What is patient-targeted sedation?

From the Guidelines

Patient targeted sedation should be achieved through a protocol that targets a light level of sedation, using either a nurse-led protocol or a daily sedation interruption protocol, as this approach has been shown to improve outcomes in critically ill patients. The goal of patient targeted sedation is to achieve the desired level of sedation while minimizing side effects and complications. According to the most recent and highest quality study 1, both nurse-led protocols and daily sedation interruption protocols are safe and effective in achieving a light level of sedation. The study found that targeting a light level of sedation is associated with improved outcomes, including reduced time on the ventilator and reduced ICU length of stay.

Key Considerations

• The choice of sedation protocol should be based on the individual patient's needs and characteristics, as well as the specific procedure being performed.
• Continuous monitoring of vital signs, including oxygen saturation, heart rate, blood pressure, and respiratory rate, is essential during the procedure.
• The sedation level should be regularly assessed using validated scales like the Richmond Agitation-Sedation Scale (RASS) or the Observer's Assessment of Alertness/Sedation (OAA/S).
• The use of benzodiazepines for sedation is no longer recommended, and alternative medications such as propofol or dexmedetomidine should be considered.

Medication Options

• Propofol may be used for deeper sedation, with a typical dose of 0.5-1 mg/kg IV initial bolus, followed by 0.25-0.5 mg/kg increments or 25-75 mcg/kg/min infusion.
• Dexmedetomidine may be used for lighter sedation, with a typical dose of 0.2-0.7 mcg/kg/hour infusion.

Benefits of Patient Targeted Sedation

• Improved outcomes, including reduced time on the ventilator and reduced ICU length of stay 1, 2.
• Reduced risk of adverse events, such as respiratory depression or prolonged recovery.
• Improved patient comfort and satisfaction.

From the FDA Drug Label

For peroral procedures, the use of an appropriate topical anesthetic is recommended. For bronchoscopic procedures, the use of narcotic premedication is recommended. When used for sedation/anxiolysis/amnesia for a procedure, dosage must be individualized and titrated. Midazolam should always be titrated slowly; administer over at least 2 minutes and allow an additional 2 or more minutes to fully evaluate the sedative effect. Individual response will vary with age, physical status and concomitant medications, but may also vary independent of these factors. Sedative doses should be individually titrated, taking into account patient age, clinical status and concomitant use of other CNS depressants.

Patient Targeted Sedation with midazolam requires:

• Individualized dosage: dosage must be titrated to the desired effect, taking into account the patient's age, physical status, and concomitant medications.
• Slow administration: midazolam should be administered over at least 2 minutes, with an additional 2 or more minutes to fully evaluate the sedative effect.
• Monitoring: continuous monitoring of respiratory and cardiac function is required.
• Titration to effect: titration to effect with multiple small doses is essential for safe administration.
• Consideration of concomitant medications: patients who have received concomitant narcotics or other CNS depressants may require reduced doses of midazolam. [3] [4]

From the Research

Patient Targeted Sedation

• Patient targeted sedation is a crucial aspect of medical care, particularly in intensive care units (ICUs) and during mechanical ventilation 5, 6, 7, 8, 9.
• The goal of targeted sedation is to achieve a specific level of sedation, typically measured using the Richmond Agitation-Sedation Scale (RASS), to ensure patient comfort and safety while minimizing the risk of adverse effects 6, 7, 8, 9.
• Various sedatives, including dexmedetomidine, propofol, midazolam, and opioids, are used to achieve targeted sedation, with the choice of sedative depending on the patient's condition, medical history, and the procedure being performed 5, 6, 7, 8, 9.

Sedation Strategies

• Dexmedetomidine and propofol are commonly used sedatives in ICUs, with studies suggesting that they have similar efficacy and safety profiles in mechanically ventilated patients 6, 8.
• Dexmedetomidine has been shown to reduce the duration of mechanical ventilation and delirium in ICU patients, while propofol may be associated with a higher risk of hypotension and bradycardia 7, 8.
• Midazolam and opioids are also used for sedation, but may be associated with a higher risk of adverse effects, such as respiratory depression and addiction 5, 9.

Monitoring and Adjustment

• Regular monitoring of sedation levels, using tools such as the RASS, is essential to ensure that patients receive the appropriate level of sedation and to minimize the risk of adverse effects 6, 7, 8, 9.
• Sedation levels should be adjusted based on patient response, with the goal of achieving a light level of sedation to facilitate patient comfort and safety while minimizing the risk of adverse effects 6, 7, 8, 9.