Daily Sedation Holiday

Daily breaks from sedative infusions have been shown to decrease mortality and shorten hospital stays.^1,2,([FOOTNOTE=Kress JP, Pohlman AS, O’Connor MF, Hall JB. Daily interruption of sedative infusions in critically ill patients undergoing mechanical ventilation. N Engl J Med. 2000;342(20):1471-1477.],[ANCHOR=],[LINK=]) Studies have shown that both lighter sedation and daily sedation holidays for mechanically ventilated patients lower the risk of mortality and complications, such as drug-induced delirium or ventilator associated pneumonia.^1,2,3,([FOOTNOTE=Luetz A, Goldmann A, Weber-Carstens S, Spies C. Weaning from mechanical ventilation and sedation. Curr Opin Anaesthesiol. 2012;25(2):164-169.   ],[ANCHOR=],[LINK=])^,([FOOTNOTE=Hooper MH, Girard TD. Sedation and weaning from mechanical ventilation: Linking spontaneous awakening trials and spontaneous breathing trials to improve patient outcomes. Anesthesiol Clin. 2011;29(4):651-661.],[ANCHOR=],[LINK=])^,([FOOTNOTE=Brook AD, Ahrens TS, Schaiff R, et al. Effect of a nursing-implemented sedation protocol on the duration of mechanical ventilation. Crit Care Med. 1999;27(12):2609-2615.],[ANCHOR=],[LINK=])

Sedation holidays can help avoid drug accumulation and oversedation.³  They may allow your patient time to reorient, and even reduce psychological trauma from critical care stresses.([FOOTNOTE=Kress JP, Gehlbach B, Lacy M, Pliskin N, Pohlman AS, Hall JB. The long-term psychological effects of daily sedative interruption on critically ill patients. Am J Respir Crit Care Med. 2003;168(12):1457-1461.],[ANCHOR=],[LINK=]) Finally, they may provide you with an important opportunity to assess your patient’s neurological and respiratory status,¹  as well as his or her readiness to be weaned from sedation and mechanical ventilation.^3,4,5,6

Though some conditions do call for uninterrupted sedation, patients under mechanical ventilation have been shown in studies to require continuous sedation as little as 20% of the time.([FOOTNOTE=Salgado DR, Favory R, Goulart M, Brimioulle S, Vincent JL. Toward less sedation in the intensive care unit: a prospective observational study. J Crit Care. 2011;26(2):113-121.],[ANCHOR=],[LINK=])  Weigh the benefit for each of your patients against the risks—both obvious and subtle. Continuously dosed medication levels can build up over time,³ while sedation depth and adequacy can be difficult to judge, even when using validated rating scales.([FOOTNOTE=Weinert CR, Calvin AD. Epidemiology of sedation and sedation adequacy for mechanically ventilated patients in a medical and surgical intensive care unit. Crit Care Med. 2007;35(2):393-401.],[ANCHOR=],[LINK=])

In one study, caregivers rated patients as oversedated only 2.6% of the time, though researchers found the same patients minimally or non-arousable in 32% of their assessments and motionless in 21% of their assessments.⁹

A sedation holiday often means first assessing whether the patient passes a safety screen for the break.^5,([FOOTNOTE=Dunn JG, Baker MW. Daily sedation breaks and breathing trials help wean patients from ventilators safely: The authors give advice on developing a nurse-implemented sedation protocol. Am Nurse Today. 2011;6(3).],[ANCHOR=],[LINK=]) If your patient is deemed ready, you'll most likely stop sedative infusion and allow the patient to awaken fully.⁴  This is usually done each day.^4,10  The duration of this break depends on the patient, the sedative used and your goals for the sedation holiday.^4,10

Generally, you will monitor for signs of discomfort as your patient awakens, and will not restart sedation until after he or she has proven alert and responsive and you have completed your assessment. ^4,10  In "spontaneous awakening trials" and titration protocols, sedation is usually resumed only if or when the patient shows signs of agitation, anxiety, pain or respiratory distress.^4,5,10  In that case, sedation is restarted at a reduced rate or the lowest dose that provides adequate patient comfort.^4,5,10

As a result of daily sedation holidays, you and your patients may see fewer complications and quicker weaning from sedatives and mechanical ventilation.³  Further benefits have been reported with sedation holidays followed by spontaneous breathing trials.^2,4,5,10,([FOOTNOTE=Girard TD, Kress JP, Fuchs BD, et al. Efficacy and safety of a paired sedation and ventilator weaning protocol for mechanically ventilated patients in intensive care (Awakening and Breathing Controlled trial): a randomised controlled trial. Lancet. 2008;371(9607):126-134. Girard TD, Pandharipande PP, Ely EW. Delirium in the intensive care unit.],[ANCHOR=],[LINK=])

If you don't have one already, you may consider a standardized program of sedation holidays and assessments to help ensure consistent care for your patients.^4,10