Sedation Protocols Presented in Literature
Beyond the choice of the specific drug [66-68], the most frequently used method for administering sedatives is the continuous intravenous route, because of its pharmacokinetic properties [63]. Intravenous infusions present predictable and easy to handle onset/offset properties, justifying the search for an early goal-directed sedation strategy [69]. Although these characteristics are necessary in short ICU stays, they may be useless, or even dangerous, for patients requiring more than 3 days of mechanical ventilation [27]. When using potent drugs, it is easy to incur in overadministration albeit goals are established and adequate [25]. Moreover, daily awakening trials produce far-from-physiological neurological fluctuations [70], and continuous deep sedation does not permit patients to recall factual memories, which has been proven effective in preventing PTSD [71].
If continuous intravenous infusion is used, the daily interruption of sedatives and analgesics is recommended in order to reduce the total administered dosage and to perform a spontaneous breathing trial, if allowed by the respiratory condition of the patient. The purpose is to reduce the development of complications and the duration of mechanical ventilation [17]. This strategy may prove less effective if specific and ICU team-shared protocols are used [72].
Many quite different sedation protocols have been presented in literature [10, 73, 74]. Some of them essentially rely on the use of different drug doses [75], with the aim to different sedation levels [56, 76]. Other protocols are based on nursing- implemented algorithms [13, 77-79] or on analgesia-first sedation [21, 80]. Moreover, tested ways to optimize sedation management in ICU are patient- controlled sedation [81] or automated sedation in patients needing deep sedation [82], the use of inhaled halogenates [83, 84], or the enteral administration of drugs [28, 85]. All these protocols rely on the continuous and adequate neurological assessment made with validated tools, in order to measure not only pain, agitation, and delirium but also level of consciousness and patient mobilization.
The most promising protocol, in terms of efficacy, recommends to join the sedation strategies with early physiotherapy [86], mobilization [87], and occupational therapy [88, 89], also engaging patient families. Even if implementing such protocols is not simple [90], from the first presentation made in 2010 [91, 92], it has offered the best results in terms of effectiveness [93]. Briefly, following the acronym ABCDEF, the authors made these suggestions:
- • Assess, prevent, and manage pain.
- • Both spontaneous awakening trial and spontaneous breathing trial.
- • Choice of analgesia and sedation.
- • Delirium: assess, prevent, and manage.
- • Early mobility and exercise (goal-directed early mobilization).
- • Family engagement and empowerment.
