Sedation in Ventilated ICU Patients

About

➀ Read and Learn

The following course content

Introduction   

The management of sedation in mechanically ventilated intensive care unit (ICU) patients stands as one of the cornerstones of patient care. The intensive care unit (ICU) is a specialized haven within the hospital that caters to the most critically ill patients that require in-depth, closely monitored care. Approximately one third of ICU admissions have diagnoses secondary to respiratory failure, requiring immediate intubation and mechanical ventilation (3).   

Respiratory failure that leads to mechanical ventilation is a common challenge in critical care and demands high level administration of analgesics and sedatives tailored to individual needs. With the complexity of these patients, effective analgesic and sedation protocols are essential to alleviate discomfort but also optimize physiological functions and minimize complications in ventilator-associated events such as tracheostomies and pneumonia. Effective sedation strategies not only improve patient comfort and cooperation but also contribute to improved outcomes. Ultimately, overall quality of care is enhanced.  

Definitions  

There are some key definitions that need to be defined, regarding sedation in mechanically ventilated critical care patients, to best provide optimal care.   

Analgesia  

Analgesia refers to the use of pain relief medications that, unlike anesthesia, do not alter sensory function or consciousness, or change the awareness of the surroundings (21). There are two main types of analgesics: anti-inflammatories and opioids (21). Anti-inflammatory drugs, such as acetaminophen, aspirin, and ibuprofen, work by causing a reduction in inflammation and swelling (21). In ventilated patients, intermittent infusions of acetaminophen can be used. Opioids or narcotics bind opioid pain receptors in the brain and spine to alleviate pain (21). Common continuous infusions of opioids include morphine and fentanyl, while intermittent narcotics include methadone, hydrocodone and oxycodone (21).  

Sedation 

Sedation refers to the induced state (through medications and techniques performed) to facilitate an optimal medical/surgical experience for the patient (20). The patient is in a reduced awareness or responsiveness state, and sedation alleviates anxiety, discomfort, and pain (20). Sedation is used, as needed, to help tolerate painful procedures, allow the body to relax, aid in ventilator synchrony, and assist in forgetting unwanted memories associated with the procedures (20).   

Mechanical Ventilation  

Mechanical ventilation refers to the medical intervention that uses a mechanical ventilator device to assist or replace spontaneous breathing for patients who have compromised ability to maintain adequate oxygenation and ventilation effectively on their own (20). Noninvasive mechanical ventilation utilizes external devices such as a face mask, that delivers and removes carbon dioxide (21). Invasive mechanical ventilation delivers a controlled mixture of oxygen and air into the patient’s lungs via an endotracheal tube or tracheostomy, through several modes of mechanical ventilation (21). These modes have titratable parameters (such as respiratory rate, tidal volume and positive end-expiratory pressure) that are adjusted according to the patient’s clinical needs to optimize comfort and minimize common ventilator-associated complications such as air leaks, aspiration and pneumonia (20).   

Common conditions that predispose patients to respiratory failure include sepsis, intrapulmonary concerns such as acute respiratory distress syndrome (ARDS), pulmonary contusions, hypercapnia and hypoxemia, and pancreatitis (21). In this Sedation in Ventilated ICU Patients course, the focus will be on invasive mechanical ventilation when referring to mechanically ventilated ICU patients, not noninvasive.  

The impact of mechanical ventilation on sedation requirements is multifaceted. Mechanical ventilation alters gas exchange, lung volumes and the mechanics of breathing, which in turn influences the effects of the sedation agent and the dosage needed. When patients need mechanical ventilation, it is commonly associated with a demand for increased sedation as well, due to the physical discomfort and anxiety associated with ventilatory support and ventilator desynchrony (20). On the other hand, sedatives also have dose-dependent respiratory depressant effects so the higher the dose of sedative, the higher the respiratory depressant effect will be. This impact can exacerbate the conditions for which the patient was initially placed on the ventilator (such as hypoventilation and impaired gas exchange) and increase the risk of ventilator induced lung injuries or ventilator associated complications (21).  

Assessment  

Effective management of sedation in ventilated patients is crucial for optimizing outcomes and ensuring patient comfort and safety. All sedation strategies are firstly managed through assessment of addressing pain prior to initiating sedation. Initial assessments include clinical observation, neurological assessments, pain assessments, assessments of sedation goals and interdisciplinary communication. Once pain medication and sedation medication have started, assessment of sedation related adverse effects such as hypotension, respiratory depression, and consistent evaluation of analgesic/sedative dosing are monitored at least every two hours (25).  

