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What is the purpose of awakening “trials”? When should awakening “trials” be done? How can we have successful awakening “trials”? Dr. Wes Ely joins us in this episode to crack the code on sedation cessation.
Episode Transcription
Kali Dayton:
Last week, I did a little survey on social media. I recognize that my followers are usually bias and more aware of the ABCDEF bundle than the general ICU community. These results may not fully capture the practices and mentalities at large. Nonetheless, I learned a lot from the responses they provided.
The first question I asked was:
Does your team practice the ABCDEF bundle?
Yes- 65%
No- 35%
I think asked more probing questions about specific practices and shared that the real purpose of the ABCDEF bundle was “to produce patients who are more awake, cognitively engaged, and physically active…… facilitate patient autonomy and the ability to express unmet physical, emotional, and spiritual needs. “
I later asked again, “With that understanding, does your team really practice the abcdef bundle?”
The initial 65% yes turned to 13%
And the 35% “no” then turned to 87%
I asked:
Does your team automatically sedate after every intubation
Yes- 92%
No- 8%
Next question:
When does your team do awakening trials?
46% said “Not until vent settings are minimal”
54% said, “When there is no longer an indication for sedation”
Does your team usually mobilize intubated patients?
Yes- 40%
No- 60%
How long after intubation until your patients are usually doing their highest level of mobility?
0-24 hrs- 9%
24-48 hrs- 15%
48-72- 25%
3-8 days- 51%
Does your team automatically start fentantyl drips for every intubated patient?
Yes- 47%
No- 53%
What does your team generally see as the objective of the ABCDEF bundle?
67% : On/off switch for sedation:
32%- to Keep pts as awake and mobile as possible-
When does your team do SATs?
25% – Early AM on night shift-
69%- Day shift
5%- When family is available/need for seation is gone
What does your team do when a pt is a RASS +1-+2
69% – Restasart sedation
31%- Find and treat the cause of symptoms
What does your team do when a pt has failed their SBT?
24%- Continue to mobilize and rehab
76%- Restart sedation
Does your team use benxos
89% Yes
11% No
By now, we can all probably agree that the ABCDEF bundle is grossely misunderstood and under-practiced. Most teams only focus on the first 1 or 2 letters of the bundle. I often hear, “Oh yeah, we’re practicing the bundle. We do daily SAT and SBT.” – but it is clear that their patients usually remain sedated for prolonged periods of time and minimal mobility is happening.
This is extremely impactful to patient outcomes. When a patient is ntubated and sedation is started, it like flipping an hourglass. That sand represents their brain and motor function. Their muscle mass, Their survival, their careers, their relatinoships, their identiy, their independence, their dignity, their quality of life. For every day- even every hour…. Sand is dropping. Time is running out. We need to have a sense of urgency to stop the hourglass. To save their lives as a whole.
Dr. Wes Ely has said that we can gauge compliance with the ABCDEF bundle by asking 3 questions: “Are they awake? Are they out of bed? Where is the family?”
Awakening trials are not the on and off switch at the end of critical illness we have made them out to be. They should be done as soon as there is no longer an indication for sedation.
I am excited Dr. Ely explore this further in this episode.
Kali Dayton 0:02
Dr. Ely, thank you so much for coming back on the podcast. I think most people know you by now. But will you give us a little intro to you?
Dr. Wes Ely 0:11
Sure. My name is Wes Ely. I’m an ICU doctor at Vanderbilt University in Nashville, Tennessee. And when I was a chief resident many years ago, you can see all this grey hair I’ve got,
I designed the randomized control trial that checked, if the ability to breathe spontaneously with SBTs was better than usual care. And we published this in the New England Journal of Medicine in 1996. It showed that spontaneous breathing trials SBTs would shorten time on the ventilator by full two days, and cut complications in half, and save over $5,000 per patient that was back almost 30 years ago, which is crazy.
Kali Dayton 0:53
That was $5,000 then!
Dr. Wes Ely 0:56
Now it would be way more. Plus now we add studies, awakening trials, which is the topic for today. But it all started with us figuring out that we should just turn the ventilator off every day, once it once per day and see if the patient can breathe spontaneously and come off that breathing machine. At a time, we thought that we might cause a bunch of heart attack. We were scared. We thought I was nervous because it was my first study to ever to design. As a chief resident. I didn’t know what I was doing. But it was it worked. And it was a great advance.
