Daily Interruptions of Sedation: A Clinical Approach to Improve Outcomes in Critically Ill Patients

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1 Feature Daily Interruptions of Sedation: A Clinical Approach to Improve Outcomes in Critically Ill Patients Elizabeth Berry, MSN, ACNP-BC Heather Zecca, MSN, ACNP-BC The continuous infusion of sedative agents is often necessary for critically ill patients. However, it has been associated with several disadvantages. Numerous interventions to reduce these risks have been evaluated, including the practice of interrupting sedative infusions on a daily basis. A literature search was conducted, and 7 studies were reviewed to evaluate the safety and effectiveness of daily interruption of sedative infusions and its outcomes. The implementation of daily sedation interruptions was suggested to minimize multiple complications associated with continuous sedative infusions and was not associated with intensive care related complications or long-term psychological effects. Additional studies have revealed perceived barriers to the implementation of daily sedation interruptions. Further randomized controlled trials enrolling larger, more diverse samples are needed to provide more evidence regarding the safety and effectiveness of this intervention. (Critical Care Nurse. 2012;32[1]:43-51) Although sedation may provide relief of anxiety and agitation, it is also associated with risks, including delirium, prolonged mechanical ventilation, and longer stays in the ICU and hospital. 4,5 Further, patients receiving sedative infusions can quickly become oversedated or sedated for a prolonged period even after the sedation is discontinued. Despite these risks, the use of continuous sedation is prevalent and has increased over the years. 3 Critically ill patients admitted to the intensive care unit (ICU) receive the most technologically advanced treatments that medicine can offer. Many ICU patients are faced with complex pathological conditions that require advanced life support, such as mechanical ventilation, which can evoke anxiety and agitation American Association of Critical- Care Nurses doi: /ccn Sedatives, such as benzodiazepines and propofol, have been used to ease the anxiety and agitation associated with the ICU experience. Some of these agents may be administered in the form of intermittent boluses; however, a few commonly used agents, such as propofol, are typically administered in the form of continuous intravenous infusions. 2 Indeed, in a recent study, 3 more than half of patients undergoing mechanical ventilation in the United States receive sedatives by continuous infusion. Management of Sedation To lessen the occurrence of these complications, caution in administration of sedatives must be exercised. Thorough assessment and management of anxiety is an important nursing responsibility. In managing the continuous infusion of sedatives, a delicate balance must be maintained between minimizing risks and optimizing delivery of care and comfort. Nurses and acute care nurse practitioners (ACNPs) working in critical care settings will often CriticalCareNurse Vol 32, No. 1, FEBRUARY

2 be faced with this challenge. Management of continuous intravenous sedation in the ICU requires high levels of skill and judgment to assess patients degrees of sedation accurately, identify indications for weaning patients off of or discontinuing sedation, and monitor patients responses. The management of sedation requires a multidisciplinary approach, including critical care nurses, ACNPs, clinical nurse specialists, physicians, and pharmacists, all of whom are involved in the implementation of evidence-based practices, such as a daily interruption of sedation (DIS). To achieve anxiety relief by using continuous sedation while avoiding its associated risks, the practice of DIS has been developed. Recent evidence suggests the implementation of DIS in conjunction with validated assessment tools and hospital-based sedation protocols can facilitate improvements in patients outcomes. 6,7 The purpose of this review is to evaluate the safety and effectiveness of DIS and the outcomes it evokes. Daily Interruption of Sedation Kress and colleagues 8 introduced the concept of DIS in They conducted a trial in which 73 patients were randomized to receive a continuous infusion of propofol or Table 1 Contraindications of daily interruptions of sedation a Receiving a sedative infusion for active seizures or alcohol withdrawal Receiving escalating doses of sedative as a result of ongoing agitation Receiving neuromuscular blocking agents Evidence of active mycocardial ischemia in the prior 24 hours Evidence of increased intracranial pressure a Based on information from Kress et al. 6 midazolam. Sedative infusions were interrupted on a daily basis. The study compared the time to achieve sedation and awakening, as well as the reproducibility of