It is crucial for staff and caretakers to recognize pain as a distressing and prevalent symptom and understand how pain is exhibited/expressed in each patient uniquely. PADIS guidelines (Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU) note the importance of addressing pain prior to initiating sedation through standardized tools such as the following (13):   

• Numeric Rating Scale (NRS): The NRS includes a subjective measure in which a patient verbalizes their pain of zero (no pain) to a score of ten (extreme pain or worst pain imaginable) (1). This scale is used to best describe pain dimension through intensity. The advantage to this scale is that it is simple, straightforward, easy to comprehend, reproduceable, is sensitive and inclusive to small changes in pain  

• Nonverbal Pain Scale (NVPS): The NVPS is a behavioral and physiological way to measure pain, and is a reliable assessment in ICU patients and patients who have no verbal communication (13). It is rated through facial expression (no expression to grimace/frown), activity/movement (lying quietly to restless), guarding (lying quietly to rigid or stiffness), physiologic changes (stable to drastic change in vital signs over the past four hours) and lastly respiratory (baseline/compliance to severe asynchrony). Each dimension is rated from zero to two, allowing for a minimum no pain score of zero, to a maximum pain score of six (13)  

• Behavior Pain Scale (BPS): The three dimensions to BPS include behavioral observations of facial expression (relaxed to grimacing), upper limbs movement (relaxed to retraction) and compliance with ventilation (patient tolerating ventilator to uncontrolled ventilation). Each dimension is rated from one to four, allowing a minimum no pain score of three, to a maximum pain score of 12 (13)  

• Critical-care Pain Observation Tool (CPOT) is used. There are four dimensions to CPOT (facial expression, muscle tension, body movement, and ventilator compliance) (11). There is a total possible score between zero and 8, with each category scored between zero and two. A score of zero indicates no pain whilst any score above two indicates pain and pain management intervention. A psychometric study showed that patient CPOT scores varied during position change but the score did not change during noninvasive blood pressure measurement, indicating the validity of this pain assessment tool (11)  

Once adequate analgesia is achieved, sedation is then considered. Some patients may not require sedation with proper pain management although in cases requiring sedation, careful consideration of both sedative choice and administration strategy is important to ensure patient comfort, safety and ventilation synchrony (1).   

•  The Richmond Agitation-Sedation Scale (RASS) is the gold standard for sedation assessment and ranges from -5 (unarousable) to +4 (combative) (5). It is helpful in controlling under and over sedation, with over sedation often occurring in ventilated patients.   

Generally, early (in the first 48 hours) deep sedation (RASS -3 to -5) has been closely associated with adverse outcomes (prolonged ventilator days, increased delirium, tracheostomy occurrence, increased ICU stay and hospital LOS) (17). This is why it’s so important to highlight the importance of lighter sedation (RASS -1 to -2) to improve patient outcomes and reduce ICU-related complications (12). However, it is very patient dependent. Deep sedation may be required in specific situations such as traumatic brain injury and status epilepticus. Furthermore, the impact of sedation practices initiated in the emergency department (ED) are typically carried out over the ICU course as well so there is a need for careful sedation management throughout the continuum of patient care.  

Indications  

Sedation is used in ventilated ICU patients to achieve clinical goals and address specific concerns, including the management of anxiety, agitation, pain, delirium and help minimize patient distress to facilitate the completion of procedures.   

Indications for sedation include:  

• Airway/endotracheal suctioning (3)  
• Discomfort with mechanical ventilation itself (3)  
• To improve patient-ventilator synchrony and tolerance, with the goal of promoting effective ventilation (3)  
• Helps with agitated and anxiety (3)  
• Help facilitate nursing care, such as regular repositioning in bed (to prevent pressure ulcers), wound care, and mouth care and eye care (3)  
• Physiotherapy rehabilitation (moving the joints during range of motion exercises) (25)  
• ICU procedures including indwelling catheter insertion such as central venous catheters urinary catheters (3) or nasogastric tube placement (3)  
• Surgical incisions such as tracheostomies or chest tube insertions (3)  
• Diagnostic procedures such as arterial blood gas sampling, venipuncture or bronchoscopies to assess patient condition (3)  
• Prevent self-harm (commonly associated with agitated altered mental status) (3)  
• Prevent removal of crucial invasive lines or accidental extubation (3)  

Thus, medication management is initiated and maintained through use of various medications including anxiolytics, antipsychotics (haloperidol, quetiapine), analgesics, sedation medications and paralytics (3).   