Kali Dayton 1:26
So then how did we get into awakening trials?
Dr. Wes Ely 1:30
So what happened was a few years later, JP Kress from University of Chicago, instead of stopping the ventilator decided to stop the sedation. And I’ll never forget it. I was walking out of the building at the American Thoracic Society. And Jesse Hall, who is the senior author on the project, walked up and said “Well, we’ve, we’ve added to the SBT project you did. Now we’re turning off the the sedation instead of the ventilator, and we’re calling them ‘sedation holidays’ or ‘sedation vacations’ “, and so that was the initial name for this to once a day turn off the sedation and follow that by turning off the ventilator.
But “sedation holiday” and “SBT” don’t go together nearly as well. It’s not trippingly falling across the tongue, as as SAT SBT. So SAT SBT is an easier way to remember it. And using Malcolm Gladwell is tipping point principles, which is make something sticky. So we can all remember, we changed the name to SAT/SBT because step a would come first awakening and SBT would come second.
Kali Dayton 2:31
Okay, that makes more sense. And for me, I’d worked in an Awake and Walking ICU where sedation was hardly ever started. So we rarely had to actually turn it off. And when there wasn’t indication for sedation, we would just turn it off. It wasn’t a quick “holiday” or break from it.
So when I started later on and and I see that was implementing the A to F bundle, I was on a night shift and the orientation nurse said, “Oh, here we do this annoying thing….”– And don’t don’t get Don’t get upset. This is just This is almost a direct quote, “At five in the morning, you just got to turn the station down enough to see them move. That’s how you know they haven’t had a stroke. And when they get agitated, you turn it just right back on. And you chart a failed vacation. And that’s it. That’s how you know that the can’t handle the ventilator and they need sedation.”
Dr. Wes Ely 3:22
To add to that, so that was that’s a great anecdote of ways that nurses could misperceive the true humanistic benefit of allowing a person an actual person to wake up, use their brain get mobilized and find their life again, because this person didn’t know that that was harmful.
And so this person doesn’t mean bad. In fact, this person, this is a good example, between the difference of benevolence and beneficence. This person is intending good, that’s benevolence, but actually doing harm, which is maleficence. To actually do good. That’s beneficence. And in this case, to actually do good, this is what medicines really real goal is our goal is not benevolence. It our goal is to actually do good to achieve beneficence, we must allow people to come off of sedation to do this full SAT, let them wake up and come all the way above the water of their consciousness, and then try to get them out of the bed, mobilized, etc.
And I’ll tell you if you want me to a story of a Canadian trial, where the nurses kind of revealed to me what had actually gone on when they failed in their attempt to investigate SATs. Yeah, please. Okay. So when we did our years after JP Crescent study was in the New England Journal, which was 2001 and we had done our study may have been 2000. But we did our study in 1996. So these two things together were the became the SAT SBT
We decided “let’s do a randomized control trial of both”. And so we did that and we published it in Lancet. And it was called the ABC study, where every day we turned off the sedation and we turned off the ventilator. And what we proved by just turning it completely off cold turkey that you could turn it back on if you needed to. But if you kept it off, you would shut benzos down by half shut propofol and narcotics down by half. And what it did was it take, it took four days, days, off the length of the ICU stay time on the ventilator. And actually the hospital stay too. And we sent that paper to the New England Journal, and it got rejected because we didn’t have one year outcomes.
By the time all that had gone on. We had one year outcomes, and the lancet took it and published it. So the ABC trial was published by Girard first author, and I was the senior author, Ely, W. And, and we showed for the very first time in the history of medicine that in critical care, you could actually save lives by turning by using less sedation. And it was very significant. One out of every seven people who got the SAT SPT combo was alive at the end of the year, who would not have been otherwise?
Well, the Canadians redid this study, and it didn’t find a difference. And a year after they published the paper in JAMA, I was walking around in the ICU where it had been headquartered. And the nurses one by one told me, I said, “Did y’all turn this the sedation off when y’all did that trial?” And they said,
Oh, well, “We turned it off until they would move a little bit. And then we would just turn it back on and ramp it all the way back up.” Because obviously we want the person snowed and immobilized. And the nurses again, we’re not trying to be mean, they weren’t trying to be bad. That was what they had been trained to do. So they were actually thinking, this is the best for the patient. And I’m not poking fun. Yeah, right. What are your thoughts? What are you thinking right now Kali, about these stories?