assessments of sedation level and the change in oxygen consumption between the state of awakening and sedation. Although this trial did not directly compare DIS with traditional methods of sedation management, it was an introduction to the concept of interrupting sedative infusions on a daily basis. The DIS process begins with the identification of patients appropriate for undergoing interruption and excluding patients who have contra - indications (Table 1). Once a patient is identified as a candidate for DIS, sedative infusions are discontinued until the patient wakes up and exhibits signs of responsiveness or intolerance of awakening. If the patient does not clinically tolerate DIS, continuous sedation may be reinitiated, typically at half of the Authors When this article was written, Elizabeth Berry was a staff nurse in the medical ICU at the Hospital of the University of Pennsylvania. She is currently an acute care nurse practitioner and lives in San Antonio, Texas. Heather Zecca is an acute care nurse practitioner in the Department of Surgery at the University of Pennsylvania Health System in Philadelphia, Pennsylvania. Corresponding author: Elizabeth Berry ( eag0299@yahoo.com) or Heather Zecca, Department of Surgery, Pennsylvania Hospital, Pine Bldg, 800 Spruce St, Philadelphia, PA ( heather.zecca@uphs.upenn.edu). To purchase electronic or print reprints, contact The InnoVision Group, 101 Columbia, Aliso Viejo, CA Phone, (800) or (949) (ext 532); fax, (949) ; , reprints@aacn.org. previous rate (Figure 1). This method of sedation management has been suggested to liberate patients more quickly and effectively from medically induced comas and, consequently, mechanical ventilation than do traditional methods of sedation management. 6,7 With this liberation comes a reduced risk of associated complications. 4,5 Review of Literature A comprehensive search of the literature was conducted for research studies evaluating DIS published between 2000 and The key words daily interruption of sedation, sedation interruptions, and daily awakening were entered into the databases PubMed, Medline, Ovid, CINAHL, National Guideline Clearinghouse, and The Cochrane Central Register of Controlled Trials. Only human studies published in English were included. Several preliminary articles found were searched by hand for additional relevant studies. Seven studies evaluating DIS were selected for review. Results Of the 7 studies reviewed, 3 randomized controlled trials 6,7,9 were used to compare DIS directly with other methods of sedation management. Three studies involved evaluation of patients undergoing 44 CriticalCareNurse Vol 32, No. 1, FEBRUARY

3 Determine eligibility for daily interruption of sedation a Failure criteria 1. Sustained anxiety, agitation, or pain 2. Respiratory rate >35/min for 5 min Discontinue sedative infusions 3. Oxygen saturation 88% for 5 min Every 24 hours 4. Acute cardiac dysrhythmia Patient opens eyes to verbal stimuli or tolerates interruption for 4 hours without exhibiting any failure criteria a Patient exhibits any failure criteria a 5. 2 signs of respiratory distress, including tachycardia, bradycardia, accessory muscle use, abdominal paradox, diaphoresis, or marked dyspnea Continue patient care without sedation Restart sedative infusion at half the previous rate Figure 1 Process of daily interruption of sedation. Based on information from Kress et al. 6 DIS and its influence on cardiac ischemia, psychological effects, and other physiological conditions. The remaining study 13 examined DIS paired with physical therapy. As summarized in Table 2, DIS has been associated with shortened duration of mechanical ventilation, 6 shorter length of stay, 7 fewer symptoms associated with posttraumatic stress disorder (PTSD), 11 and fewer other ICU-related complications. 12 In 2000, Kress and colleagues 6 conducted the first major study to evaluate DIS. In that trial, 128 medical ICU patients were randomly assigned to undergo DIS or receive sedation managed by the ICU team. The DIS group was associated with a reduced duration of mechanical ventilation (P=.004), shorter ICU stay (P=.02), and less unnecessary use of computed tomography and magnetic resonance imaging (P=.02), as depicted in Figure 2. Several limitations of this study were identified. Because the study included only medical ICU patients at 1 medical center, these findings cannot be generalized to all critically ill patients. As sedation in the control group was manipulated at the discretion of the ICU team, infusions could have been interrupted in the same manner as in the intervention group, giving the control group the ability to experience the potential benefit of the intervention. Further, the clinicians managing both groups were not blinded. To mitigate this limitation, the end points of the study were not revealed. This trial was initially met with criticism as the safety of DIS was questioned. 