Advances in sedation for critically ill patients

The use of sedation is required for the majority of mechanically ventilated patients in order to ensure comfort. For many years, deep sedation was the standard of care to avoid unpleasant memories and anxiety and provide comfort. Research over the past decade has shown the importance of using different tools to assess the level of sedation in order to guide appropriate dosing of sedative and to measure the clinical response to sedation. Given the progress in recent trials in this area, the management of sedation in the Intensive Care Unit (ICU) can be improved using various approaches that have shown improved outcomes in the ICU. The most prominent of these interventions involves linking daily interruptions in sedation (i.e., spontaneous awakening trials, SATs) with ventilator weaning protocols that incorporate spontaneous breathing trials (SBTs). Intensivists should combine the goals of ensuring patient comfort and avoiding unpleasant memories with other important goals that can be achieved with these new strategies (i.e. SATs plus SBTs or the so-called "wake up and breather approach"), such as a three day reduction in time spent on the ventiilator, a four day reduction in ICU and hospital stays and a 14% absolute reduction in death at one year. New choices for sedation, such as alpha-2 agonists and ultra short narcotics, are also being actively investigated, which may lead to complementary improvements in the future management of these critically ill, vulnerable patients.