Management/Treatment  

As there are a wide variety of medications to best optimize patient care and outcomes, the selection is always patient specific, and must require constant re-evaluation and monitoring. Several special considerations should always be taken into account when evaluating sedation strategies for ventilated ICU patients.   

The Society of Critical Care Medicine’s (SCCM) ICU Liberation Bundle (ABCDEF elements) is the gold standard of implementing a comprehensive approach to patient care in the ICU (13). This bundle prompts providers to attach each patient with unique sedation requirements while balancing concerns regarding their underlying condition/etiology of distress, hemodynamic stability, potential for adverse effects, pharmacokinetic variables such as interactions with other drugs, and noting the desired depth of sedation or sedation required to achieve the goal (3).    

Assess, Prevent, Manage Pain  

The “A Element: Assess, Prevent, and Manage Pain” focuses on regularly evaluating patients to manage pain and minimize the need for continuous sedation medication (13). Proper and regular assessment of sedation depth and patient response to sedation is crucial in optimizing sedation levels (3). Use of RASS scores as the sedation scale (1), and evaluating patient CPOT/BPS scores for pain (11). Close monitoring vital signs such as heart rate, blood pressure, respiratory rate, oxygen saturation, is necessary as well. Regular monitoring will also help maintain patient comfort while minimizing the risk of oversedation. Oversedation is closely associated with longer hospital stays, longer mechanical ventilation use, and ICU related delirium (13).   

Several non-pharmacological, holistic interventions can be used regardless of sedation level, such as environmental modifications (lighting control, noise reduction, orientation of bed towards the window), social support (hearing the voices of loved ones, enhancing psychological and social connection with family/friends, promoting family involvement), pet therapy, and orientation aids (glasses and large clocks) (12). These improvements facilitate a healing environment with the goal of minimized stressors to prevent delirium.  

Both Spontaneous Awakening Trials and Breathing Trials  

The “B Element: Both Spontaneous Awakening Trials (SATs) and Spontaneous Breathing Trials (SBTs)” should be incorporated daily, should the patient’s hemodynamic status prove stable (13). Daily sedation interruptions or sedation vacations help combat development of delirium and reduces the length of mechanical ventilation (3). The 30-minute daily sedation vacations allow for a more accurate assessment of the patient’s neurological status, and spontaneous breathing trials can also be completed, as this has also been shown to improve patient outcomes (1). There is long term follow up of patients that had daily interruptions of sedation, that later suggested lower rates of posttraumatic stress disorder (1). This also helps prevent sedation withdrawal and delirium (12).  

SAT evaluates the absence of seizures, paralysis, alcohol withdrawal and other critical diagnoses affecting patient hemodynamic stability (13). The SBT screen evaluates the continued need for ventilator support and allows in support of ventilatory weaning (13). Failure criteria for both SAT and SBT include the inability to maintain adequate oxygenation, excessive respiratory effort or use of accessory muscles, hemodynamic instability, and signs of acute change in mental status such as agitation or delirium that would lead to inability to follow commands (13).  

Choice of Analgesia and Sedation 

The “C Element: Choice of Analgesia and Sedation” focuses on the appropriate use of medications and how medications are used (13). Continuous assessment of level of consciousnesses at least every four hours is vital to preventing over and undersedation (13). Multimodal use of analgesics and sedation would reduce the need for high doses of medications and would minimize potential for adverse effects. Continual assessment of renal and hepatic laboratory values is vital as there is also a potential for sedative accumulation (13). Using appropriate dosing strategies or considering agents with shorter half-lives would relieve pressure on hepatic/renal clearance.   

Delirium: Assess, Prevent, Manage 

The “D Element: Delirium: Assess, Prevent, and Manage” focuses on screening for delirium (13). The Confusion Assessment Method for ICU (CAM-ICU) is a four-feature screening tool that includes observation of acute onset/fluctuation in mental status, delivering an inattention test, calculation of altered level of consciousness score, and assessing disorganized thinking with a standardized set of questions (13). The criteria is met, as delirium positive, if feature one plus two, and either three or four are present.   

