Sedation is a cornerstone of modern intensive care practice — but our approach to it has changed dramatically over the past few decades. What was once considered routine and benign is now recognised as a powerful intervention with significant consequences for patient outcomes.
This article summarises key lessons from the Critical Care Practitioner Podcast’s sedation mini-series, exploring the history, evidence, and evolving best practice of sedation in the ICU.
A Short History: From Deep Sleep to Daily Awakening
In the 1980s and 1990s, continuous benzodiazepine sedation was considered standard. Patients were deeply sedated to prevent self-extubation, reduce oxygen demand, and maintain calm working environments.
But by the late 1990s, research began to challenge this approach. Kress et al. (1998) demonstrated that continuous sedation prolonged ventilation and ICU stays. Brook et al. (2000) showed that structured, protocol-based sedation improved outcomes compared to empiric dosing.
These studies shifted the question from “how much should we sedate?” to “do we need to sedate at all?”
The Sedation Hold: A Game-Changer
The introduction of the daily sedation hold — or spontaneous awakening trial (SAT) — was a pivotal moment.
-
Kress et al. (2000): Daily interruption reduced ventilation days and ICU length of stay without increasing adverse events.
-
Girard et al. (2008, ABC Trial): Combining SATs with spontaneous breathing trials improved one-year survival.
The idea was simple but revolutionary: sedation should be the exception, not the default.
Sedation Depth: Why Less is More
The SPICE study (Shehabi et al., 2013) showed that deep sedation in the first 48 hours was linked with higher mortality, prolonged ventilation, and more delirium.
Other studies confirmed these risks, highlighting that early deep sedation is a modifiable factor in ICU outcomes. The modern mantra has become:
Light sedation unless there’s a clear indication for deep sedation.
Sedation Protocols: Turning Knowledge into Practice
Evidence alone doesn’t change practice — culture and systems do. Sedation protocols, typically nurse-driven and scale-based, provide structure and consistency.
Benefits include:
Barriers remain, however — from staffing ratios to resistance to change. Successful implementation requires trust, training, and interprofessional collaboration.
Choosing the Right Agent: Benzos, Propofol, Dexmedetomidine
Not all sedatives are created equal:
-
Benzodiazepines: Effective, inexpensive, but associated with delirium and prolonged stays. Now largely reserved for alcohol withdrawal or seizures.
-
Propofol: Short-acting, easily titratable, ideal for daily sedation holds. Watch for hypotension and rare infusion syndrome.
-
Dexmedetomidine: Produces cooperative sedation, reduces delirium, but carries risks of bradycardia and hypotension, and is more expensive.
Choice depends on patient context, clinical goals, and resources — but the guiding principle is always tailored sedation, not default dosing.
The Future of Sedation: Human-Centered Care
Current guidelines (PAD 2013, ATS/Chest 2016) emphasise light sedation, protocolised care, and regular reassessment. Yet practice still lags, with deep sedation and benzodiazepines common in many ICUs.
The future points toward:
-
Human-centered sedation: prioritising wakefulness, communication, and dignity.
-
Integrated care bundles (e.g., ABCDEF): combining sedation with delirium prevention, mobility, and sleep support.
-
Personalised approaches: tailoring sedation to patient phenotype and physiology.
-
Technology and non-pharmacological methods: EEG-based monitoring, circadian rhythm support, and family engagement.
Key Takeaway
Sedation is not a benign background process — it is a clinical decision that profoundly shapes recovery. The evidence is clear: lighter, structured, and patient-focused sedation strategies improve outcomes.
The challenge for today’s ICU teams is to align practice with evidence, shifting from “snowed and stable” to “awake and engaged.”