Kali Dayton 6:41
Oh, I that’s absolutely seen it. And I’ve seen it, you know, in my practice as a travel nurse. And I’ve seen it now with teams that I’m training. And I think this is rooted in sincere belief that sedation is sleep, that it’s more comfortable and more humane for patients. So nurses are not provided any real insight into the reality of sedation, the risks and repercussions of it. So they don’t really have a reason to wake them up to keep them awake and mobile to avoid those medications.
Because they don’t, they are not trying to understand how dangerous they are. And so when we’re training the wakening trials, the words vacation interruption trial all insinuate This is a brief break. And that reinforces this culture of do it just to check for stroke and then restart it because that’s what’s humane. And so what happened in that Canadian trial, what did they find on the in the group that did the awakening trials?
Dr. Wes Ely 7:34
What they found was that the that they restarted the sedation so often and use such high doses of benzos, that they had a very high read intubation rate, they had a very high rate of failure of spontaneous breathing trials. And what we what we know from another trial that we did called our diurnal study, Chris Seymour, s. E. Y mo EUR is the first author published in critical care medicine.
Is that not every nurse increases the dose of sedation at night, but when you do, it doubles the likelihood of the patient failing their spontaneous breathing trial the next morning, and in the Canadian trial was discussing with you, the average dose of benzodiazepines was in the triple digits above 100 milligrams a day. That’s a lot of benzodiazepines.
Yeah, and they had a tremendous amount. And in the intervention group, it only went down to I think, 80 milligrams or something. So it was not it really, they had no separation of groups. And they had a ton of problems with people failing their SBTs.
Kali Dayton 8:41
So when I’m looking with teams at their dashboard to see what the compliance is with the bundle, it can look like the B is very compliant. But I question this because they’re still not doing mobility, they’re still not, they’re still having prolong times and ventilator so you can chart and awakening trial, and it looks very compliant and the charting, but are we actually doing awaken trials the way that they were meant to do? Are we striving to fulfill the purpose of awakening trials? How would you describe the purpose of an awakening trial?
Dr. Wes Ely 9:13
Well, Polly Bailey, who is your mentor at Utah, told me that the purpose of the waking trial is to find the person again, and have the moving out of the bed. So if we simply shut off the drug for an awakened trial, and that’s at and the person doesn’t move or get out of the bed, then we’ve actually failed even if, you know, even if we say we’ve done it and chart that we’ve done it, we actually haven’t done it, because the entire goal is to move the patient out of the bed so they can begin to have life experiences again.
Kali Dayton 9:43
Absolutely. And do we need to restart it? Is this really just a brake is it’s just an on and off switch? Or what are we working towards?
Dr. Wes Ely 9:54
The drug should be shut off, and we should not restart the drug unless the patient becomes dangerous. us to sell for others. If the basis is dangerous to sell brothers RASS plus three, RASS plus four, that’s a restart the drug. But if they’re just even zero plus one plus two seem agitated, that is not a reason to restart this drug, because what they really are wanting is to move. So this person wants to mobilize and get around. And we can’t do that if the person is still on drug and still has boatloads of drug in their body.
Kali Dayton 10:25
And I think this is one of the biggest barriers to having success. Successful awakening trials is the agitation that can emerge. And there is a fear if you’ve had a patient come out thrashing. And nurses are held at such high liability for any unplanned estimations or falls or line and tube removals.
There’s so much fear that if you have a patient go at a rate of one or two, when your back is turned are they going to become a three or four. And so even at a one or two, you can see the discomfort and the tears in their eyes. And it’s really jarring to the clinician. And so we’re not trained to respond to that appropriately, we’re not given tools to know how to assess and treat the root cause of that psychomotor activity of that agitation that we may be seen. You’re talking about a RASS of +3 or +4, that is the definition of agitation. I perceive that we’re using the word agitation to describe any kind of sign of discomfort.
Dr. Wes Ely 11:25
Right. And you know, when you wake up somebody, Kaylee, as you well know, as a very veteran ICU nurse, they’re going to appear a little uncomfortable when they first start waking up, that’s to be expected. That is not a downside. That’s, that’s the norm. And so when they feel a little uncomfortable, and you’re looking at them, the idea there would be to bring the family in, have the family start talking to the patient, that’s how they’re going to respond to the best or simply guide them through it.
