Sedation and Pain Management

In the ICU, there are many medications that physicians use to keep a patient calm and comfortable while they are requiring a ventilator. Each medication has different uses, some work better for anxiety while others are primarily used to treat pain and shortness of breath. These medications may be given continuously (an “infusion”) or just as needed. While keeping a patient comfortable is always a goal of the medical team, overuse of these medications has been linked to higher risk of the patient developing delirium, longer time on the ventilator, and longer ICU and hospital stays. To avoid these complications, the medical team will try to use the least amount of medication possible to achieve comfort.

The medical team uses different tools to determine how much medication a patient needs. Two different tools are commonly used: sedation scores and daily awakening trials. Sedation scales involve a nurse or physician asking the patient questions to determine wakefulness and attentiveness. Pain levels are also assessed frequently throughout the day. Based on how well the patient is waking up and answering these questions, the amount of sedation and pain medication will be adjusted. If the patient is well enough, these medications will be stopped at least once a day to allow the patient to fully awaken; this is referred to as the daily awakening trials. Daily awakening trials have been linked with a 2-day decrease in time that patients spend on the ventilator.

Patients frequently appear to be sleeping while receiving sedation. While patients may not be able to meaningfully interact with their loved ones, it may be beneficial to both patients and their family to hold the patient’s hands, talk to them, and play their favorite music at a low volume.

Weaning

If a patient is improving, the medical team will begin thinking about stopping therapies that are no longer needed, such as the ventilator. Due to risks of infection and weakening of muscles while in bed, it is always the goal of the medical team to get a patient off the ventilator as soon as it is safely possible. However, it is rarely safe for the medical team to simply disconnect the patient from the ventilator as they may be unable to breathe independently yet. The process for determining if the patient is ready to be removed from the ventilator is called “weaning.”

Weaning begins with daily awakening trials. If the medical team thinks the patient is strong enough, they will pair the daily awakening trials with a period of time during which the patient breathes with minimal assistance from the ventilator—a “spontaneous breathing trial” (SBT). The spontaneous breathing trial can last anywhere from 30 minutes to 2 hours, depending on the patient’s condition and the reason for intubation. Often, patients will require several spontaneous breathing trials before they are ready to be removed from the ventilator. Once the patient has passed a spontaneous breathing trial, they can be removed from the ventilator, called “extubation.”