiety medications.” 

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

Even patients on mechanical ventilation who are intubated can be managed without sedation, says Dr. Eikermann. “It is, of course, important that patients understand what we are doing and feel that staff are sensitive to their needs. While it’s impossible to speak with a breathing tube, patients can effectively communicate with the help of experts in nonverbal communication, such as speech-language pathologists.” 

Some ICU physicians say that it’s unsafe to not sedate patients on mechanical ventilation. “One argument is that distressed patients might remove devices they are connected to, but we can take steps to make sure that doesn’t happen,” says Dr. Eikermann. “The second argument is that patients can suffer lasting psychological trauma from the ICU experience. But several trials have shown that the no-sedation approaches do not affect long-term outcomes or increase rates of post-traumatic stress disorder.” 

Many of Dr. Eikermann’s recommendations for eliminating sedation have already been successfully implemented at Montefiore, 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. 

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

The commentary, published on May 12 in Lancet Respiratory Medicine, is titled, “Multimodal, patient-centered symptom control: a strategy to replace sedation in the ICU.” The other contributors include Dale M. Needham (Johns Hopkins University, Baltimore, MD) and John W. Devlin (Brigham and Women’s Hospital, Boston, MA).

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About Montefiore Health System

Montefiore Health System es uno de los sistemas de salud académicos más importantes de Nueva York y un líder reconocido en brindar atención excepcional, personalizada y responsable a aproximadamente tres millones de personas en comunidades del Bronx, Westchester y el Valle del Hudson. Está compuesto por 10 hospitales, incluyendo el Hospital Infantil de Montefiore, el Hospital de Rehabilitación Burke y más de 200 centros de atención ambulatoria. La investigación clínica y traslacional avanzada de su facultad de medicina, Albert Einstein College of Medicine, influye directamente en la atención al paciente y mejora los resultados. Desde los Centros de Excelencia Montefiore-Einstein en cáncer, cardiología y atención vascular, pediatría y trasplantes, hasta su destacado programa de salud escolar, Montefiore es un sistema de atención médica totalmente integrado que brinda atención integral y coordinada a los pacientes y sus familias. Para obtener más información, visite www.montefiore.org. Síganos en Twitter, Instagram y LinkedIn, o véanos en Facebook y YouTube .