Monday, February 18, 2008

Wake Up and Smell the Coffee then Wake Up Your Patients and Let Them Breathe

A few weeks ago in The Lancet ( ) appeared a wonderful and pragmatic article demonstrating the effectiveness of combining Spontaneous Awakening Trials (SATs) with Spontaneous Breathing Trials (SBTs) in the ICU. This strategy of "Wake Up and Breathe" was highly effective and critical care practitioners everywhere should take heed. Unfortunately, a penchant for the status quo and a heaping of omission bias led the editorialist to foment skepticism for the adoption of "wake up and breathe." My colleagues and I find this skepticism unfounded and frankly dangerous in that it risks reducing the adoption of this highly effective strategy, the benefits of which clearly exceed the risks. Our letter to the editor of The Lancet was not accepted for publication, but is posted below. Hats off to Girard and Ely and co-workers for this vital addition to our literature. Now if we can just convince critical care practitioners to wake up and wake their patients up...

We read with interest the report of the ABC Trial which demonstrated the efficacy of combining daily awakenings with breathing trials in mechanically ventilated patients (1). In the accompanying editorial, Dr. Brochard contends that “sedation is also an important component of care for critically ill patients,” but he cites only one review article to support this claim (2). It is unknown if the disturbing weaning experiences he references are related to sedation restriction. What is known with reasonable certainty is that oversedation is common and associated with increased delirium (1;3), neuroimaging (4), long-term psychiatric consequences (5) and mortality (1) and longer duration of mechanical ventilation and ICU stay (1;4). The ABC trial adds to this body of literature by demonstrating the practical utility of combining daily sedation cessation with spontaneous breathing trails. That 92% of spontaneous awakening trials were well-tolerated strongly suggests that patients were no worse without sedation, and is consistent with prior studies showing that oversedation, not undersedation, is the principal risk to critically ill patients.
For too long, we suffered from a dearth of quality evidence to guide the care of the critically ill. Now that such evidence is available, we would be wise to act upon it. We therefore disagree with Dr. Brochard’s statement that “more information is needed to show that the approach is feasible and safe.” Each year that we await another confirmatory trial is another year that our patients suffer prolonged mechanical ventilation and illness due to our fondness for the status quo.

Reference List

1. Girard TD, Kress JP, Fuchs BD, Thomason JW, Schweickert WD, Pun BT et al. Efficacy and safety of a paired sedation and ventilator weaning protocol for mechanically ventilated patients in intensive care (Awakening and Breathing Controlled trial): a randomised controlled trial. Lancet 2008;371(9607):126-34.
2. Brochard L. Sedation in the intensive-care unit: good and bad? Lancet 2008;371(9607):95-7.
3. Pandharipande P, Shintani A, Peterson J, Pun BT, Wilkinson GR, Dittus RS et al. Lorazepam is an independent risk factor for transitioning to delirium in intensive care unit patients. Anesthesiology 2006;104(1):21-6.
4. Kress JP, Pohlman AS, O'Connor MF, Hall JB. Daily interruption of sedative infusions in critically ill patients undergoing mechanical ventilation. N.Engl.J Med 2000;342(20):1471-7.
5. Kress JP, Gehlbach B, Lacy M, Pliskin N, Pohlman AS, Hall JB. The long-term psychological effects of daily sedative interruption on critically ill patients. Am.J Respir.Crit Care Med 2003;168(12):1457-61.

James M. O'Brien, Md, MSc
Naeem A. Ali, MD
Scott K. Aberegg, MD, MPH

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