| Mehta et al.(1717 Mehta S, Burry L, Martinez-Motta JC, Stewart TE, Hallett D, McDonald E, Clarke F, Macdonald R, Granton J, Matte A, Wong C, Suri A, Cook DJ; Canadian Critical Care Trials Group. A randomized trial of daily awakening in critically ill patients managed with a sedation protocol: a pilot trial. Crit Care Med. 2008;36(7):2092-9.)
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Midazolam and morphine (or fentanyl, if CrCl < 10mL/min) reduced every 15 - 30 minutes if SAS 1-2. Boluses were administered if there was agitation, and sedative and analgesic doses were increased. SAS was reassessed every 1 - 2 hours |
The infusion of sedatives and opioids was maintained identically to the protocol, but sedatives and analgesics were turned off after 9 hours, and the patients were assessed for their ability to obey three out of four commands (open your eyes, follow the investigator with your eyes, shake hands and wiggle your toes). If the doctor felt that the patient needed to be sedated, sedation was reinitiated at half the dose. In this case, the protocol continued, targeting SAS 3-4. If it was decided that the patient would not receive any more sedatives, they were only resumed if the patient was at SAS 6 - 7 |
| de Wit et al.(1818 de Wit M, Gennings C, Jenvey WI, Epstein SK. Randomized trial comparing daily interruption of sedation and nursing-implemented sedation algorithm in medical intensive care unit patients. Crit Care. 2008;12(3):R70.)
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Analgesia with morphine or fentanyl (if renal failure or hemodynamic instability) in bolus. If boluses were frequent, continuous infusion began. Sedation followed the same pattern, with the use of midazolam or lorazepam. Where there was a need for continuous infusion, lorazepam or propofol were used if there was renal or hepatic failure and lorazepam and midazolam if there was hemodynamic instability. The analgesics and sedatives of patients with RASS 1 or 2 points below the target were reduced by 25 - 50% every 4 hours. If the RASS was more than two points below the target, the drugs were discontinued |
The sedatives and opioids were turned off 48 hours after the beginning of mechanical ventilation. Patients were considered awake if they could follow three of four commands (open your eyes, follow the researcher, put out your tongue and shake hands). The resumption of sedatives was at the discretion of the investigators. Sedatives were restarted at half the dose if the patient was awake, agitated or had a change in vital signs (RR > 35ipm; SaO2 < 90%; HR > 140bpm or change of 20% in either direction; SBP > 180mmHg or < 90mmHg). The team had to target RASS -2 to -3 and performed sedative infusion in the absence of the investigators |
| Anifantaki et al.(1919 Anifantaki S, Prinianakis G, Vitsaksaki E, Katsouli V, Mari S, Symianakis A, et al. Daily interruption of sedative infusions in an adult medical-surgical intensive care unit: randomized controlled trial. J Adv Nurs. 2009;65(5):1054-60.)
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Sedatives (midazolam or propofol) and opioids (remifentanil) were adjusted to maintain Ramsay 3-5. The adjustments were performed every 2 minutes until the target was reached. |
Sedative infusion was turned off after patient recruitment, but the remifentanil infusion was maintained at a rate of 0.05 - 0.25mg/hour. If the patient was agitated, presented respiratory distress, hemodynamic instability or neurological deterioration (e.g., increased ICP), sedatives and analgesics were reinitiated at half the previous dose |
| Strom et al.(2020 Strom T, Martinussen T, Toft P. A protocol of no sedation for critically ill patients receiving mechanical ventilation: a randomised trial. Lancet. 2010;375(9713):475-80.)
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Analgesia with morphine. If discomfort was experienced, the team searched for reversible causes. If delirium was suspected, haloperidol was administered. If agitation was still present, propofol was initiated for 6 hours. After this period, the propofol was discontinued. If there was a need to start sedatives three times, the patient was sedated in the same manner as the daily awake group |
Morphine and propofol to maintain Ramsay 3 - 4, assessed every 2 - 3 hours. Sedation was stopped and awakening assessed daily. In this regard, the patient had to be able to complete three of four tasks: open his eyes, follow with his eyes, shake hands, put out his tongue. After awakening, the sedative was reinitiated at half dose to maintain Ramsay 3 - 4. After 48 hours, propofol was replaced with midazolam |
| Yiliaz et al.(2121 Yiliaz C, Kelebek Girgin N, Ozdemir N, Kutlay O. The effect of nursing-implemented sedation on the duration of mechanical ventilation in the ICU. Ulus Travma Acil Cerrahi Derg. 2010;16(6):521-6.)
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Fentanyl for pain control, with target of BPS ≤ 6 and midazolam for agitation control with a target of Ramsay 3 - 4. Additional sedatives (diazepam, propofol and dexmedetomidine) could be used if the Ramsay target was not reached |
Sedation interruption was employed at any time (without further details) |
| Mehta et al.(2222 Mehta S, Burry L, Cook D, Fergusson D, Steinberg M, Granton J, Herridge M, Ferguson N, Devlin J, Tanios M, Dodek P, Fowler R, Burns K, Jacka M, Olafson K, Skrobik Y, Hébert P, Sabri E, Meade M; SLEAP Investigators.; Canadian Critical Care Trials Group. Daily sedation interruption in mechanically ventilated critically ill patients cared for with a sedation protocol: a randomized controlled trial. JAMA. 2012;308(19):1985-92. Erratum in: JAMA. 2013;309(3):237.)
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Adjustment of opioid infusion and sedatives for achieving the target, as in the 2008 study |
Daily sedation interruption was employed. If the patient could follow three out of four commands, the infusion was kept off at the discretion of the doctor and nurse. If there was a need for sedation or agitation or discomfort, then the doses instituted were half of the previous doses |
| Nassar Junior e Park(2323 Nassar Junior AP, Park M. Daily sedative interruption versus intermittent sedation in mechanically ventilated critically ill patients: a randomized trial. Ann Intensive Care. 2014;4:14.)
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Maintain without sedation. Analgesia with fentanyl. If the patient was agitated (SAS ≥ 5), the team searched for the causes of agitation, and delirium was treated with haloperidol. If the patient remained agitated, sedation was initiated with midazolam or propofol |
Daily sedation interruption was employed until the patient could follow commands (open your eyes, follow with your eyes, shake hands and open your mouth). Sedatives and opioids were reinitiated at half the dose if agitated (SAS ≥ 5) |