14 In response, Schweickert and colleagues 12 conducted a blinded, retrospective review of the charts of the patients enrolled in the trial by Kress et al. 6 This study compared the incidence of 7 specific complications associated with mechanical ventilation and critical illness (ventilator-associated pneumonia, upper gastrointestinal hemorrhage, bacteremia, barotrauma, venous thomboembolism, cholestasis, and sinusitis requiring surgical intervention) between the DIS group and the control group. Twelve patients from the DIS group experienced 13 of these complications whereas 19 patients in the control group experienced 26 complications (P=.04; Figure 3). The main limitations of this study relate to its retrospective CriticalCareNurse Vol 32, No. 1, FEBRUARY

4 design. The complications examined by Schweikert and colleagues 12 were defined retrospectively, creating the potential for bias. In an effort to address this problem, reviewers were blinded to each patient s assigned group and were not involved with the original, prospective study. The increased incidence of upper Table 2 Review of primary sources Reference (year of publication) Girard et al 7 (2008) Aims To determine if routine SAT improves patients outcomes when combined with routine SBT Sample Four large tertiary-care hospitals, 336 MICU patients requiring MV Intervention group: SAT paired with SBT; total = 167 Control group: No SAT; SBT only; total=168 Study design Multicenter randomized controlled trial Compared SAT with SBT vs usual patient-targeted sedation with SBT Kress et al 6 (2000) To determine whether DIS would decrease the duration of MV and LOS in MICU patients Tertiary-care hospital, 128 MICU patients requiring MV Intervention group: sedation interruptions 48 h after enrollment; total = 68 Control group: sedation managed by the MICU team; total = 60 Randomized controlled trial comparing DIS vs sedative infusions managed by the MICU team Schweickert et al 12 (2004) To determine whether DIS reduces the incidence of complications commonly associated with critical illness Tertiary care hospital, 126 MICU patients requiring MV Intervention group: DIS; total = 66 Control group: sedation managed by the MICU team; total = 60 Blinded, retrospective chart review Kress et al 10 (2007) To determine if DIS in patients requiring MV with coronary risks precipitates myocardial ischemia MICU patients requiring MV enrolled from a large tertiary-care hospital Convenience sample of 74 patients Prospective, blinded observational study to evaluate prevalence of myocardial ischemia in patients undergoing DIS; ischemia compared: before interruption (baseline) vs when clinically awake and sedation on (baseline) vs sedation off Kress et al 11 (2003) To evaluate the longterm psychological effects of DIS on critically ill patients Tertiary care hospital, 32 MICU patients Psychological outcomes in ICU survivors who experienced DIS vs ICU survivors receiving traditional sedation management; a blinded clinical psychologist performed detailed psychological evaluations on each blinded patient Strøm et al 9 (2010) To investigate whether the duration of MV can be reduced with a protocol of no sedation vs sedation with DIS University hospital in Denmark, 140 medicalsurgical ICU patients requiring MV Intervention group: No sedation; total = 70 Control group: Sedation with DIS; total=70 Randomized controlled trial to determine the effect of no sedation on MV days and ICU and hospital LOS; patients were randomly assigned by using concealed envelopes; participants, investigators, and clinicians giving interventions or assessing outcomes were not blinded Abbreviations: DIS, daily interruption of sedation; ICU, intensive care unit; LOS, length of stay; MICU, medical intensive care unit; MV, mechanical ventilation; SAT, spontaneous awakening trial; SBT, spontaneous breathing trial. 46 CriticalCareNurse Vol 32, No. 1, FEBRUARY

5 gastrointestinal bleeding in the DIS group was not fully explained and warrants further investigation. In 2008, Girard and colleagues 7 conducted a subsequent randomized controlled trial in which 336 medical ICU patients from 4 tertiarycare hospitals were randomly assigned to either undergo DIS Duration of MV ICU LOS Hospital LOS Duration of MV ICU LOS Hospital LOS End points 7 complications: ventilator-associated pneumonia, upper gastrointestinal hemorrhage, bacteremia, barotrauma, venous thromboembolic event, cholestasis, sinusitis requiring surgery Study findings SAT group spent more days breathing without assistance, discharged 4 days earlier from the ICU; shortened duration of coma; increased 1-year survival No significant difference in tracheostomy placement, duration of delirium, time to tracheostomy placement, reintubations Limitations: enrolled only MICU patients; MICU team not blinded; because sedative infusions in the control group were at the discretion of the MICU