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Sedation hold

Why perform sedation holds?

Sedatives are used in intensive care unit (ICU) to improve patient comfort, decrease anxiety, permit mechanical ventilation and help facilitate interventions. Sedatives may include benzodiazepines, short- or long acting opioids, alpha-agonists (eg. clonidine, dexmedetomidine) and propofol. Excessive sedation should be avoided because of the following potential problems:

  • Prolonged mechanical ventilation
  • Haemodynamic instability
  • Gastric stasis
  • Immune suppression
  • Organ toxicity
  • Difficulty in assessing neurological status
  • Increased risk of Ventilator Acquired Pneumonia
  • Increased risk of venous thrombo-embolism
  • Upper gastro-intestinal bleeding

Excessive sedation can be avoided with the use of planned sedation holds, and by titrating sedation to the optimal level of patient comfort. A number of commonly used sedation scoring systems include:

Richmond Agitation Sedation Scale (RASS)

Riker Sedation Agitation Scale (SAS)

Ramsay Sedation Scale

When should sedation hold be avoided?

  • Raised intracranial pressure
  • Neuromuscular blockade
  • Certain modes of mechanical ventilation

How do you perform a sedation hold?
There are many different methods of performing sedation holds. One method is to:

  • Reduce/Stop sedative agent
  • Wait for the patient to emerge
  • Check - Is the patient awake and calm?
  • If not, restart sedation at half the rate and titrate according to sedation scoring systems (usually Ramsay Sedation Scale 3, SAS 4 or RASS 0)
  • If yes - Assess the patient’s pain and if necessary, titrate opioids as needed

Sedation holds potentially risk abrupt waking of the patient with agitation, cardiovascular instability and self–extubation. However, with adequate staffing and training sedation holds can be performed safely. Sedation holds with spontaneous breathing trials have been shown to significantly reduce duration on mechanical ventilation and ICU length of stay (Girard TD et al).