COMMENTARY

Lilian Maria Sobreira Tanaka1 , Rodrigo Bernardo

Serafim2 , Jorge Ibrain Figueira Salluh3
What every intensivist should know about light
sedation for mechanically ventilated patients

O que todo intensivista deveria saber sobre sedação leve em

pacientes em ventilação mecânica

INTRODUCTION
1. Critical Care Department, Hospital Copa D’Or - Rio
de Janeiro (RJ), Brazil.
Pain, agitation and anxiety are frequently experienced by patients
2. Internal Medicine Department, Universidade requiring intensive care unit (ICU) admission. These events are often
Federal do Rio de Janeiro, Rio de Janeiro (RJ), Brazil. associated with tracheal intubation, mechanical ventilation (MV) and bedside
3. Department of Critical Care and Postgraduate procedures(1). Sedatives and analgesics can be used to minimize distress, ensure
Program in Translational Medicine, Instituto D’Or de
Pesquisa e Ensino - Rio de Janeiro (RJ), Brazil. comfort, and decrease the work of breathing to achieve better synchrony with
the ventilator.(2) A number of landmark studies have been published in the
past decade, improving our understanding about the choice of sedatives
and how their use affects the short- and long-term outcomes of critically
ill patients.(2,3) One of the key evidence-based concepts that emerged from
observational studies and randomized controlled trials was a protocolized
light sedation approach, which was included in recent guidelines. (3) Light
sedation is considered the ideal target for most mechanically ventilated
patients, where a “calm, comfortable and collaborative” state can ensure
synchronous ventilation with minimal pain and anxiety, coupled with
cognitive preservation. Potential patient-centered benefits of light sedation
also include the possibility of active cognitive and motor stimulation
(including early mobilization interventions) as well as improved interaction
with the health care team and family members.(4)
What is the evidence behind light sedation?
Strong evidence demonstrates that oversedation is associated with worse
clinical outcomes, and most recently, special attention has been given to
the intensity of sedation in the early phase of MV. Studies demonstrate that
allowing deep sedation even in the first 48 hours of MV can be detrimental.
In a prospective multicenter longitudinal study on sedation practices
Conflicts of interest: None.
comprising patients under MV for a period of 24 hours or more, Shehabi et
Submitted on April 23, 2021 al. demonstrated that early deep sedation was independently associated with
Accepted on May 23, 2021 longer time to extubation, hospital death and 180-day mortality.(5) Similarly,
Corresponding author:
an observational prospective multicenter study including 322 patients from
Jorge Ibrain Figueira Salluh 45 Brazilian ICUs showed that deep sedation within the first 48 hours of MV
Instituto D’Or de Pesquisa e Ensino was independently associated with a 2-fold increase in hospital mortality.(6)
Rua Diniz Cordeiro, 30, 3º andar As “light sedation” uses fewer drugs and reduces overall resource use, it can
Zip code: 22281-100 - Rio de Janeiro (RJ), Brazil
E-mail: [email protected] be considered a cost-effective intervention in the ICU. Additionally, deep
sedation is associated with worse functional and cognitive outcomes, as it
Responsible editor: Viviane Cordeiro Veiga decreases the possibility of early mobilization and significantly increases the
DOI: 10.5935/0103-507X.20210069 risk of delirium.(7)

Rev Bras Ter Intensiva. 2021;33(4):000-000 This is an open access article under the CC BY license https://creativecommons.org/licenses/by/4.0/).
 What every intensivist should know about light sedation for mechanically ventilated patients 2

