Tracheotomy does not affect reducing sedation requirements of patients in intensive care--a retrospective study

Abstract

Introduction: Translaryngeal intubated and ventilated patients often need sedation to treat anxiety, agitation and/or pain. Current opinion is that tracheotomy reduces sedation requirements. We determined sedation needs before and after tracheotomy of intubated and mechanically ventilated patients.

Methods: We performed a retrospective analysis of the use of morphine, midazolam and propofol in patients before and after tracheotomy.

Results: Of 1,788 patients admitted to our intensive care unit during the study period, 129 (7%) were tracheotomized. After the exclusion of patients who received a tracheotomy before or at the day of admittance, 117 patients were left for analysis. The daily dose (DD; the amount of sedatives for each day) divided by the mean daily dose (MDD; the mean amount of sedatives per day for the study period) in the week before and the week after tracheotomy was 1.07 +/- 0.93 DD/MDD versus 0.30 +/- 0.65 for morphine, 0.84 +/- 1.03 versus 0.11 +/- 0.46 for midazolam, and 0.62 +/- 1.05 versus 0.15 +/- 0.45 for propofol (p < 0.01). However, when we focused on a shorter time interval (two days before and after tracheotomy), there were no differences in prescribed doses of morphine and midazolam. Studying the course in DD/MDD from seven days before the placement of tracheotomy, we found a significant decline in dosage. From day -7 to day -1, morphine dosage (DD/MDD) declined by 3.34 (95% confidence interval -1.61 to -6.24), midazolam dosage by 2.95 (-1.49 to -5.29) and propofol dosage by 1.05 (-0.41 to -2.01). After tracheotomy, no further decrease in DD/MDD was observed and the dosage remained stable for all sedatives. Patients in the non-surgical and acute surgical groups received higher dosages of midazolam than patients in the elective surgical group. Time until tracheotomy did not influence sedation requirements. In addition, there was no significant difference in sedation between different patient groups.

Conclusion: In our intensive care unit, sedation requirements were not further reduced after tracheotomy. Sedation requirements were already sharply declining before tracheotomy was performed.

Figure 1

Diagram of the sedation protocol and Sedation Intensive Care (SEDIC) score. IV, intravenous; MV, mechanical ventilation.

Figure 2

Daily administration of morphine, midazolam and propofol and percentages of patients needing these sedatives. Data are expressed as mean DD/MDD. When comparing the summed data of seven days before and after tracheotomy there was a significant difference in dosage and percentage of patients using these sedatives before and after tracheotomy (P < 0.01 with the Wilcoxon signed-rank test and the McNemar test). However, a repeated-measurements analysis of variance showed that, from day -7 to day -1, morphine dosage declined by 3.34 (95% confidence interval -1.61 to -6.24), midazolam dosage by 2.95 (-1.49 to -5.29) and propofol dosage by 1.05 (-0.41 to -2.01) DD/MDD (P < 0.01). The percentage of patients using sedatives also decreased before tracheotomy. After tracheotomy there was no further increase in decline rate, and the dosage remained stable.