Standardized, cost-effective sedation guidelines in a tertiary medical intensive care unit (MICU)

Introduction: Nonstandardized approaches to sedation often lead to frequent sedative changes, use of multiple agents, risk of over- or undersedation, and reliance on chemical paralysis in mechanically ventilated patients. We developed standard guidelines combining published recommendations for lorazepam use and our 5 year experience in processed electroencephalography-(EEG)-guided sedation. Our goal was to provide effective sedation, attenuate stress response, reduce prolonged recovery, and decrease cost. Methods: 15 patients predicted to require ≥ 48 hours sedation comprised the study group. Patients received an initial lorazepam bolus[0.1 milligram(mg)/kilogram(kg)]and were begun on a weight-based infusion(0.1mg/kg/hour). Weight-based boluses(every 1-2 hours) were guided by clinical requirement/modified observational sedation scale. Infusion rate was changed once each 24 hours based on the total dose of boluses for effective sedation. If ≤ 12 mg boluses were required, infusion rate was decreased 20% each 12-24 hours. Analgesia with morphine sulfate at 1 mg/hour was recommended; 11 patients received morphine sulfate. Results were compared with a reference group of 13 similar patients monitored by continuous processed EEG. Results: Mean effective lorazepam dose in 10 patients was 1.7 mg/kg/day compared with 1.6 mg/kg/day in the reference group. Mean dose in 5 patients with ethanol/drug withdrawal was 2.6 mg/kg/day, compared with 3.9 mg/kg/day, reflecting effective bolus dosing rather than frequent increases in infusion rate. No physiologic dependence or prolonged MICU stay attributable to oversedation was observed. No other sedatives or neuromuscular blockers were used. Conclusions: Standard guidelines for sedation in a tertiary MICU achieved results comparable to those observed with continuous processed EEG monitoring. These guidelines proved clinically effective and reduced costs associated with multiple sedative regimens and the use of neuromuscular blockers.