Strategies for delirium treatment include identifying potential etiology then reconsidering pharmacological therapies (potentially reducing deliriogenic drugs, reducing sedation, providing daily sedation vacations) (13). Nonpharmacologic strategies include removing catheters and invasive devices as soon as possible, balancing nutrition and hydration, reducing visual/hearing impairment through use of hearing aids and glasses, clustering patient care, promoting interaction and engagement with loved ones, and daily and regular reorientation to environment and situation (12).  

Early Mobility and Exercise 

The “E Element: Early Mobility and Exercise” highlights the benefits that hemodynamically stable ICU patients would receive when involved with rehabilitation activities, early on in the ICU course (13). For patients not hemodynamically stable, range of motion exercises are beneficial as well. This helps prevent deconditioning, muscle weakness and muscle contraction.  

Family Engagement and Empowerment 

The “F Element: Family Engagement and Empowerment” recognizes the role of patient and family centered care, which involves understanding the patients’ cultural beliefs, personal goals and understanding of prognosis (13). This includes assessing for key family members, decision makers, and family support needs. The best way for providers to keep patients and families informed in a transparent manner, as the hospital course progresses, is through daily meetings, encouragement of family to be involved in interdisciplinary rounds, flexible visitation (in an in-person and virtual capacity) and offering resources to assist family understanding of medical terminology (13).  

 Procedural Levels of Sedation  

There are four main stages to drug induced sedation that range from minimal sedation to general anesthesia. Once sedation medications have started, minimal sedation (anxiolysis) is the initial state where the patient still remains awake and alert but with limited sedation effects (19). Patients can interact, and respond to verbal stimuli and follow commands, without impairment of cognitive or physical functioning (19). Cardiovascular and respiratory function is intact (18). Generally local or regional anesthesia will align as minimal sedation, for procedures such as abscess incision and drainages, and lumbar punctures (18).  

Moderate sedation (conscious sedation) or procedural sedation includes a depressed level of consciousness (19). The patient is purposefully responsive to light tactile stimulation and verbal commands but has a decreased awareness of their surroundings (18). Often an impaired memory of the chain of events occurs as well. This level of sedation is used for procedures that necessitate analgesia and muscular relaxation (18). No external breathing support devices are needed (19).  

In deep sedation, the patient can still be aroused (not easily) with repeated, vigorous or painful stimulation but displays a decreased level of consciousness (19). There may be limited ability for the patient to maintain their airway on their own, so ventilation assistance may be required (19). In the operating room, this level of sedation is used during procedures requiring muscular relaxation with minimal patient movement (19).  

General anesthesia is the induced state of complete unconsciousness, where the patient is not arousable, not even through painful stimulation (18). The patient is unresponsive to external stimuli and now demands artificial support for airway management, ventilation and hemodynamic stability (19).  

Although RASS and CAM-ICU are the gold standards for assessing sedation levels, the Ramsay scale is another way, albeit limited way, to rank levels of restlessness and agitation, when evaluating the degree of sedation (19). There are six categories from “patient awake but anxious, agitated, or restless, to patient awake but cooperative, orientated, and tranquil, to patient drowsy but responsive to commands, patient asleep (brisk response to glabella tap or loud auditory stimulus), patient asleep with sluggish response to a stimulus, and finally patients with no response to noxious stimuli.” (19).

Medications  

When sedating ventilated ICU patients, there are a variety of medications that are commonly used to achieve the desired level of sedation while concurrently ensuring patient safety and comfort. These medications include opioids, benzodiazepines, propofol, dexmedetomidine, ketamine and neuromuscular blocking agents. While no single sedative has proven superior in terms of efficacy or mortality, The SCCM guidelines advise against long term use of benzodiazepines due to evidence that suggests its correlation with prolonged intubation duration (3). 

Opioids 

Opioids such as fentanyl and morphine, are commonly used for analgesic effects but do contribute to sedation at high enough doses (10). They are the recommended first line prior to sedation and if patient care is not able to be optimized at this point, paralytics are then involved.  

Benzodiazepines 

Benzodiazepines, such as midazolam and lorazepam, can be used as an anxiolytic but also produce sedative and amnestic effects (10). They are more commonly used for short term continuous sedation as it may yield more negative effects in patients with prolonged ventilation.   

