Impact of difficult sedation on the management and outcome of critically ill patients

Abstract

Background: The term "difficult sedation" (DS) refers to situations of therapeutic failure, tolerance, or deprivation of the sedatives administered.

Aims: To characterize the profile of patients who developed DS and to assess its impact on the duration of mechanical ventilation (MV) and intensive care unit length of stay (ICU-LOS), as well as other complications related to their stay.

Design: A prospective descriptive analysis was conducted of the practices of analgesia/sedation in a medical-surgical intensive care unit (ICU) over a 2-year period.

Methods: All critically ill patients undergoing MV and sedation for more than 24 hours were prospectively followed until death or discharge. Demographic data, type, duration, complications of analgesia/sedation, and clinical outcome during ICU stay were recorded. Patients who developed DS were compared with those who were not difficult to sedate (not-DS).

Results: A total of 327 patients were included, 24.1% of whom were difficult to sedate (DS). Patients in the DS group were younger (P = .001); less severely ill (P = .003); and were more likely to have a history of smoking (P = .045), alcohol (P < .001), and psychotropic use (P = .001) than the not-DS group. Patients included in the DS group were sedated for longer periods (P < .001) and required higher doses of midazolam (P < .036), propofol (P = .023), and remifentanyl (P = .026) than those in the not-DS group. Difficult-to-sedate patients were twice as likely to require more than one sedative simultaneously (P < .001), presented more periods of over-sedation (P = .031)/under-sedation (P = .024), and suffered more pain (P < .001) than patients in the not-DS group. Patients in the DS group had prolonged MV times (P < .001), developed more pressure ulcers (P > .001) and ventilator-associated pneumonias (P = .025), and were more likely to require tracheotomy (P = .001) than those in the not-DS group.

Conclusion: DS develops in one of four critically ill patients and has a negative impact on their outcomes_. Early identification of the clinical profile of this group and active prevention and treatment are essential strategies in order to minimize its impact.

Relevance to clinical practice: A quarter of mechanically ventilated patients may develop situations of DS, which negatively affects their outcome. Early detection and prevention of DS are essential to minimize its impact.

Keywords: difficult sedation; intensive care; mechanical ventilation; sedation.