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If you want to know when it is necessary and when it is not necessary to sedate an ICU patient who’s waiting to be woken up, stay tuned. I’ve got news for you.

My name is Patrik Hutzel from intensivecarehotline.com and I have another quick tip for families in intensive care.

Currently, we are working with one of our clients and members who has their father in intensive care with cardiac arrest, and who’s currently on ECMO (extracorporeal membrane oxygenation) therapy. 

Our member wants to know, 

“When is it necessary and when is it not necessary to sedate an ICU patient who we are waiting to wake up? My father has been more aware and agitated but continues to not follow commands. It seems like now that he’s not a candidate for advanced therapies. They want to just keep him sedated and not have to deal with him.”

So normally, what happens is sedation can be given if the patient is in pain, anxious, combative, agitated, aggressive, especially with the risk of him pulling out tubes, breathing tubes in particular and also, this particular gentleman is obviously with the breathing tube, mechanical ventilation and ECMO. So, there’s a fairly high risk that tubes will come out if sedation is being taken away.

Now, by the same token, a lot of it also comes down to having a calming presence of nursing staff, doctors, families, a lot of it comes down to that as well, having a calming presence of the surroundings.

Also, when a patient in intensive care is critically ill and they’re requiring multiple forms of sedation or opiates such as morphine, fentanyl, midazolam/Versed, in particular, it’s also an element of addiction to those drugs and they need to be slowly weaned off because if someone is addicted to them and if they’re not being taken away gently and slowly, patients are going through withdrawal, and that’s not good, so.

So, let’s break it down in more detail when sedation may be necessary. 

Like we said, agitation or delirium if a critically ill patient is excessively agitated or delirious and poses a risk of self-harm, i.e. removing lines, tubes, or injuring themselves.

Next, mechanical ventilation tolerance. If a patient is intubated and struggling to tolerate the ventilator or endotracheal tube causing respiratory or cardiovascular instability, that is especially the case here in our member’s situation where her dad is on ECMO. If he’s agitated, it will not only impact on, potentially, intolerance of mechanical ventilation, it could also come down to intolerance of ECMO therapy.

I have worked in critical care nursing for 25 years in 3 different countries, where I have worked as a nurse unit manager for over 5 years in intensive care, and I’ve looked after many ECMO patients, and it’s definitely clear that when you take sedation off on ECMO and the patient is not ready, that flows might drop, oxygenation might drop. Then, patients have a risk, especially when they’re on VA-ECMO (venoarterial extracorporeal membrane oxygenation) for heart failure, that they may have other episodes of cardiac failure, including cardiac arrest, so you can’t really risk that.

Next, post-seizure management. Following seizures or status epileptic, sedation might be required to control brain activity and prevent further injury.

Next, pain and discomfort. If a patient is in significant pain or discomfort that would impede recovery or worsen physiological stress.

Next, severe neurological injury. In cases of elevated intracranial pressure or conditions requiring reduced brain metabolic demand, i.e., traumatic brain injury.

Then, procedural necessity. During certain procedures, i.e., imaging studies or bedside interventions for patient, movement must be minimized, and that is definitely the case during ECMO therapy and mechanical ventilation.

So, let’s look at when sedation may not be necessary. 

Number 1, stable neurological status. The patient shows signs of emerging consciousness and is stable without agitation or distress. Avoiding sedation allows for more accurate neurological assessments. In this situation, our members’ dad is not quite awake yet and he’s too agitated at this stage.

Next, weaning from sedation in patients transitioning out of sedation protocols to facilitate awakening, particularly in post-surgery or prolonged ICU stays.

Next, minimal support requirements. If the patient is stable on low ventilator settings or has been extubated, sedation may not be required.

Number 4, awakening trials. During plan sedation interruptions, i.e. daily awakening trials to assess neurological function and readiness to wake up.

Next is stable hemodynamics. If a patient is hemodynamically stable and agitation is not present, sedation may be unnecessary and counterproductive. Once again, if a patient is on ECMO, especially on VA-ECMO for heart failure, they’re definitely hemodynamically unstable.

So, here are some key considerations. 

Number 1, frequent reassessment. The patient’s sedation needs can change rapidly, continuous monitoring is essential to ensure sedation levels are appropriate. Individualized care decisions should account for the patient’s underlying condition, prognosis, and overall treatment goals. 

Sedation scale use. Tools like the Richmond Agitation Sedation Scale, also known as RASS or Sedation Agitation Scale (SAS) can help guide sedation levels.

Communication with families. Explanation for the rationale for sedation, or lack thereof is crucial to ensure alignment with patient and family expectations.

The goal is to use the minimal sedation necessary to ensure safety, comfort, and an optimal environment for neurological recovery and accurate assessment.

So, I hope that answers your question today.

Now, like I said, I have worked in critical care nursing for 25 years in three different countries where I worked as a nurse manager in intensive care for over five years. I’ve been consulting and advocating for families in intensive care since 2013 here at intensivecarehotline.com. I can very confidently say that we have saved many lives for our clients and members in intensive care. 

You can verify that on our testimonial section at intensivecarehotline.com and you can verify it on our intensivecarehotline.com podcast where we have done client interviews.

That’s why we have helped hundreds and hundreds of members and clients over the years to improve their lives instantly by helping our clients to make informed decisions, have peace of mind, control, power, and influence, making sure their loved one gets best care and treatment, always.

That’s why I do one-on-one consulting and advocacy over the phone, Zoom, Skype, WhatsApp, whichever medium works best for you. I talk to you and your families directly. I handhold you through this once in a lifetime situation that you simply cannot afford to get wrong. When I talk to doctors and nurses directly on your behalf, I also ask all the questions that you haven’t even considered asking but must be asked when you have a loved one critically ill in intensive care. 

I also represent you in family meetings with intensive care teams, so that you have a professional advocate there.

We also do medical record reviews in real time, so that you can get a second opinion in real time. We also do medical record reviews after intensive care if you have unanswered questions, if you need closure, or if you are suspecting medical negligence.

All of that you get at intensivecarehotline.com where we also have a membership for families of critically ill patients in intensive care. You can become a member if you go to intensivecaresupport.org or if you go to intensivecarehotline.com and you click on the membership link. In the membership, you have access to me and my team, 24 hours a day, in the membership area and via email, and we answer all questions intensive care related. In the membership, you also have exclusive access to 21 e-books and 21 videos that I have personally written and recorded. All of this information, including my one-on-one consulting and advocacy, will help you to make informed decisions, have peace of mind, control, power, and influence, making sure your loved one gets best care and treatment, always.

All of that, you get at intensivecarehotline.com. Call us on one of the numbers on the top of our website or simply send us an email to [email protected] with your questions.

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Thank you so much for watching.

This is Patrik Hutzel from intensivecarehotline.com and I will talk to you in a few days.

Take care for now.