team, sedation could have been interrupted in a similar fashion as in the intervention group DIS group had significantly reduced duration of MV by 2.4 days (P =.004) and ICU LOS by 2.5 days. No difference in hospital LOS between groups No difference in adverse events between groups (2 self-extubations and 1 central venous catheter removal in DIS group vs 4 self-extubations in control group) No difference in reintubation rates between groups No difference in in-hospital mortality between groups Limitations: enrolled only MICU patients; MICU team not blinded; because sedative infusions in the control group were at the discretion of the MICU team, sedation could have been interrupted in a similar fashion as in the intervention group DIS group experienced significantly fewer complications overall compared with the control group (P =.04) 13 complications in the DIS group (2.8%) vs 26 complications in the control group (6.2%) Occurrence of myocardial ischemia measured Posttraumatic stress disorder evaluated with Total Impact of Events Scale Depression evaluated with Beck Depression Inventory Perceived health and psychological well-being evaluated with SF-36 Anxiety evaluated with State-Trait Anxiety Inventory Number of days without MV after successful extubation in a 28-day period Occurrence of needed radiological studies (magnetic resonance imaging, computed tomography), accidental removal of endotracheal tube, and ventilator-associated pneumonia A total of 18 patients were ischemic; comparing baseline vs clinically awake, 8 were ischemic during both periods, 3 were ischemic while awake but not at baseline, and 7 were ischemic at baseline but not while awake Comparing sedation on vs sedation off, 12 patients were ischemic during both periods, 1 was ischemic with sedation off but not at baseline, and 5 were ischemic at baseline but not with sedation off 24.3% of sample was ischemic, and those patients had an increased ICU LOS (P =.04) and a longer duration of MV than did patients who were nonischemic No significant increase in myocardial ischemia during sedation interruption Limitations: Holter monitoring used, which is less extensive in the ICU setting; convenience sampling creates potential for bias; only MICU patients enrolled DIS group exhibited significantly less posttraumatic stress disorder No significant difference in remaining end points between groups Limitations: small sample size; single-center study; no randomization; enrolled only MICU patients Patients in the intervention group receiving no sedation spent fewer days undergoing MV than did patients receiving DIS Patients receiving no sedation also had a shorter ICU LOS (P =.03) and hospital LOS (P =.003) Limitations: Single-center study; unblinded; limited generalizability due to the uncommon 1 to 1 nurse to patient ratio in the ICU and the use of an additional person to calm the intervention group; both groups received boluses of morphine as needed, which may have affected the data CriticalCareNurse Vol 32, No. 1, FEBRUARY

6 Days Ventilator days (P =.004) ICU length of stay Daily interruption of sedation Figure 2 Comparison of median ventilator days and median length of stay in the intensive care unit (ICU) between patients treated with conventional methods and patients treated with daily interruption of sedation. No. of cases Ventilator-associated pneumonia Figure 3 Incidence of complications. Based on data from Schweikert et al. 12 paired with a spontaneous breathing trial or receive sedation managed by the ICU team with a spontaneous breathing trial. The results revealed a significant decrease in ICU and Ventilator days ICU length of stay (P =.01) Kress et al 6 (2000) Girard et al 7 (2008) Upper gastrointestinal bleeding Bacteremia Daily interruption of sedation Barotrauma Venous thromboembolism Conventional methods Cholestasis Conventional methods Sinusitis requiring surgery hospital lengths of stay in patients receiving DIS (P=.01 and P=.04, respectively). These patients also experienced a reduction in time spent receiving mechanical ventilation (P=.02; Figure 2). One-year survival analysis revealed that at any point during the year following enrollment, patients in the DIS group were 32% less likely to die than were patients in the control group (P=.01). Like the trial conducted by Kress and colleagues, 6 this study included only medical ICU patients; however, 4 large medical centers located in different areas of the country participated. Neither the researchers nor the clinicians involved in the patients care were blinded, creating the potential for bias. With evidence supporting the benefits of minimizing sedation with DIS, a Danish study published in 2010 by Strøm and colleagues 9 was conducted to evaluate the benefit of no continuous sedation versus DIS in 140 ICU patients receiving mechanical ventilation. Patients were randomly assigned. The intervention group (n=70) received