Propofol 

Propofol is a potent sedative-hypnotic agent with rapid onset and offset of action, which allows for quick titration (5). It is often used for continuous sedation due to its short half-life and favorable sedation profile as it is generally well tolerated. However, there are potential concerns. A common side effect is the systemic vasodilation that occurs, for which providers must watch for hypotension (5).   

Another common concern is due to its lipid emulsion formulation, providers must draw serum labs to prevent hypertriglyceridemia (5). A rare but potentially fatal condition is the propofol related infusion syndrome, which is essentially characterized through multiple organ collapse – metabolic acidosis, rhabdomyolysis, hyperlipidemia, hepatomegaly, acute renal failure and cardiovascular collapse (5). There is limited but promising data surrounding the water-soluble prodrug version of propofol, Fospropofol, that would be a viable alternative to propofol, as it mitigates the concerns related to the lipid emulsion formation (5).   

Dexmedetomidine 

Dexmedetomidine is a centrally selective alpha-2 adrenergic agonist that is often used in conjunction with other sedatives, due to its unique ability to maintain a more natural sleep-wake cycle, which allows a more interactive patient with a lower potential for delirium (5). It is versatile as it works well as an anxiolytic, analgesic and a sedative, and has a shorter half-life, allowing it to be quickly titrated and generally well tolerated (5).   

There are multiple clinical trials that have shown that its strong efficacy and safety to be used as long-term sedation (5). As it has minimal effect on respiratory drive, allowing it to be used when respiratory wise, patients are ready to be trialed and weaned off the ventilator, but are exhibiting anxiety or aggression (6). Concerns that surround dexmedetomidine, include hypotension, bradycardia and a potential for withdrawal symptoms upon completion of long-term therapy.   

In a randomized, placebo-controlled study carried out by Skrobik and colleagues, there was a significant decrease in cases of delirium when low dose dexmedetomidine was used (7). In a multicenter, double-blind trial carried out by Hughes and colleagues, there was evidence for when light sedation was used in patients with dexmedetomidine or propofol, there were similar safety end points and outcomes did not differ (6). Due to this and similar studies, for sedation, the PADIS guidelines now suggest initial use of dexmedetomidine or propofol use over benzodiazepines (5).   

Ketamine 

Ketamine is a N-methyl-D-aspartate (NMDA) antagonist that has both analgesic, amnestic and cataleptic properties, depending on dosage (8). More recently it has also been used concurrently with psychotherapy and posttraumatic stress disorder and depression (8). It can be used in hemodynamically unstable patients or in patients with refractory pain, severe bronchospasm, intracranial hypertension, and traumatic brain injury (8).  

Neuromuscular Blocking Agents 

Neuromuscular blocking agents such as cisatracurium, succinylcholine, rocuronium, and vecuronium, are temporary paralytics, and work in conjunction with anxiolytics, analgesics and sedation medications (9). It is vital to note that they are not used solely for sedation purposes as they have a lack of sedative properties.   

They induce temporary paralysis of skeletal muscles by blocking the transmission of nerve impulses at the neuromuscular junction (9). They are most commonly used to eliminate ventilator-patient desynchrony, but are also appropriately indicated in patients needing therapeutic hypothermia treatment post-ventricular fibrillation related cardiac arrest, status asthmaticus, and adult respiratory distress syndrome (9). Paralytics are associated with longer duration of hospital/ICU stays, ICU-acquired weakness, and the unknowing suppression of seizure activity (9).  

Special Considerations/Guidelines and Protocols for Sedation Management  

There are several considerations of why providers would choose an analgesic/sedative/paralytic over another. For instance, fentanyl, hydromorphone, and morphine are the most commonly used opioids in the ICU (1). For ease of titration and rapid onset, the intravenous route is ideal. Due to how medications are metabolized and accumulated in the body, there are specific concerns that providers must take into account. As the vast majority of opioids are primarily metabolized through the kidneys, following the renal function is paramount (1). For example, morphine poses concern when it’s byproducts or active metabolites build up in the kidneys, whilst hydromorphone is metabolized into an inactive form so it is less likely to cause problems in terms of accumulation in the body (1). Fentanyl offers a rapid onset but has a high likelihood of accumulating in the fatty tissue after prolonged or repeated dosing (1).  