Having a deeply sedated, immobilized patient and cooperative) and 3 (difficult to rouse and obey simple
transition to an awake and cooperative patient is an commands) adequate for most patients.(3,10) Strategies to
essential part of best practices in the ICU. However, it achieve light sedation such as daily interrupted sedation,
is not without its challenges. The ICU team must assure targeted sedation or even no sedation can be used
adequate control of potential distress and reduction of without a clear superiority of one over the other. (10,13) A
adverse outcomes using a multidisciplinary approach. preference for the use of fast-acting sedative agents may
Monitoring for pain and agitation is essential not only to allow dose titration and adjustment to the target level of
the patients’ well-being but also for safety reasons, as an consciousness.(14)
agitated patient may inadvertently remove intravascular Propofol or dexmedetomidine is recommended
devices or the endotracheal tube. Studies using light over benzodiazepines in patients requiring continuous
sedation have found that patients who are more awake sedation to achieve early (3,5,15) and continuous light
and aware can contribution to their pain evaluations sedation (3,16) and to minimize the risk of delirium.
through reliable self-report, delirium assessments and (15)
In sepsis patients, propofol and dexmedetomidine
early rehabilitation.(3,4) Light sedation was also associated have been shown to be comparable in terms of clinical
with reduced ICU length of stay and shorter duration outcomes when light sedation was targeted.(17) Opioids
of MV with no increases in anxiety and depression(8). In remain a mainstay for pain management in the
studies where long-term follow-ups were reported, there ICU, (3,18) but the use of adjuvant analgesic therapy,
was no sign of increased negative neuropsychological such as acetaminophen, clonidine, dexmedetomidine,
outcomes.(9) gabapentin, ketamine, pregabalin, and tramadol,
promotes a reduction in pain scores as well as a
Who should receive light sedation in the intensive reduction in opioid consumption, as demonstrated
care unit? in a recent meta-analysis. (18) Only a minority of the
The 2018 Pain, Agitation/Sedation, Delirium, patients admitted to the ICU have a clear indication
Immobility and Sleep Disruption (PADIS) guidelines for continuous deep sedation: patients with severe
suggested a protocol-based, stepwise assessment for respiratory failure, status epilepticus, intracranial
pain control and sedation management in critically hyper tension and the need for neuromuscular
ill adults. (3) Clearly, the emphasis should not be on blockade. (19) Patients with these conditions may be
sedation but rather on multidisciplinary approaches underrepresented in studies on analgesia and sedation
to monitor, prevent and promptly treat pain and because they are frequently excluded.(10,19) However, even
agitation while ensuring participation by an awake and when deep sedation is needed, it should be considered
aware patient. Light sedation was recommended for a transitory strategy, and the use of combinations
most patients to reduce anxiety and stress, to control of sedatives may be used to minimize the use of
symptoms of hyperactive delirium, and to facilitate benzodiazepines.(19)
invasive procedures and MV.(3,10) Additionally, the early A schematic approach to analgesia and sedation is
comfort using analgesia, minimal sedatives and maximal suggested in figure 1.
human care (eCASH) (4) and the ABCDF-R bundle CONCLUSION
(R = respiratory-drive-control)(11,12) guidelines emphasize
the use of analgesia first with minimal sedation, In conclusion, recent studies demonstrate that the use
communication aids, noise reduction to facilitate good of light sedation is feasible and safe in most mechanically
sleep, early mobilization, delirium monitoring and family ventilated patients in the intensive care unit. The shift
involvement as strategies to promote patient-centered from a deeply sedated patient to a calm, comfortable and
care and comfort in the ICU. collaborative patient is associated with reduced intensive
Despite no universal definition of light sedation, care unit stay, duration of mechanical ventilation and
guidelines considered a Richmond Agitation Sedation delirium as well as improved survival rates. The use of light
Scale (RASS) score of between +1 (slightly restless) sedation is a cost-effective, evidence-based strategy that
and -2 (awake with eye contact to voice) or a Riker should be considered the standard of care in the intensive
Sedation-Agitation Scale (SAS) score of between 4 (calm care unit.

Rev Bras Ter Intensiva. 2021;33(4):000-000

3 Tanaka LM, Serafim RB, Salluh JI

Figure 1 - Schematic approach to analgesia and sedation.

RASS - Richmond Agitation Sedation Scale; SAS - Riker Sedation-Agitation Scale; ARDS - acute respiratory distress syndrome. Benzodiazepines should be used as the last option for sedation and interrupted as soon as possible.

8. Treggiari MM, Romand JA, Yanez ND, Deem SA, Goldberg J, Hudson L, et
al. Randomized trial of light versus deep sedation on mental health after
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