Wake up your patients!

In 1998, Thomas L. Petty expressed his concern about deep sedation and suggested a new link between sedation and severe complications.(1) His phrasing emphasized that it is not the underlying disease, but the physicians themselves that cause the gloomy situation he experienced in his intensive care unit (ICU). As more evidence supporting his theory has emerged, Petty’s editorial seems even more visionary today than during the time it was published. In 2012 and 2013, Shehabi et al. demonstrated for the first time that deep sedation within the first 48 hours of intensive care treatment results in significantly higher 180 day mortality and that every individual event of over-sedation led to significantly prolonged mechanical ventilation.(2,3) The results of these observational studies were impressive and snowballed a discussion about sedation, sedation-practice and related outcomes. In 2000, a study investigating daily interruptions of sedation-infusion published by Kress et al. showed that daily awakening trials are associated with 2.4 fewer days of mechanical ventilation.(4) Eight years later, Girard et al. conducted a randomized clinical trial on awakening and breathing versus solely breathing and showed that the combination led to a 32% lower 1-year-mortality.(5) In 2010, the working group around Thomas Strøm published the “no-sedative” approach. Patients received a protocol of “no-sedation”, which actually meant a morphine, haloperidol, propofol based step-regime that avoided sedatives wherever possible to keep the patient awake.(6) Patients had a lower time of ventilation, ICU length of stay and in-hospital length of stay, and his publication became one of the most discussed papers in intensive care medicine in that year. There is profound evidence that critically ill patients benefit from being awake. Today, it seems likely that any type of sedation is associated with a worsened outcome; therefore, it is limited to very few and specific indications (e.g., increased intracranial pressure in patients with traumatic brain injury, prone-positioning in acute respiratory distress syndrome patients). International guidelines recommend a goal-directed approach: a target for sedation has to be defined at least once per day, and the level of sedation should be assessed frequently to avoid over-sedation.(7,8) The definition and the assessment should be conducted with a validated scoring system. Regarding recent evidence, the “Richmond-Agitation-and-Sedation-Scale” (RASS) should be the standard for sedation-monitoring in ICU patients.(7,8) This 10 point scale allows practitioners to distinguish between different stages of sedation and agitation.(9) It is easy to use, utilizes objective criteria (arousal to verbal stimulus or tactile stimulus), has been validated in different languages, Björn Weiss1, Claudia D. Spies1