Table 1. Considerations for the commonly used opioids (13) 

Table 2. 2018 PADIS Considerations for Nonopioid Analgesia (12) 

Side effects of analgesics include respiratory depression, drowsiness/lightheadedness and sedation which may impair cognitive and motor function, nausea and vomiting, induce constipation and lead to potential bowel obstruction, itching or pruritis, and cause mood swings (21).   

Opioids are closely controlled substances as long-term use can lead to physical dependance and are easily prone to abuse (21). Signs of opioid dependance can manifest itself in various ways, most of which are subtle and not always easily detected (21). However, in ventilated ICU patients, it’s generally not common to develop a long-term reliance on opioids.  

The following are PADIS guidelines recommendations for ventilated ICU patients with agitation: (13)  

• Light sedation (minimal use of sedation as necessary)   
• Recommend using propofol or dexmedetomidine over benzodiazepines (midazolam or lorazepam)  

Table 3. Considerations for the most commonly used sedatives for ventilated ICU patients (13, 15) 

Complications  

Sedation in ventilated ICU patients can pose numerous potential complications, including the following:  

Muscle Weakness 

Prolonged use of sedatives can lead to muscle atrophy due to disuse, which complicates and prolongs long term recovery. This applies to neuromuscular weakness and impairments in both physical function (14).  

Respiratory Depression   

Oversedation can lead to respiratory depression, resulting in hypoxemia, hypoventilation, and respiratory failure. Whilst inadequate sedation in a ventilated patient can compromise ventilation where airway obstruction, hypoventilation and apnea are of high concern (13).  

Prolonged Mechanical Ventilation  

Oversedation can delay ventilation weaning which would prolong the duration of mechanical ventilation use and lead to increased risk of ventilator associated complications that can affect all facets of life (13). 

Ventilator-Associated Pneumonia 

Ventilator-associated Pneumonia (VAP): one of the most common ventilator-associated complications as it is most often caused by aspiration, secondary to sedation-related suppression of cough and gag reflexes (3).  

Hemodynamic instability 

Special consideration regarding potential adverse effects when starting medications must be exercised, especially in patients who are already hemodynamically unstable, regardless of etiology. Continual assessment is needed (13). 

Medication Withdrawals/Rebound 

Abrupt cessation or rapid tapering of sedatives can cause withdrawal symptoms such as seizures, tremors, agitation, especially in patients who have been on high dose or prolonged continuous infusions (13). 

Accidental Extubation/Self-Harm 

Patients not optimally medicated may develop delirium or agitation and may unintentionally self-extubate, leading to respiratory distress, airway obstruction, and additional airway trauma if emergent reintubation (if indicated) (4). 

Adverse Drug Affects 

As is true with all medications, there is a risk of adverse drug reactions, especially when medications are not cleared properly through the liver or kidney. This can further complicate and prolong the patient’s ICU course (15). 

Cardiovascular Instability 

Patients with compromised myocardial function or low vascular tone due to diagnoses such as sepsis, may be more vulnerable to hypotension. Hypovolemia must be properly corrected and monitoring while on sedation (15). 

Post-Traumatic Stress Disorder 

Sedation-related experiences can potentially contribute to long-term psychological distress (1) and can impact the quality of life negatively post hospital discharge. Consider the dire consequences a patient may have, if oversedation occurred with an inadequate analgesic amount administered. Patients can still feel pain even when sedated as sedatives do not possess strong analgesic properties (25). Failing to recognize and address the pain will contribute to agitation (25). Patients have memories of pain, and with inadequate analgesia and high anxiety can cause accidental removal of endotracheal tubes or catheters needed for life saving measures (25)  

Sedation in End-of-Life Care  

In the critical care setting, prognoses are often unclear and so frequent discussion revolving around the consistently changing treatment goals occur early and frequently (4). The goals of palliative care include emotional support for families, alignment of treatment plans with patient’s preferences and goals, as well as optimizing medical management (4).  

It is a holistic approach through early identification of psychological, physical, social and spiritual concerns (4). Palliative care includes a multidisciplinary team approach, involving various nurses and doctors, case management, chaplain, nurse managers and educators, whom closely work with the patient’s loved ones (4). Studies have shown that palliative care when integrated early in a patient’s medical course, improves quality of life, reduces caregiver burden, and shortens ICU and hospital stays (4).   

