The evolving approach to sedation in ventilated patients: a real world perspective

The choice of the right sedative regimen is one of the most important supportive therapies in the treatment of critically ill patients, given mounting evidence that sedation, especially when deep, is associated with worse outcomes including mortality (1-5). The new 2013 Pain Agitation and Delirium (PAD) guidelines from the Society of Critical Care Medicine therefore has specific recommendations with regards to use of sedation in the critically ill—(I) monitor patients for level of sedation; (II) consider an analgesia first approach; (III) if a sedative is required, then a non-benzodiazepine regimen (so propofol or dexmedetomidine) should be used; and (IV) patients should be managed with the lightest level of sedation and undergo daily spontaneous awakening trial (6). These recommendations have been made on the back on numerous important investigations in this last decade, which have brought to light the perils associated with sedation, but have also provided some insights on what best practices should be (2,3,5,7-12). The specific recommendations with regards to non-benzodiazepines choice of sedative medication have been appropriately based on robust randomized controlled trials of benzodiazepines versus either propofol (11) or dexmedetomidine (7,9,12) to determine causal associations, yet the outcomes of these sedatives needed to be studied when the population sample is generalized (without the exclusions enforced in randomized controlled trials) and in real world practices where numerous confounders exist and medications are often co-administered.