Daily Sedation Interruption Versus Continuous Sedation and the Duration of Mechanical Ventilation in Critically Ill Adults: A Systematic Review and Meta-Analysis

Abstract

Background.  Daily sedation interruption (DSI) aims to limit sedative accumulation in mechanically ventilated adults. Trials have conflicted. Implementation studies have not been synthesized with randomized data.

Objective.  To compare DSI with continuous sedation without scheduled interruption for ventilation duration and clinical outcomes in critically ill adults.

Methods.  PubMed, Europe PMC and Scopus were searched, with citation searching. Randomized trials, concurrent cohorts and before–after studies were eligible. Standardized mean differences (SMDs) were pooled with random-effects models (DerSimonian–Laird, Hartung–Knapp). Risk of bias was assessed with RoB 2 and ROBINS-I, and certainty with GRADE.

Results.  Twenty-three studies were included (12 randomized trials, one cohort, 10 before–after studies), and 10 (2,297 patients) were pooled for the primary outcome, in which DSI did not significantly shorten ventilation (SMD −0.11, 95% confidence interval [CI] −0.49 to 0.28; I² 89.1%; 95% prediction interval −1.13 to 0.92; ratio of means 0.88, 0.66 to 1.17). The SMD was 0.05 (−0.42 to 0.53) in randomized trials (p=0.16 versus non-randomized studies) and 0.00 (−0.71 to 0.70) against protocolized sedation. Point estimates for mortality (risk ratio 0.85, 0.54 to 1.33, randomized trials) and tracheostomy (0.64, 0.40 to 1.00) favored DSI, but the intervals included no effect. Self-extubation, reintubation, delirium and length of stay did not differ. Certainty was very low for ventilation duration and low for mortality.

Conclusion.  DSI did not consistently shorten mechanical ventilation compared with continuous sedation. Randomized trials showed no effect. A possible benefit in intensive care units (ICUs) without protocolized light sedation rests mainly on non-randomized evidence.