Pilot Study on Pairing Sedation Strategies and Weaning

A three-arm, randomized, pilot feasibility, study to assess the effect three validated
sedation strategies on outcomes of patient on mechanical ventilation.

A significant proportion of patients admitted to the intensive care unit (ICU) require
mechanical ventilation (MV). To maintain comfort and facilitate quality care, large
quantities of sedatives and analgesics are often administered either by continuous infusion,
with or without daily interruption (DI) of sedation, or as intermittent doses of analgesics.
Three validated sedation strategies are currently available. A recently published study (
trial has shown that instituting protocol-directed sedation in patients requiring continuous
infusion of sedatives and analgesics, whether or not daily interruption (DI) of the sedative
occurs, will improve MV outcomes, specifically the duration of MV. Girard et al performed a
randomized, multicenter, clinical trial (ABC- Awakening and Breathing Controlled trial)
evaluating the pairing of a spontaneous awakening trial (SAT) with an SBT. Most recently, a
Danish study by Strom et al. investigated whether an analgesia-first approach to patient
comfort that consisted of intermittent doses of intravenous opioids, and the initiation of IV
sedation for short periods only when acute agitation was present, would be superior to a
protocol similar to the ABC trial. While the three above mentioned approaches are accepted
and currently implemented in the critical care community there is no comparative study or
evaluation on the optimal timing to conduct a spontaneous breathing trial (SBT) for assessing
weaning readiness with each of these strategies. It is possible that a SAT strategy, where
sedative and opioid infusions are interrupted, may lead to more agitation and anxiety than a
strategy in patients managed with a sedation protocol where intravenous sedative and
analgesic therapy is regularly titrated to maintain patients in a lightly sedated state.
Moreover, it remains unclear whether there are advantages of an analgesia-first sedation
strategy over either an SAT or sedation protocol strategy in terms of the time it takes to
wean patients from MV. However, it is noteworthy to mention that the analgesia-first strategy
was associated with more delirium episodes, which were attributed to the ability to assess
for it in a more awake patient. However, comparing delirium occurrence in studies with
different sedation goals and methodologies may be inaccurate.

The investigators therefore propose a three-arm, randomized, pilot feasibility, study to
assess the effect of these three (3) validated strategies for sedation and pain management

Inclusion Criteria:

1. ≥ 18 years of age

2. Mechanically ventilated with an expected duration of MV ≥ 48 hours

3. ICU team has initiated continuous sedative and/or /analgesic infusions

Exclusion criteria:

1. Admission after resuscitation from cardiac arrest

2. Admission with traumatic brain injury or another acute neurologic event (e,g. stroke,
uncontrolled seizures).

3. History of severe dementia

4. Admission because of acute alcohol withdrawal or acute drug intoxication

5. Administration of more than 24 hours of continuous sedation

6. Allergy to fentanyl, midazolam, and/or propofol

7. Lack of informed consent