SAN FRANCISCO — Intensive care unit patients leave the hospital more than 4 days early if they receive spontaneous awakening and breathing trials every day, Dr. E. Wesley Ely said at the International Conference of the American Thoracic Society.
The multicenter, controlled ABC (awakening, breathing, controlled) trial involved 335 patients randomized to either standard goal-directed sedation or the awakening, breathing approach.
Compared with controls, the ABC trial patients left the ICU an average of 3.8 days sooner (9.1 days vs. 12.9 days), were discharged from the hospital 4.4 days sooner (14.8 days vs. 19.2 days), and spent 3.1 more days alive and off the ventilator (14.7 days vs. 11.6 days). There was no significant difference in the percentage of patients who survived for 28 days or more (72% for the ABC patients, 65% for controls).
“You can save somewhere in the neighborhood of $5,000–$15,000 per patient via protocols like this,” said Dr. Ely of Vanderbilt University, Nashville, Tenn.
Earlier studies demonstrated daily breathing trials improved the outcomes of ventilated patients, and daily lifting of medically induced comas improved the outcomes of critical care patients. This was the first trial to put both of those protocols together.
“For years we have not optimized the removal of those sedatives, analgesics, and the ventilator. Instead, we allow the patients on average to probably get 2 or 3 days of additional unnecessary time on the ventilator, all the while being exposed to these high doses of very potent psychoactive drugs, “Dr. Ely said. “On average patients receive too long of a duration and too high of a dose of these medicines, and while it's well intentioned,… I think we're overshooting. People generally think of these drugs as not harmful, but we're actually finding that ICU delirium, which is a result of these drugs, is a very important predictor of death.”
The ABC trial protocol is easy to implement, Dr. Ely said. All it takes is the will to make the change among the providers who manage patients in the ICU.
About half the patients enrolled in the trial had sepsis or acute respiratory distress syndrome. Other common diagnoses were myocardial infarction/congestive heart failure, chronic obstructive pulmonary disease/asthma, and altered mental status. Surgical ICU patients were excluded because the investigators did not want to discontinue analgesia in patients with incisions.
Dr. Ely emphasized patients under the ABC trial protocol must be watched closely. “A very important point here is that we did not sacrifice patient comfort,” he said. If patients exhibited signs of distress such as rapid breathing or sweating, sedation and analgesia were resumed, beginning at half the previous dose.