You know, nurses, one of the basic tenets of nursing care is mobility. So the nurse can start realizing they look at they look uncomfortable, and perhaps a bit disconcerted because they need to move, they need to get out of the bed, and be allowed to start walking using their muscles again, or even just to get to a bedside chair. This is the way that the person will start to realize what their Why is to live. Remember that during delirium, they a lot of times don’t know why they’re there, or what their Why is, and if they lose their why to live, then they will lose hope. And we can’t allow them to lose hope.
Kali Dayton 12:25
And I think that is what gives nurses so much power when they do understand what’s happening during sedation, when nurses finally understand that they’re not sleeping under sedation, they’re not necessarily comfortable. They’re not necessarily pain free. The nursing heart reacts to that. And so then they know when they’re doing an awakening trial, if they see that they’re out to fix it, and they recognize it.
Sedation doesn’t fix it. I worry about session vacations being done at five in the morning as a standard. When there’s no family at the bedside, no therapists, no one there to help a nurse. How can the nurse mobilize them? How can the nurse respond appropriately to that discomfort if they’re the only person there at the end of their shift with another patient to take care of? I don’t think exactly success.
Dr. Wes Ely 13:10
I totally agree. And I I’m very opposed to these early am SATs and SBTs. I think that the SATs SBTs should be done when the rounding team is available. They don’t have to be done in front of them. But usually they should not be done until after the sign out of the new daytime nurse. And if that is the case, then the daytime nurse will be there.
And we’ll be able to communicate to the team. what went on during that sad and sad instead of saying, well, they failed it. Why did they fail? I don’t know it wasn’t here it was done in the night changing that whole idea of of 3am baths and 5am SATs. That’s a convenience for the for the medical providers. And it’s not anything that benefits the patient.
Kali Dayton 13:53
Absolutely. And it just proceed is easier for the team. But a 5 am awaiting trial is not easier for the team. When the last two days longer on the ventilator days longer in the ICU and hospital. That’s not easier for anybody that’s not in anybody’s interest, best interest. I think we also don’t train them to know how to perform awaiting trial.
I would love to see that be a role of the family saying “We’re going to turn sedation off, you need to be here. You are vital to this. Get at the bedside, touch them be involved be part of this.” Preparing the family and saying “here’s what they likely are experiencing under sedation. And here’s how they may come out. And that’s okay, we’re going to embrace this we’re going to work through it.” Equipping a family with the knowledge to then help the patient but unless clinicians have that knowledge, they can’t share that with the families and it makes a lot of difficult and even traumatic experiences for everyone.
Dr. Wes Ely 14:51
So now I think you’re hitting, Kali, on something so critical for each ICU team out there listening, which is this the physicians The nurses, the respiratory therapists, the care partners, all of them need to be on the same page that our goal here is to create a survivorship program for Miss Smith, Mr. Jones, whoever this person is we’re caring for, and that survivorship program begins the moment that they’re intubated.
So as soon as somebody’s intubated and crashing, we then start to get control of their disease advancement, we start to get stability, stability, and right then, when you start asking ourselves, when can we remove all this? When can this go away, and it’s oftentimes later that day, or the first thing the next morning, and if everybody’s on the page with to, for this person to survive, and go out and enjoy their job, their life, they’ll be the matriarch or the patriarch of their families, I’ve got to prevent them from getting picks post intensive care syndrome.
And the it all Begins with SATs, pain control, and the SATs SBTs, which reduce their delirium, mobilization and reducing their delirium, having the families there, which is a beautiful thing to reduce delirium. And that’s what creates in our minds, who is this entire person, I like to I like the expression cada persona, so moonbow each person is a world. And what we want to do is find out who is this person, this world, and let me do what I can to uplift them, magnify their dignity and, and dive into their chaos, so that I can provide lifting and healing for them, which is the definition of mercy.
Kali Dayton 16:33
It’s been so astounding to me to see what clinicians are capable of what they come up with, when they really see their patients as human. When they have that expectation and the desire to have their eyes open. Have them be communicative, autonomous mobile.
These clinicians innately find ways to customize their care and achieve that, that goal, when they really want sedation off, they’re looking for sedation cessation, and they know how each member of the team plays into achieving that goal. Magic happens and suddenly, the nurses are not left alone. With this senseless and insane process of turning on and off. They can finally get it done.
