The effects of sedation cessation within the first four hours of intensive care unit admission in mechanically ventilated critically ill patients – a quality improvement study

BACKGROUND: Early deep sedation in mechanically ventilated patients during the first 48 h of intensive care unit (ICU) admission can be associated with adverse outcomes. We hypothesised that moving the ‘daily sedation break’ process forwards, might allow earlier titration of sedation to target levels – an ‘early sedation cessation’ (ESC). METHODS: We commenced a quality improvement project with the primary outcome being to stop sedation completely, within 4 h of ICU admission, in 95% of eligible patients. This was done by small, step-wise tests of change. No ethical approval was required. FINDINGS: Between 1 February 2014 and 31 January 2018, 1787 intubated patients were included. 1052 received an ‘ESC’ within 4 h (‘Yes’), 545 were excluded (‘Excluded’), and 190 were inadvertently omitted from ‘ESC’ (‘No’). The primary aim was achieved for the first time after 12 months. Compared to the ‘Yes’ group, the ‘Excluded’ group received 38% more propofol in the first 48 h of admission (IRR 1.38 (1.31–1.47), p<0.001), while the ‘No’ group received 32% more (IRR 1.32 (1.22–1.43), p<0.001). At four hours, 19·6% (12·9–27·9) of the ‘Yes’ group had attained a target RASS of -1, 0 or 1, compared to 13·6% (8·0–21·0) of those in the ‘No’ group. This proportion increased to 55·6% (46·1–64·9) at 24 h compared with 44·9% (35·6–54·4) in the ‘No’ group. INTERPRETATION: Ceasing sedative infusions as soon as possible, is safe and feasible, in both medical and surgical patients, and can be implemented into ‘real life’ with no additional staffing.