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Daily interruption of continuous sedation is not detrimental to long term psychological outcome

Citation/s: John P. Kress, Brian Gehlbach, Maureen Lacy, Neil Pliskin, Anne S. Pohlman and Jesse B. Hall, The Long-term Psychological Effects of Daily Sedative Interruption on Critically Ill Patients. AJRCCM 2003 Vol 168. pp. 1457-1461

Lead author's name and fax: John P Kreiss, M.D., Section of pulmonary and critical care medicine, MC 6026, University of Chicago, 5841 Maryland Ave, Chicago, IL 60637. Email jkress@medicine.bsd.uchicago.edu

Three-part Clinical Question: In critically ill mechanically ventilated patients with continuous IV sedation, daily interruption of sedation reduces length of ICU stay and ventilator days. Does it affect the long-term psychological outcome?
 

Search Terms: Sedation, Intensive care, interruption.

The Study: Single-blinded, non-randomised, cohort study

The Study Patients: 105 medical patients (75 from previous study of sedative interruption & 30 contemporaneous) who had survived to discharge from ICU and hospital were screened. 32 of 35 contactable patients agreed to participate in an interview. All patients had been mechanically ventilated and given continuous IV sedation. Both groups were followed up for 6 months post discharge and underwent psychiatric analysis for posttraumatic stress and adverse psychological outcomes. Of the 105 patients screened there was a 30% inclusion rate.  The interviewers were blinded to the patients history.

Control group (N =86; 19 analysed): Standard ICU care, with mechanical ventilation and continuous sedation. 7 patients from 60 in the original study control group and 12 from 26 in the contemporaneous control group were interviewed.

Experimental group (N =72; 13 analysed): Standard ICU care with mechanical ventilation and continuous sedation. Sedation was interrupted daily to the point of waking. 11 patients from 68 in the original study intervention group and 2 from 4 in the contemporaneous intervention group were interviewed.
 

The Evidence:

 EBM summary questions:

1.      Do the methods allow the adequate testing of the hypothesis- No: This was a small study with large numbers of patients lost to follow-up.  Only 32 patients were interviewed of the 105 screened, an inclusion rate of only 30%.  Furthermore the cohort was not randomised.  The use of contemporaneous patients (who were not included in the original trial looking at daily sedative interruption and length of ICU stay by the same authors) was not justified in the trials methodology

2.      Do the statistical tests correctly test the results to allow differentiation of statistically significant result- Yes, tests stated seem correct, but sample size may invalidate results

3. Are conclusions valid in light of results- Yes, however as previously mentioned sample size was small. Daily interruption of sedative infusions is not detrimental to the long-term psychological well being of critically ill patients.  Sedative interruption significantly reduces the signs of PTSD but causes no significant difference on the long-term prevalence of anxiety & depression compared to standard ICU care.  The majority of patients interviewed recalled being in ICU (68.4% control vs. 69.2% intervention p = 1.0) although very few recalled awakening in ICU, and there was a trend towards more people in the control group recalling awakening (26.3% vs. 0%, p = 0.06). Surprisingly, no one in the intervention group recalled awakening.  Furthermore, daily interruption of sedation is not associated with harmful outcomes with regards to patients quality of adjustment to their current illness

4. Did results get omitted, and why- No,

5. Did they suggest areas of further research- No, but further larger studies may show lack of psychological detriment or even possible benefit in terms of protecting against PTSD

6. Did they make recommendations based on results and were they appropriate- Yes, daily interruption is a safe and practical approach to treating patients who are receiving mechanical ventilation, and is not detrimental to long term psychological outcome compared to standard ICU treatment.  However, the power of evidence for with regards to long-term psychological effect is poor.

7. Is this study relevant to my clinical practice- Yes, the benefits of daily interruption of sedative therapy in terms of length of ICU stay and days on a ventilator are relevant.  This study is the first attempt to look at its psychological effects, and although its statistical power is weak it does not demonstrate any detriment in this intervention.

8. What level of evidence does this study represent- 2-

9. What grade of recommendation can I make on this result alone- N/A

10. What grade of recommendation can I make when this study is considered along with other available evidence- C, when the benefit for daily interruption of sedation in terms of ICU stay and days on a ventilator is taken into account.

11. Should I change my practice because of these results- Yes, the study should alleviate some concerns over the long-term effects of interruption continuous sedation, although it is far from conclusive evidence.

12. Should I audit my current practice because of these results- No

Appraised by: Tim R Geary and Kevin D Rooney, Intensive Care Unit, Royal Alexandra Hospital, Corsebar Road, Paisley. PA2 9PN; 12 April 2005

Email: timgeary@doctors.org.uk

Kill by date 2010. 

Citation: EBM Critical Appraisals. Scottish Intensive Care Society EBM Group. Geary RT, Rooney KD. 2005. : John P. Kress JP, et al. The Long-term Psychological Effects of Daily Sedative Interruption on Critically Ill Patients. ALRCCM 2003 Vol 168. pp. 1457-1461. 

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