So it’s really inspiring to hear. Occupational Therapists talk about how the nurses are now grabbing them the halls and saying, “I’m having a hard time with getting sedation off, not just down to off on this patient. Can you come help me?” And occupational comes in does cognitive therapy mobilizes them. And then they reassess? Do we still need this at half dose? Can we turn it off, turn it off, and it’s gone. So they work together to get this done, because they no longer see it as just a quick holiday. They see this as a toxic and dangerous medication and then have to get it off. And they will work together to do that.
Dr. Wes Ely 17:43
I love that that teamwork between the OT and the PT and the rest of the therapists and the nurse. And the OT is such a key person in all this because they engage with the family in a beautiful way to find out what matters to this person. What do they like to do think about do with their hands do with their mind, and they can activate this person to give them activities, which will again immediately begin to rebuild their manual dexterity and their brain with cognitive rehabilitation as well.
Kali Dayton 18:09
And I had to put a shout out for the SLPs to one speech therapist in Episode 103. And communication, talked about how I think this was a PICU. A 14 year old that was on a ventilator, they were having a really hard time getting sedation off and they were trying to extubate him. And he just was thrashing. So they were so smart to bring an SLP and said “We don’t know what to do.” And they figured out a way to for him to communicate, he wrote, “Am I dying?”
That’s why he was agitated. He was terrified that he was dying. Now, other teams and other environments, he probably would have been re sedated. But they brought in a communication expert who valued him as a human and gave him the power to ask that question. And they brought in the family, the intensive, the right people who sat down and talked with him helped them understand and he calmed down and sedation was off.
Dr. Wes Ely 19:02
That’s a beautiful story. It really is. And that just shows you when you actually when your antennae are up. And you can have those antennae proceed Who is this human being in front of me? And how can I respond to their needs? Then you can find out what is it that they’re that’s frightening them? What’s the what’s the fear that’s driving them and help them deal with that so they can make progress and move forward in a constructive way. And I love that your podcasts you’re Walking Home From the ICU is waking people up to the needs of the person in the bed.
Kali Dayton 19:36
And I refer back to I think it’s episode 76 I’m not totally positive. It’s with Meghan Wakeley. She is I’ll link it into the transcript of this podcast episode. She was 32 year old had been immobilized and sedated for eight days had terrible delirium when she came to our facility and then we can walk in ICU.
She’d already been on benzos for days she was had a lot of risk factors very sick people 14, 80% We turned on sedation and she was a RASS of three or four. We had to turn it back on for a little while, and then transition to propofol cover for her benzodiazepine dependence with Klonopin, we had to figure out what are the root causes. We didn’t touch her fentanyl. We made sure that pain was treated.
But we didn’t just call it a “failed vacation”. We saw delirium, she was CAM positive. This is a huge warning sign, we treat like a positive troponin and then brought everyone together and empowered and said, What do we need to do moving forward. So they kept sedation going to the level of a RASS of plus one and then mobilized her.
They got her walk in and she was weak. She was delirious. It was really hard for her, and it took a couple extra people. But after that she slept. And we reevaluated, “Does she still need the dexmedetomine?” Nope, turned it off. And then she would sleep, she’d wake up and never again was she rest three or four, but maybe she was the rest of one or two, they’d walk her she’d sleep.
And within less than 40 hours, even though her lungs got worse, her delirium was gone. She was off restraints, she was communicating, everything got better. And after three plus weeks in mechanical ventilation, she walked out the doors. But as because that team approached an awakening trial, with a goal of assessing her need, getting her human getting her liberated from sedation and delirium and setting her up to succeed.
Dr. Wes Ely 21:22
You know, while you were talking, you heard me say, “Let me call you back”. The ICU team has called me and I know what they’re calling me about. We’ve had a guy in keeping with your story, it’s an that’s an amazing story.
We’ve had a man up up in the ICU now for a week. And every single day, we’ve been transitioning off of drugs, and and tried to control his agitation. Without revealing any of his name or any HIPAA violation issues. He has had enough of a neurologic injury that’s creating a lot of anxiety for him. And we’ve had to use very high doses of dexmedetomidine. I don’t have any financial conflicts of interest with dexmedetomidine, by the way, but this is a generic alpha two agonist that we’re using for him. And we are now we now have him off of that medication.
And he’s transitioned over to an oral form of an alpha two agonist. And he’s doing quite well, and people who did not think that that was possible. But it your story was one of delet of due diligence. And our story is one of due diligence, where we said, we’re not just going to keep this person snowed with GABAergic drugs is not going to do any good.
