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ED Oversedation May Cause ICU Harm

August 15, 2017

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Excessive sedation of intubated adult patients in the ED was associated with increased in-hospital mortality.  Aim for a RASS of -2 or -1.

Why does this matter?
Sedation for mechanically ventilated patients is important.  But oversedation may be harmful, according to this study.  This is a modifiable variable that may improve outcome for our patients.

Not too little, not too much…just right!
 It’s important to provide adequate sedation of intubated patients, but this study says to avoid giving them too much.  In this retrospective registry, they found deep sedation in the ED, defined as RASS -3 to -5, was associated with increased in-hospital mortality.  But I have some reservations about this study.  Deeper sedation may have simply been a marker of sicker patients.  Non-survivors were more likely to have had cirrhosis, been on dialysis, had malignancy, or had immunosuppression.  Could a deeper RASS simply have been a marker of more severe disease?  Also, RASS was rarely measured in the ED, so the RASS calculated in the first 3 hours of ICU admission was imputed to the ED.  Regardless, multivariate regression for confounders still found the association of deep sedation with mortality. It looks like a good practice to moderately sedate rather than deeply sedate if possible.  Aim for a RASS of -2 or -1.

Analgosedation practices and the impact of sedation depth on clinical outcomes among patients requiring mechanical ventilation in the emergency department: a cohort study.  Chest. 2017 Jun 20. pii: S0012-3692(17)31076-0. doi: 10.1016/j.chest.2017.05.041. [Epub ahead of print]

Peer reviewed by Thomas Davis, MD.

What are your thoughts?