How to Provide Targeted Sedation for Intubated Emergency Department Patients

Written by Sam Parnell

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This pilot trial showed that an educational initiative focused on reducing deep post-intubation sedation in the Emergency Department was feasible and associated with lower mortality, more ventilator-free and ICU-free days, and no increase in adverse events.

Why does this matter?
We certainly don’t want to forget appropriate sedation on our intubated patients and risk awareness with paralysis. However, mechanically ventilated patients who are deeply sedated have worse outcomes compared to those who are lightly sedated^1,2, and patients in the ED are at high risk of deep sedation³. Deep sedation initiated in the ED is associated with increased mortality, ventilator duration, and length of stay³ and is more likely to persist throughout the first few days in the ICU^4,5. Unfortunately, there is a dearth of evidence on sedation depth in the ED, and there is a wide variation of practice patterns related to sedation management. Can anything be done to reduce deep sedation in the ED?

Don’t sleep on your post-intubation sedation protocols…
The ED-SED trial was a pragmatic, multicenter, prospective before-after pilot and feasibility trial designed to assess whether a large-scale clinical trial regarding ED-based sedation was possible. The trial was conducted at three academic, tertiary care medical centers with a pre-intervention period, a protocol implementation period, and a post-intervention period.

The intervention was an educational initiative that aimed to improve adherence to guideline-recommended protocols to facilitate appropriate post-intubation sedation. Providers were educated with lectures, inservices, and informal bedside interactions on the importance of sedation, sedation depth assessments and documentation, and defaulting to light sedation. Reminder cards and emails were also used.

A total of 415 patients were included in the study cohort. Patients in the intervention group had reduced incidence of deep sedation (38.8% vs 60.2%; p < 0.01) and increased documentation of sedation depth (88.6% vs 64.8%; p < 0.01). Furthermore, patients in the intervention group had lower mortality (10.0% vs 20.4%; p < 0.01), more ICU-free days [20.8 (8.7) vs 18.1 (10.4); p < 0.01], and more ventilator-free days [22.0 (9.0) vs 19.9 (10.6); p = 0.03]. There was no significant increase in adverse events, and no patients in the intervention group required reintubation.

There were several limitations to this study, including potential unmeasured confounders and cohort imbalances. Interestingly, although the intervention group achieved lighter sedation, they did not receive less sedation overall. This discordance could be due to the Hawthorne effect and improved sedation practices and documentation. Therefore, the jury is still out until a larger trial is completed.

Nevertheless, this small study confirmed the feasibility of educational initiatives to improve ED sedation practices, reduce deep sedation, and improve patient outcomes. So, next time you have a mechanically ventilated patient in the ED, closely monitor the sedation depth and shoot for light sedation.

Source
The Feasibility of Implementing Targeted SEDation in Mechanically Ventilated Emergency Department Patients: The ED-SED Pilot Trial. Crit Care Med. 2022 Aug 1;50(8):1224-1235. doi: 10.1097/CCM.0000000000005558. Epub 2022 Apr 11.

Works Cited

1. Ely EW, Shunting A, Truman B, et al: Delirium as a predictor of mortality in mechanically ventilated patients in the intensive care unit. JAMA 2004; 291:1753–1762
2. Kollef MH, Levy NT, Ahrens TS, et al: The use of continuous i.v. sedation is associated with prolongation of mechanical ventilation. Chest 1998; 114:541–548
3. Stephens RJ, Ablordeppey E, Drewry AM, et al: Analgosedation practices and the impact of sedation depth on clinical outcomes among patients requiring mechanical ventilation in the ED: A cohort study. Chest 2017; 152:963–971
4. Fuller BM, Mohr NM, Roberts BW, et al: Protocol for a multicentre, prospective cohort study of practice patterns and clinical outcomes associated with emergency department sedation for mechanically ventilated patients: The ED-SED study. BMJ Open 2018; 8:e023423
5. Fuller BM, Roberts BW, Mohr NM, et al: The ED-SED study: A multicenter, prospective cohort study of practice patterns and clinical outcomes associated with emergency department sedation for mechanically ventilated patients. Crit Care Med 2019; 47:1539–1548