Analgosedation practices and the impact of sedation depth on clinical outcomes among patients requiring mechanical ventilation in the emergency department: a cohort study

Background

Analgesia and sedation are cornerstone therapies for mechanically ventilated patients. Despite data showing that early deep sedation in the intensive care unit influences outcome, this has not been investigated in the emergency department (ED). Therefore, ED-based sedation practices, and their influence on outcome, remain incompletely defined. This study's objectives were to describe ED sedation practices in mechanically ventilated patients, and to test the hypothesis that ED sedation depth is associated with worse outcomes

Methods

This was a cohort study on a prospectively compiled ED registry of adult, mechanically ventilated patients at a single academic medical center. Hospital mortality was the primary outcome and hospital-, ICU-, and ventilator-free days were secondary outcomes. A backward, stepwise, multivariable logistic regression model evaluated the primary outcome as a function of ED sedation depth. Sedation depth was assessed with the Richmond Agitation-Sedation Scale (RASS).

Results

Four hundred fourteen patients were studied. In the ED, 354 (85.5%) patients received fentanyl, 254 (61.3%) received midazolam, and 194 (46.9%) received propofol. Deep sedation was observed in 244 (64.0 %) patients. After adjusting for confounders, a deeper ED RASS was associated with mortality [aOR 0.77, 95%CI (0.63 - 0.94)].

Conclusions

Early deep sedation is common in mechanically ventilated ED patients and is associated with worse mortality. These data suggest that ED-based sedation is a modifiable variable that could be targeted to improve outcome.

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