Firstly, should the patient’s prognosis come to be, transition to do-not-resuscitate (DNR)/ do-not-intubate (DNI) and conversations revolving around hospice care, can be initiated (4). When hospice care is initiated, goals of care change for terminal sedation, with the sole purpose of providing compassionate and dignified care while relieving suffering. Terminal sedation does not hasten death and is not the same as euthanasia or physician-assisted suicide (4).   

End-of-life sedation involves the administration of sedation medications with the goals of relieving distressing symptoms such as dyspnea, pain, anorexia, thirst, agitation, fear, depression, anxiety, constipation, fatigue, and delirium, while allowing the patient to remain minimally conscious or unconscious until death occurs (4). In addition to opioids (most commonly, morphine) for analgesia, most commonly used sedatives include midazolam and propofol.   

External non-invasive oxygen devices (such as nasal cannulas) are used to manage dyspnea, as it is closely associated with anxiety, fatigue and pain (4). If patients are already ventilated, once end-of-life treatment is initiated, patients are terminally extubated as it no longer brings benefit to the patient (4). Additional doses of opioids and sedatives are given before extubating; the overall course of extubation (preparation, action and clean up) is quick, generally taking about 20 minutes total (4). Patients are then placed on oxygen to assist with work of breathing, and can naturally breathe for minutes, hours to days. Anxiolytics, bronchodilators, diuretics and corticosteroids are also used to reduce the anxiety element (4).   

In terms of hydration and nutrition, there is a need for more individual, case by case basis. Clinical judgement and experience, and respect for patient dignity and autonomy take priority here (4). When patients are dying, the body shuts down and no longer sees food and water as a necessity. There is no longer a need to eat and drink water, as those are life sustaining measures. Feeding and hydration may increase the chance of aspiration pneumonia as patient’s cough/gag and stomach muscles are no longer functioning properly, and increase gastrointestinal discomfort including diarrhea (4). By upholding principles of nonmaleficence, autonomy and beneficence, healthcare providers can navigate the complexities of end-of-life care with compassion and respect for each patient.  

Ethical Considerations  

Patient safety is the main concern. Ethical considerations in sedation management in ventilated ICU patients include a range of complex topics that require careful conversations, reflection and ethical decision-making. These cautions are due to the inherent vulnerability of ICU patients (if not discussed prior to altered consciousness) and the potential for sedatives to influence patient autonomy long term. Medically speaking, ethical dilemmas can arise when balancing the risks of oversedation or undersedation, with the goals of sedation (for pain relief, anxiety rection, patient comfort and medical treatment necessity) (13).   

Additionally, unnecessary prolongation of sedation may contribute to patient adverse outcomes such as immobility and delirium (13). Special circumstances of shortages in medical supplies, medications, or treatments, can require a healthcare provider to balance the availability of resources and the emergent needs for assistance (16). Should ventilated ICU patients requiring sedation for the context of end-of-life decision making, goals of care, withdrawal of life-sustaining treatment, and palliative sedation, while still upholding principles of respect for patient autonomy and beneficence (4).   

The principals of ethical decision making in sedation management is a code of respect for patient autonomy. ICU patients when ventilated and sedated, have diminished capacity to play a part in medical decision-making, especially as the medical course progresses (16). Therefore, healthcare providers must do their best to uphold patient autonomy (4). They must also ensure that the patients, or designated decision makers, understand and are involved in all discussions regarding sedation management and treatment goals (13).    

The goal is always to provide the best quality of life and respect the patient’s preferences. This includes sensitivity to each individual’s cultural beliefs, values and personal preferences in the decision-making process. Effective and open communicative conversations (especially to directly ask for clarity), cultural competence, and respect for diverse perspectives would be the best way to foster trust, understanding and collaboration.  

Research Findings  

Recent research findings have shed new light on the use of volatile anesthetic agents such as isoflurane and sevoflurane in ventilated ICU patients, presenting abundant possibilities in improving sedation effects as well as outcomes in the critical care setting. These general anesthesia maintenance medications have traditionally been used as first line medications, in the operating room due to their cardioprotective and bronchodilatory properties (1).   

They work by inhibiting the gamma-aminobutyric acid (GABA) neurotransmitter located in the central nervous system (1). There is special expertise, and a need for specialized equipment and training involved when using volatile anesthetic agents, as this mode of sedation is inhaled rather than given via the continuous intravenous route (24). Volatile anesthetics have minimal reliance on renal and hepatic function due to minimal accumulation in the body, precise titration, rapid onset allowing for quick induction, and its effect dissipate quickly upon discontinuation (1).   