boluses of morphine as needed but no continuous sedation, whereas the control group (n=70) received continuous sedation with DIS. The study compared the number of days without mechanical ventilation in a 28-day period, length of ICU stay, and length of hospital stay. The findings revealed that patients receiving no continuous sedation experienced a reduced duration of mechanical ventilation (P=.02), ICU length of stay (P=.03), and hospital length of stay (P=.004) compared with patients receiving DIS (Figure 4). However, more patients in the intervention group (20%) than in the control group (7%) experienced delirium (P=.04). This was an unblinded, singlecenter study, 9 limiting the generalizability of these results. Further, the nurse to patient ratio was 1:1, and 48 CriticalCareNurse Vol 32, No. 1, FEBRUARY

7 an additional person was used to calm agitated patients in the intervention group. This availability of staff is unrealistic in many ICU settings; further, the methods, training, and credentials of the persons who calmed the patients were not discussed. This study explores an alternative method of administering sedation that may improve outcomes by reducing the duration of mechanical ventilation and lengths of stay; however, further research is needed to establish whether this strategy can be reproduced in other facilities and to expand upon the potential risks, such as delirium and long-term psychological effects, of this method. Although this evidence suggests numerous benefits associated with minimizing sedation, the safety of DIS in vulnerable populations of patients, specifically patients with coronary artery disease, has been further investigated. Kress and colleagues 10 conducted a prospective, blinded, observational study of 74 medical ICU patients at high risk for coronary artery disease. They investigated the incidence of myocardial ischemia during mechanical ventilation, in addition to the influence of DIS on myocardial ischemia. Holter monitoring was used to identify myocardial ischemia (defined as ST-segment elevation or depression >0.1 mv from baseline), which was present in 24% of the sample (n=18) and was associated with a longer ICU stay and duration of mechanical ventilation than was seen in patients without ischemia. In a subgroup analysis of the 18 patients with ischemia, ischemia did not increase notably during the sedation interruption. The use of convenience sampling limited the Days Days without mechanical ventilation Figure 4 Comparison of days without mechanical ventilation and lengths of stay (mean days) in the intensive care unit (ICU) and the hospital between sedated and nonsedated patients. Based on data from Strøm et al. 9 No sedation study by Kress et al 10 ; however, assessments with the Holter monitors were blinded. Further, although Holter monitoring can be used in the ICU, it is not typical, limiting its usefulness as a tool for detecting myocardial ischemia in this setting. Only patients in the medical ICU were enrolled in that study, limiting extrapolation to critically ill patients in other settings. The psychological impact of DIS on the ICU patient population has also come into question. 14 Intensive care patients faced with critical illness may be subject to severe psychological problems such as PTSD following their hospitalization. 15 To examine the psychological effects of DIS, Kress and colleagues 11 conducted a study to compare psychological outcomes in patients undergoing DIS versus outcomes in patients whose sedation was managed by the ICU team. PTSD was assessed by using various validated tools, including the Total Impact of Events Scale, a self-report questionnaire of 15 questions to measure ICU length of stay (P =.03) Sedation Hospital length of stay (P =.004) the subjective response to stress. The DIS group exhibited a lower Total Impact of Events score (P=.02). However, no significant difference was found between the 2 groups in the incidence of anxiety and depression. Consequently, DIS may not result in adverse psychological outcomes and may actually reduce symptoms of PTSD. More research is warranted because of the small sample size of this single-center study. Many patients died after discharge or were lost to follow-up, further limiting the study (105 patients were screened, 35 were contacted regarding the study, 32 participated). However, patients lost to the study were demographically similar to participants, minimizing this limitation. Again, only patients from the medical ICU were enrolled. Although these studies suggest the benefits associated with implementation of DIS, newer studies incorporating DIS have been conducted to optimize outcomes for critically ill patients. In 2009, CriticalCareNurse Vol 32, No. 1, FEBRUARY

