ICU patients are being kept sedated
and on ventilators longer than necessary, according
to a study presented at the American Thoracic Society
International Conference in San Francisco in May. Physicians
treating these critically ill patients tend to err on
the side of caution because of uncertainty over when
it's safe.
The authors of the current study
say they have the answer: a two-step "wake up and breathe"
strategy. The protocol is designed to wean patients
from these aids faster than current common practices
allow, shaving days off of hospital stays and reducing
the number of deaths.
"Wake up and breathe" is the brainchild
of Dr Wes Ely, associate director of the geriatric research
education and clinic center at Vanderbilt University
in Nashville and is part of the multicentre Awakening
and Breathing Controlled (ABC) trial. He says the method
could save hospitals $5,000 to $15,000 US per patient
by slashing ICU stays by four days.
SOFTLY,
SOFTLY
Dr Ely and his co-researchers studied 335 critically
ill ICU patients in four hospitals, all on sedative
medication and mechanical ventilators, for 28 days.
Patients were matched for baseline characteristics and
randomized to either the "wake up and breathe" study
group, which received daily spontaneous awakening trials
(SAT) followed by spontaneous breathing trials (SBT),
or an SBT-only control group.
In the SAT step, sedation is turned
off to determine whether patients are able to breathe
unassisted while awake. Sedation resumes if the patient
is distressed. In the SBT step, the patient is taken
off the ventilator and is allowed to breathe on their
own. They are placed back on ventilation if unable to
breathe on their own.
A nurse handles the first step,
while in the second, a respiratory therapist stops the
ventilator and tests breathing. Compared to the control
group, patients receiving the "wake up and breathe"
treatment spent four days less in the ICU and hospital,
1.2 fewer days on mechanical ventilation and two fewer
days with either delirium or coma. Forty-seven patients
in the experimental group died, compared to 58 in the
control group.
Dr Ely attributes the mortality
difference to either deleterious health effects of longer
sedation and a higher overall dosage of sedatives experienced
by the control group, or earlier time out of the ICU
and off of a ventilator predisposing the study group
to less risk of infection.
The study's findings were "a real
surprise," says Dr Ely, because he had expected the
difference between the study and control group results
would be negligible or even negative. "I thought patients
would have improved enough with either approach that
we would not see a big difference when they were combined.
This way of enforcing the combined protocol and the
cooperation between medical and non-medical professionals
can have striking results."
THE
DRUG STOPS HERE
Dr Ely noted that current practices don't force removal
of sedation or mechanical ventilation on a regular basis.
"In fact, patients generally stay two or three days
or longer on a ventilator beyond what they need because
it's nobody's 'job' to stop the sedative analgesics,"
he said, adding that "This is the first study to ever
fully enforce the idea that, while on a ventilator,
a patient should be screened every single day for the
ability to remove both sedation and ventilation. We've
shown it to be safe and effective with dramatic clinical
proof."
He thinks the protocol could and
should be implemented, as is, stressing that the results
are absolutely definitive. "Physicians [in the US] are
already starting to implement this into practice," he
says. "It's very easy to incorporate."
"The next step is to see if this
ABC trial changed long-term cognitive outcomes," adds
Dr Ely. "It's possible that the increasingly recognized
acquired dementia that the patients get after their
stay in the ICU is partly due to drug exposure, and
it could be that the early interruption of sedative
drugs — the 'awakening' step — could improve
long-term cognitive outcome," he says.
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