Implementing sedation protocols: closing the evidence-practice gap

Sedation and analgesia are frequently used in the critical care unit. Pain has already been described as the “fifth vital sign,” and most people describe experiencing pain as a source of great stress during an intensive care unit (ICU) stay.(1,2) Sedation can be used to ease discomfort, to facilitate adaptation to mechanical ventilation, and to prevent self-harm.(3) However, despite its humanitarian intentions, over-sedation is associated with prolonged mechanical ventilation, increased delirium rates, longer ICU lengths of stay (LOS), and increased mortality.(4,5) In recent decades, many studies have addressed the risks of over-sedation.(6) Kress et al. were the first to demonstrate that a protocol of daily awakening led to a reduced duration of mechanical ventilation and of ICU LOS.(7) Subsequently, Girard et al. performed a trial comparing daily awakening plus spontaneous breathing trials with standard sedation practices plus spontaneous breathing trials and showed that the intervention group had an improved 1-year mortality, with an impressive NNT of 7.(8) More recently, a “no-sedation, analgesia-based” trial also showed more ventilator-free days and reduced ICU and hospital LOS.(9) Despite all the impressive evidence available, there is a wide variation among sedation surveys worldwide. Self-reported adherence to daily interruption of sedation varies from 14% in Malaysia(10) to 78% in the UK.(11) In North America, Patel et al. showed that only 44% of the respondents performed sedation interruption on more than half of the ICU days, and 29% did not have a written sedation protocol.(12) The use of a sedation protocol also varies among countries, ranging from 33% in Denmark(13) to 80% in the UK.(14) In Brazil, a recent survey showed that only 52.7% of the respondents use a sedation protocol, and 68.3% of physicians do not practice sedation interruption at all.(15) Why there is such a wide evidence-practice gap? There are many possible explanations, such as the lack of personnel or equipment support, concern about risk of patient-initiated device removal, and fear of patient discomfort and increase in workload.(16) In this context, the trial presented in this edition of the journal by Bugedo et al. clarifies much.(17) The authors performed a nationwide, multicenter study in 13 ICUs evaluating an analgesia-based, goal-directed, nurse-driven sedation protocol. They showed that after an educational effort, the proportion of patients in deep sedation or coma could be reduced from 55.2% to 44% with no increase in agitation events. This paper shows us that the implementation of sedation protocols is feasible, although it requires a persistent educational effort and the participation of all of the staff working in the ICU. Cássia Righy Shinotsuka1,2