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 is one of New York’s premier academic health systems and is a recognized leader in providing exceptional quality and personalized, accountable care to approximately three million people in communities across the Bronx, Westchester and the Hudson Valley. It is comprised of 10 hospitals, including the Children’s Hospital at Montefiore, Burke Rehabilitation Hospital and more than 200 outpatient ambulatory care sites. The advanced clinical and translational research at its medical school, Albert Einstein College of Medicine, directly informs patient care and improves outcomes. From the Montefiore-Einstein Centers of Excellence in cancer, cardiology and vascular care, pediatrics, and transplantation, to its preeminent school-based health program, Montefiore is a fully integrated healthcare delivery system providing coordinated, comprehensive care to patients and their families. For more information please visit www.montefiore.org. Follow us on Twitter and Instagram and LinkedIn, or view us on Facebook and YouTube.