8 Schweickert et al 13 conducted a trial in which 104 patients were randomly assigned to either an intervention group (n=49) that received early physical and occupational therapy during periods of DIS or a control group (n=55) that received therapy as ordered by the primary care team and DIS. During the 28-day followup period, more patients in the intervention group returned to their independent functional status at hospital discharge (P=.02). The intervention group also experienced a shorter duration of delirium (P=.02) and more ventilator-free days (P=.05; Figure 5). These findings suggested that implementation of whole-body rehabilitation consisting of DIS plus physical and occupational therapy early in critical illness is a well-tolerated practice and may improve outcomes at hospital discharge. Clinical Relevance Recently, the practice of DIS has been integrated into the evidencebased care bundles for critical care. 16 Further, the American College of Critical Care Medicine 1 established guidelines to aid clinicians in the management of sedatives and analgesics in critically ill adults. To minimize complications, the guidelines suggest a defined goal and end point for sedation, use of a validated assessment tool, and the implementation of an algorithm or protocol. Consequently, the incorporation of DIS when appropriate may aid in achieving optimal comfort and safety. Barriers to Implementation of DIS A recent survey revealed several barriers to implementing DIS, including lack of nursing acceptance, Days or No. of patients Duration of mechanical ventilation (P =.05) Early physical therapy Figure 5 Comparison mechanical ventilation, delirium (mean days), and return to independent functional status (No. of patients). Based on data from Schweikert et al. 13 safety concerns (eg, patient-initiated device removal), respiratory compromise, and decreased comfort of patients. 17 Despite the recommendations for the use of sedation protocols or algorithms, less than 33% of medical ICUs in the United States use a sedation protocol or algorithm. 2 Perceived barriers may contribute to the relatively low implementation rate. The ease with which DIS is provided, or its feasibility, may also stand as a perceived barrier. In consideration of this perceived barrier, a pilot trial conducted in 2008 by Mehta and colleagues 18 examined the feasibility of a DIS protocol among nurses and respiratory therapists in the ICU. The study randomized 65 adult patients from 3 medical-surgical ICUs to an intervention group with a sedation protocol and DIS or a control group including patients managed with a sedation protocol alone. Feasibility was determined by using a visual analog scale, whereby nurses and respiratory therapists were asked to rate patient management on a scale from 1 ( very easy ) Hospital delirium Conventional methods Return to independent functional status at hospital discharge to 10 ( extremely difficult ). In both groups, the acuity of the patients and the nurse to patient ratio were similar. Nurses identified patient management in the DIS group as very easy to fairly easy in 82% of the intervention group versus 77.6% of the control group, and respiratory therapists corresponding values were 82.5% and 80.4%. Although this was a pilot trial, it was a randomized multicenter trial, reflecting the feasibility of DIS reported by nurses and respiratory therapists from a wider variety of backgrounds and perspectives. However, larger randomized controlled trials may be necessary to evaluate the usability of DIS and the potential for an increased nursing workload. Another barrier perceived by clinicians is the safety of DIS. When Girard and colleagues 7 examined the safety of DIS, their results revealed that although more patients in the DIS group self-extubated, there was no difference in the rate of reintubation between the groups. This finding is clinically relevant, as these 50 CriticalCareNurse Vol 32, No. 1, FEBRUARY

9 patients were ready to be liberated from the ventilator sooner than anticipated by practitioners. Additionally, Kress and colleagues 6 reported no significant difference in adverse events, including self-extubation and removal of central venous catheters, between the DIS group and the control group. Although this evidence suggests no additional risks to patients undergoing DIS, further research must be conducted to examine the safety of DIS. These patients may require careful observation and monitoring, as most critically ill patients do, but this concern should not manifest itself as a barrier to DIS implementation but rather a utilization of the skill and expertise in clinical assessment that critical care nurses possess. Conclusion Discomfort and anxiety are common experiences for many critically ill patients. Continuous sedation, although necessary for many of these patients, has the disadvantage of prolonged mechanical ventilation and its associated risks. 