And I’m hoping that when I call him back here in just a few minutes, that they tell me that he’s had a great night, he, he’s now fully on PO drugs, they were controlling his agitation because of this neurologic injury, and is disinhibition of this, and that we can get him out of the ICU today. That’s, that’s what we’ve been, that’s been our goal.
Kali Dayton 22:48
And that’s the ultimate goal of awakening trials, to see and make sure that patients are safe to be off sedation. And if they’re not, if something’s happening, why is it happening, and we’re going to treat that we’re going to try to minimize the risks of pics moving forward.
Dr. Wes Ely 23:02
And your team is going all the teams listening, if you just remember this, the 1990s, early 2000s way of sedating people, and then the COVID way of sedating people are wrong. They are not good, it is not in the patient’s best interest. I’m not saying that we deliberately did anything wrong during COVID, we did the best we could at the beginning.
But now that we know that PPE works, that family should be at the bedside, that they do not need to be behind the glass away from us we can we can mobilize him in the room, even if they can’t come out of the room for some form of isolation, I have what’s called a perpetual you, and I have them walk around the bed in the shape of a you, they just go back and forth back and forth when they’re on isolation. So even those are not reasons to keep somebody in the bed.
And all of this is geared towards humanism, that is lifting the human being up and respecting their innate price lessness so that we as clinicians will not lose sight of why we are there at the bedside. And what a gift it is to be with these people to help them find their wide lives find their way back. And when I say get back into the land of the living,
Kali Dayton 24:09
and maybe in addition to awakening trials, we can use the term “Re-humanization”. We’re tring to “re-humanize them”.
Dr. Wes Ely 24:17
Yes. We put people in the old way, we put them through a “dehumanization chamber”. And now I want to open up a re-humanization chamber of the ICU. So we can truly say that it’s an intensive care unit where “I see you with my eyes. And I see you with my mind.”
And this is the beauty of the ICU liberation program, the ABCDEF’s and it’s really not just about shortening length of stay. It’s about lifting people up when they least expect it. And we can be a big part of that in the ICU as the team.
Kali Dayton 24:52
Dr. Ely, thank you so much for all of your work throughout our community and for sharing this information with us today. And I look forward to learning more from you. Thank you.
Dr. Wes Ely 24:59
Thank you, Kali. I appreciate you.
Transcribed by https://otter.ai
Resources
First Breathing Trial Study:
Ely, E. W., Baker, A. M., Dunagan, D. P., Burke, H. L., Smith, A. C., Kelly, P. T., Johnson, M. M., Browder, R. W., Bowton, D. L., & Haponik, E. F. (1996). Effect on the duration of mechanical ventilation of identifying patients capable of breathing spontaneously. The New England journal of medicine, 335(25), 1864–1869.
First Awakening Trial Study:
Kress, J. P., Pohlman, A. S., O’Connor, M. F., & Hall, J. B. (2000). Daily interruption of sedative infusions in critically ill patients undergoing mechanical ventilation. The New England journal of medicine, 342(20), 1471–1477.
Failed SAT Study:
Barnes-Daly, M. A., Phillips, G., & Ely, E. W. (2017). Improving Hospital Survival and Reducing Brain Dysfunction at Seven California Community Hospitals: Implementing PAD Guidelines Via the ABCDEF Bundle in 6,064 Patients. Critical care medicine, 45(2), 171–178.
The ABC Trial:
Girard, T. D., Kress, J. P., Fuchs, B. D., Thomason, J. W., Schweickert, W. D., Pun, B. T., Taichman, D. B., Dunn, J. G., Pohlman, A. S., Kinniry, P. A., Jackson, J. C., Canonico, A. E., Light, R. W., Shintani, A. K., Thompson, J. L., Gordon, S. M., Hall, J. B., Dittus, R. S., Bernard, G. R., & Ely, E. W. (2008). Efficacy and safety of a paired sedation and ventilator weaning protocol for mechanically ventilated patients in intensive care (Awakening and Breathing Controlled trial): a randomised controlled trial. Lancet (London, England), 371(9607), 126–134.
The Dirunal Study- The impact of increased sedation overnight:
Seymour, C. W., Pandharipande, P. P., Koestner, T., Hudson, L. D., Thompson, J. L., Shintani, A. K., Ely, E. W., & Girard, T. D. (2012). Diurnal sedative changes during intensive care: impact on liberation from mechanical ventilation and delirium. Critical care medicine, 40(10), 2788–2796.
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