Impact of difficult sedation on the management and outcome of critically ill patients.

ABSTRACT

BACKGROUND: The term "difficult sedation" (DS) refers to situations of therapeutic failure, tolerance, or deprivation of the sedatives administered. AIMS: To characterize the profile of patients who developed DS and to assess its impact on the duration of mechanical ventilation (MV) and intensive care unit length of stay (ICU-LOS), as well as other complications related to their stay. DESIGN: A prospective descriptive analysis was conducted of the practices of analgesia/sedation in a medical-surgical intensive care unit (ICU) over a 2-year period. METHODS: All critically ill patients undergoing MV and sedation for more than 24 hours were prospectively followed until death or discharge. Demographic data, type, duration, complications of analgesia/sedation, and clinical outcome during ICU stay were recorded. Patients who developed DS were compared with those who were not difficult to sedate (not-DS). RESULTS: A total of 327 patients were included, 24.1% of whom were difficult to sedate (DS). Patients in the DS group were younger (P = .001); less severely ill (P = .003); and were more likely to have a history of smoking (P = .045), alcohol (P < .001), and psychotropic use (P = .001) than the not-DS group. Patients included in the DS group were sedated for longer periods (P < .001) and required higher doses of midazolam (P < .036), propofol (P = .023), and remifentanyl (P = .026) than those in the not-DS group. Difficult-to-sedate patients were twice as likely to require more than one sedative simultaneously (P < .001), presented more periods of over-sedation (P = .031)/under-sedation (P = .024), and suffered more pain (P < .001) than patients in the not-DS group. Patients in the DS group had prolonged MV times (P < .001), developed more pressure ulcers (P > .001) and ventilator-associated pneumonias (P = .025), and were more likely to require tracheotomy (P = .001) than those in the not-DS group. CONCLUSION: DS develops in one of four critically ill patients and has a negative impact on their outcomes. Early identification of the clinical profile of this group and active prevention and treatment are essential strategies in order to minimize its impact. RELEVANCE TO CLINICAL PRACTICE A quarter of mechanically ventilated patients may develop situations of DS, which negatively affects their outcome. Early detection and prevention of DS are essential to minimize its impact.