This allows for precise control of sedation levels, as is required in the ICU setting. These pharmacological properties make it appealing to the ICU environment as they are well-tolerated, efficient and titratable (24). There is strong evidence that shows prolonged use of inhaled sedation (for over 48 hours) that parallels with patient safety and strong effects on hemodynamic stability (24). Through Yassen and colleagues’ narrative review, encapsulating data published between 2005 and 2023, they found that volatile anesthetics reduced the time to extubation, lowered opioid and muscle relaxant requirements, decreased weaning time from mechanical ventilation, and further led to increased potential for improved outcomes (26).  

There are several challenges that remain regarding the use of volatile anesthetics in the critical care setting. The first complication is the lack of standardized protocols and dosing procedures. This leads to variability in practice and uncertainty of use. Secondly, as the risk of malignant hyperthermia is exceedingly rare (according to the Malignant Hyperthermia Association of the United States, occurrence is estimated to be about one in 50,000 to 100,000) (27), it still must be recognized as it requires urgent intervention and treatment (26).  

Malignant hyperthermia occurs in genetically predisposed individuals, and presents with hypercarbia, hyperthermia and hemodynamic instability (26). Should symptoms of malignant hyperthermia develop, immediate discontinuation of the medication should be done, and administration of intravenous dantrolene sodium to help dissipate symptoms (27). Dantrolene is an FDA-approved postsynaptic muscle relaxant that works as an antagonist to the ryanodine receptors (the calcium channels that are acted on by the anesthetics), to prevent progression of symptoms and further patient decline (27). Other concerns include the adverse effects of these medications, which include dose-dependent reduced cardiac output, decreased arterial pressure, and respiratory depression (26). Lastly, there is potential cost savings due to better potential outcomes leading to shorter ICU stays but there is also a concern as volatile anesthetic agents and equipment needed are costly.  

Since it has not been extensively studied or standardized as with other sedative agents, and ICU providers are not as familiar with its use, further research is needed to establish its long-term role in the ICU setting (1).  

Commonly Asked Questions by Caretakers  

Educating and involving family members and caretakers in the patients care, has shown to improve patient outcomes significantly (23). Addressing commonly asked questions in a simple and direct way, can help clarify caretaker understanding/bias (23).  

What is the tube in their mouth for?  

To help the sedated patient breathe safely, a temporary plastic breathing tube is inserted through their mouth into their lungs, and the exterior is connected to a breathing machine or a ventilator (23).   

Is sedation in ICU a coma?   

Yes, we chemically induce your loved one into a coma with sedatives in a controlled environment to keep them comfortable. We can safely use more or less of the medication as needed. We turn the medications down or off to allow patients to wake up, when we believe it is safe to do so (23).  

How long can a person be sedated in ICU?   

Patients are given sedatives until their situation improves. Some patients may require sedation for extended periods of time, hours, days or even weeks. If they are able to wake up, breathe by themselves and are strong enough, we can remove the breathing tube (23).  

Can sedated ICU patients hear?   

It depends on how much sedation the patient is on. On a general note, we don’t know for sure but we know from anecdote and previous patients, that sometimes they remember sounds or things that were said to them when they were sedated (23).  

Can sedated ventilated ICU patients talk?  

If they have a breathing tube in their mouth, they cannot talk because the tube presses on the larynx or the voice box. We still talk to sedated ventilated patients as if they can hear us, to help reorient them and help keep them calm (23).  

Conclusion

In the critical care environment, the proper management of sedation in ventilated ICU patients is vital to optimal clinical outcomes. Understanding the physiological principles, clinical nuances, and therapeutic decisions based on evidence-based practice help give healthcare providers insight to enhance clinical practice and mitigate or manage implications should they occur. Sedation management involves not only selecting and titrating sedative agents (and balancing the need for analgesics/paralytics and avoiding pharmacological contraindications), it also involves assessing and monitoring the use of sedation, according to institutional protocols, for each patient as an individual.  

Even as there are still currents of innovation and unknowns, healthcare providers all have a singular goal of the pursuit of excellence and commitment to patient centered care. Through clinical expertise and compassionate engagement, healthcare providers can provide the best care for ventilated ICU patients.   

➁ Complete Survey

Give us your thoughts and feedback

➂ Click Complete

To receive your certificate