Early Deep Sedation Practices Worsened During the Pandemic Among Adult Patients Without COVID-19: A Retrospective Cohort Study

Abstract

Background: There is substantial evidence that patients with COVID-19 were treated with sustained deep sedation during the pandemic. However, it is unknown whether such guideline-discordant care had spillover effects to patients without COVID-19.

Research question: Did patterns of early deep sedation change during the pandemic for patients on mechanical ventilation without COVID-19?

Study design and methods: We used electronic health record data from 4,237 patients who were intubated without COVID-19. We compared sedation practices in the first 48 h after intubation across prepandemic (February 1, 2018, to January 31, 2020), pandemic (April 1, 2020, to March 31, 2021), and late pandemic (April 1, 2021, to March 31, 2022) periods.

Results: In the prepandemic period, patients spent an average of 13.0 h deeply sedated in the first 48 h after intubation. This increased 1.9 h (95% CI, 1.0-2.8) during the pandemic period and 2.9 h (95% CI, 2.0-3.8) in the late pandemic period. The proportion of patients that spent over one-half of the first 48 h deeply sedated was 18.9% in the prepandemic period, 22.3% during the pandemic period, and 25.9% during the late pandemic period. Ventilator-free days decreased during the pandemic, with a subdistribution hazard ratio of being alive without mechanical ventilation at 28 days of 0.87 (95% CI, 0.79-0.95) compared with the prepandemic period. Tracheostomy placement increased during the pandemic period compared with the prepandemic period (OR, 1.41; 95% CI, 1.08-1.82). In the medical ICU, early deep sedation increased 2.5 h (95% CI, 0.6-4.4) during the pandemic period and 4.9 h (95% CI, 3.0-6.9) during the late pandemic period, compared with the prepandemic period.

Interpretation: We found that among patients on mechanical ventilation without COVID-19, sedation use increased during the pandemic. In the subsequent year, these practices did not return to prepandemic standards.

Keywords: critical care; mechanical ventilation; sedation.

Figure 1

Deep sedation use during the prepandemic, pandemic, and late pandemic periods. Dots represent the average duration of deep sedation for all patients intubated on a given day. Red line represents the 14-d moving average of average durations of deep sedation for all patients intubated on a given day. Blue lines represent average duration of deep sedation utilization for each period.

Figure 2

Exposure to deep sedation during the first 48 h after intubation. Patients are categorized at each interval based on the weighted average Richmond Agitation Sedation Scale (RASS) score during the prior 12-h period. An alluvial plot illustrates the proportions of patients in each cohort with a deep (RASS score −3, −4, or −5) or target (RASS score −2 to 1) weighted average RASS score during the prior 12-h period. Transitions from one category to another that correspond to < 1% of the data, which included transitions to all agitated states, are not visualized.

Figure 3

Time to breathing without mechanical ventilation among patients who were intubated in the prepandemic, pandemic, and late pandemic periods.