In the article, Dr. Eikermann and his co-authors argue that ICU sedation could be safely reduced and, in many cases, eliminated with a multidisciplinary, patient-centric approach that targets the underlying causes of agitation or discomfort.

The article is titled “Multimodal, patient-centered symptom control: a strategy to replace sedation in the ICU.” Dr. Eikermann’s co-authors are Dr. Dale M. Needham, Medical Director of the Critical Care Physical Medicine & Rehabilitation Program at Johns Hopkins University, and Dr. John W. Devlin, a Critical Care Pharmacist and Associate Scientist at Brigham and Women’s Hospital in Boston.

Dr. Eikermann and his team of researchers in the Montefiore Einstein Anesthesiology Digital Health Lab are working on a retrospective analysis of data for approximately 10,000 Montefiore Einstein patients who had stays in one of ten ICUs during the 2016 to 2023 period. The goal of the study is to analyze the effect of distress ICU experiences – pain, anxiety, agitation, and coma – on patients’ risk of adverse discharge to a nursing home or in-hospital death. The researchers’ preliminary findings have shown that distress ICU experiences are associated with an increased risk of adverse discharge – additional evidence that treating patients’ underlying causes of agitation or discomfort while limiting sedation in the ICU is paramount.

ICU patients who require mechanical ventilation are commonly sedated for lengthy periods, with the goal of reducing agitation and traumatizing memories of the critical care experience. However, sedation can have negative consequences and impede recovery. Studies show that among ICU patients, sedation is the most common modifiable risk factor for delirium, which is associated with long-lasting impairments in cognitive function.

“We also know that early mobilization is a predictor of enhanced recovery,” Dr. Eikermann said. “But patients who are sedated cannot get out of bed and walk.”

What’s more, sedation prevents patients from participating in their medical care or interacting with family members. By focusing on the underlying causes of a patient’s symptoms, ICU staff can safely reduce the need for sedation, Dr. Eikermann explains. Common causes of distress in mechanically ventilated adults include pain, shortness of breath, a full bladder, constipation, anxiety, and drug withdrawal — each of which can be addressed.

“For instance, patients in pain can be helped with measures such as massage therapy or analgesics,” he said. “Anxiety can be reduced by visits with family members, music therapy, or anti-anxiety medications. In my experience, ICU patients generally appreciate knowing that they can participate in their care and that they have an option other than sedation.”

Even patients on mechanical ventilation who are intubated can be managed with little or no sedation, says Dr. Eikermann.

“It is, of course, important that patients understand what we are doing and feel that staff are sensitive to their needs,” he said. “While it’s impossible to speak with a breathing tube, patients can effectively communicate with the help of experts in nonverbal communication, such as speech-language pathologists.”

Some ICU physicians say that it’s unsafe to not sedate patients on mechanical ventilation, arguing that these patients may remove the devices to which they are connected or may experience psychological trauma from being awake in the ICU. But Dr. Eikermann said that measures can be put into place to ensure patients do not remove their medical equipment and that several clinical trials have shown that no-sedation approaches in the ICU do not increase rates of post-traumatic stress disorder.

Dr. Eikermann does not offer a blueprint for implementing his recommendations, emphasizing instead that each hospital needs to develop its own approach based on available resources. At Montefiore, Dr. Eikermann is leading a pilot multidisciplinary effort to better understand the steps needed to advance the concept of a patient-centered ICU.

With the findings from the new retrospective analysis, researchers in the Department of Anesthesiology can determine which interventions were taken that addressed patients’ underlying symptoms and ultimately led to better outcomes. This data can then be used to implement best practices at Montefiore Einstein ICUs in the future.

“Replacing sedation by a symptom control-focused approach will help our patients recover faster and to a more complete level,” Dr. Eikermann said. “This study as well as other research and quality improvement topics conducted by the Surgical Intensive Care Unit team will help us arrive at this ambitious goal."