4 One intervention aimed at minimizing these risks while maintaining patients comfort and safety, the practice of interrupting sedation infusions on a daily basis, has been examined. Despite the proposed benefits associated with DIS demonstrated in this review, additional research into this technique and its safety are warranted. To learn more about the management of sedation in the critical care setting, read Daily Interruption of Sedation in Patients Receiving Mechanical Ventilation by Weisbrodt et al in the American Journal of Critical Care, July 2011;20:e90-e98. Available at Recommendations for Future Research The study samples in this review consisted of predominately medical ICU patients, limiting the ability to generalize these findings to other populations of patients. Additional studies involving patients from surgical and trauma ICUs are warranted. Further, although some data have shown the psychological safety of DIS, such data are limited. 11 Additional data, both quantitative and qualitative, in this area are needed. Moreover, additional rigorous randomized controlled trials enrolling larger samples would provide further evidence for clinicians managing and caring for these critically ill patients and potentially address speculations regarding the practice. Another area worth exploring further is the impact on clinicians working with patients at the bedside, including nurses and respiratory therapists. How feasible is it to incorporate a sedation protocol that involves DIS, and are there strategies that facilitate this incorporation? Further research addressing such concerns could be useful for all critical care settings, particularly those whose staff are unfamiliar with sedation protocols and DIS. CCN Now that you ve read the article, create or contribute to an online discussion about this topic using eletters. Just visit and click Submit a response in either the full-text or PDF view of the article. Financial Disclosures None reported. References 1. Jacobi J, Fraser GL, Coursin DB, et al. Clinical practice guidelines for the sustained use of sedatives and analgesics in the critically ill adult. Crit Care Med. 2002;30(1): Rhoney DH, Murry KR. National survey of the use of sedating drugs, neuromuscular blocking agents, and reversal agents in the intensive care unit. J Intensive Care Med. 2003;18(3): Wunsch H, Kahn JM, Kramer AA, Rubenfeld GD. Use of intravenous infusion sedation among mechanically ventilated patients in the United States. Crit Care Med. 2009; 37(12): Kollef MH, Levy NT, Ahrens TS, Schaiff R, Prentice D, Sherman G. The use of continuous i.v. sedation is associated with prolongation of mechanical ventilation. Chest. 1998;114(2): Pandharipande P, Shintani A, Peterson J, et al. Lorazepam is an independent risk factor for transitioning to delirium in intensive care unit patients. Anesthesiology. 2006; 104(1): Kress J, Pohlman AS, O Connor MF, Hall JB. Daily interruption of sedative infusions in critically ill patients undergoing mechanical ventilation. N Engl J Med. 2000;343(20): 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 randomized controlled trial. Lancet. 2008;371(9607): Kress JP, O Connor MF, Pohlman AS, et al. Sedation of critically ill patients during mechanical ventilation: a comparison of propofol and midazolam. Am J Respir Crit Care Med. 1996;153(3): Strøm T, Martinussen T, Toft P. A protocol of no sedation for critically ill patients receiving mechanical ventilation: a randomised trial. Lancet. 2010;375(9713): Kress, JP, Vinayak, AG, Levitt, J, et al. Daily sedative interruption in mechanically ventilated patients at risk for coronary artery disease. Crit Care Med. 2007;35(2): Kress JP, Gelbach B, Lacy M, Pliski N, Pohlmam AS, Hall JB. The long-term psychological effects of daily sedative interruption of critically ill patients. Am J Crit Care Med. 2003;168(12): Schweickert WD, Gehlbach BK, Pohlman AS, Hall JB, Kress JP. Daily interruption of sedative infusions and complications of critical illness in mechanically ventilated patients. Crit Care Med. 2004;32(6): Schweickert WD, Pohlman AS, Nigos C, et al. Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomized controlled trial. Lancet. 2009;373(9678): Heffner JE. A wake-up call in the intensive care unit. N Engl J Med. 2000;342(20): Kapfhammer H, Rothenhausler H, Krauseneck T, Stoll C, Schelling G. Post-traumatic stress disorder and health-related quality of life in long term survivors of acute respiratory distress syndrome. Am J Psychiatry. 2004;161(1): Fulbrook P, Mooney S. Care bundles in critical care: a practical approach to evidencebased practice. Nurs Crit Care. 2003;8(6): Tanios MA, de Wit M, Epstein SK, Devlin JW. Perceived barriers to the use of sedation protocols and daily sedation interruption: a multidisciplinary survey. J Crit Care. 2009; 24(1): Mehta S, Burry L, Martinez-Motta JC, et al. A randomized trial of daily awakening in critically ill patients managed with a sedation protocol: a pilot trial. Crit Care Med. 2008;36(7): CriticalCareNurse Vol 32, No. 1, FEBRUARY