Sedation Practices in Mechanically Ventilated Neurocritical Care Patients from 19 Countries: An International Cohort Study

Shi Nan Feng¹, Lindsay H Laws¹, Camilo Diaz-Cruz², Raphael Cinotti^{3

4}, Marcus J Schultz^{5

6

7

8}, Karim Asehnoune³, Robert D Stevens⁹, Chiara Robba^{10

11}, Sung-Min Cho¹²; ENIO collaborators

Affiliations

¹ Division of Neuroscience Critical Care, Departments of Neurology, Neurosurgery, and Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
² Department of Neurology, Thomas Jefferson University Hospital, Philadelphia, PA, USA.
³ Department of Anesthesia and Critical Care, Centre Hospitalier Universitaire de Nantes, Nantes Université, Hôtel Dieu, Nantes, France.
⁴ UMR 1246 SPHERE Methods in Patients-Centered Outcomes and Health Research, Institut National de la Santé et de la recherche médicale, University of Nantes, University of Tours, Nantes, France.
⁵ Department of Clinical Medicine, University of Oxford Nufeld, Oxford, UK.
⁶ Department of Intensive Care, Amsterdam University Medical Centers, Amsterdam, The Netherlands.
⁷ Mahidol-Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand.
⁸ Department of Anesthesia, General Intensive Care and Pain Management, Division of Cardiothoracic and Vascular Anesthesia & Critical Care Medicine, Medical University of Vienna, Vienna, Austria.
⁹ Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, MD, USA.
¹⁰ Istituto di Ricovero e Cura a Carattere Scientifico Ospedale Policlinico San Martino, Genoa, Italy.
¹¹ Department of Surgical Science and Integrated Diagnostic, University of Genova, Genoa, Italy.
¹² Division of Neuroscience Critical Care, Departments of Neurology, Neurosurgery, and Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA. csungmi1@jhmi.edu.

PMID: 39776348
DOI: 10.1007/s12028-024-02200-1

Observational Study

Sedation Practices in Mechanically Ventilated Neurocritical Care Patients from 19 Countries: An International Cohort Study

Shi Nan Feng et al. Neurocrit Care. 2025 Aug.

. 2025 Aug;43(1):232-242.

doi: 10.1007/s12028-024-02200-1. Epub 2025 Jan 7.

Authors

Affiliations

¹ Division of Neuroscience Critical Care, Departments of Neurology, Neurosurgery, and Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
² Department of Neurology, Thomas Jefferson University Hospital, Philadelphia, PA, USA.
³ Department of Anesthesia and Critical Care, Centre Hospitalier Universitaire de Nantes, Nantes Université, Hôtel Dieu, Nantes, France.
⁴ UMR 1246 SPHERE Methods in Patients-Centered Outcomes and Health Research, Institut National de la Santé et de la recherche médicale, University of Nantes, University of Tours, Nantes, France.
⁵ Department of Clinical Medicine, University of Oxford Nufeld, Oxford, UK.
⁶ Department of Intensive Care, Amsterdam University Medical Centers, Amsterdam, The Netherlands.
⁷ Mahidol-Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand.
⁸ Department of Anesthesia, General Intensive Care and Pain Management, Division of Cardiothoracic and Vascular Anesthesia & Critical Care Medicine, Medical University of Vienna, Vienna, Austria.
⁹ Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, MD, USA.
¹⁰ Istituto di Ricovero e Cura a Carattere Scientifico Ospedale Policlinico San Martino, Genoa, Italy.
¹¹ Department of Surgical Science and Integrated Diagnostic, University of Genova, Genoa, Italy.
¹² Division of Neuroscience Critical Care, Departments of Neurology, Neurosurgery, and Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA. csungmi1@jhmi.edu.

PMID: 39776348
DOI: 10.1007/s12028-024-02200-1

Abstract

Background: Our objective was to characterize the impact of common initial sedation practices on invasive mechanical ventilation (IMV) duration and in-hospital outcomes in patients with acute brain injury (ABI) and to elucidate variations in practices between high-income and middle-income countries.

Methods: This was a post hoc analysis of a prospective observational data registry of neurocritically ill patients requiring IMV. The setting included 73 intensive care units (ICUs) in 18 countries, with a total of 1,450 patients with ABI requiring IMV. There were no interventions.

Results: Patients were categorized into day 1 propofol, midazolam, propofol and midazolam, dexmedetomidine, or sodium thiopental. The primary outcome was duration of IMV. Secondary outcomes were ICU and hospital mortality, ICU length of stay, days to first extubation, extubation failure, and withdrawal of life-sustaining therapy. Multivariable analyses were adjusted for clinically preselected covariates. Of 1,450 included patients (median age 54 years, 66% male), 41.2% (n = 597) were started on propofol, 26.1% (n = 379) were started on midazolam, 19.9% were started on propofol and midazolam, 0.3% (n = 5) were started on sodium thiopental, 0.7% (n = 10) were started on dexmedetomidine, and 11.8% (n = 171) were treated without sedation. After adjustment, there was no significant difference in IMV duration between patients who received midazolam (aβ = 0.64, p = 0.43, 95% confidence interval [CI] - 0.96 to 2.24) or propofol and midazolam (aβ = 0.32, p = 0.46, 95% CI - 1.44 to 2.12) compared with patients who received propofol. Patients who were started on midazolam had an average length of ICU stay that was 2.78 days longer than patients started on propofol (p = 0.003, 95% CI 0.94-4.63). There were no differences in mortality, days to first extubation, extubation failure, or withdrawal of life-sustaining therapy. Patients from high-income countries (n = 1,125) were more likely to receive propofol on day 1 (45.7 vs. 25.5%), whereas patients from middle-income countries (n = 325) were more likely to receive midazolam (32.6 vs. 24.3%) (p < 0.001).

Conclusions: In an international registry of patients with ABI requiring IMV, IMV duration did not differ significantly relative to initial sedation strategy. However, patients started on midazolam had longer ICU stay.

Keywords: Acute brain injuries; Critical care; Midazolam; Propofol; Sedative.

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Conflict of interest statement

Conflict of interest: None of the authors have conflicts of interest that are directly relevant to the content of this article. Ethical approval/informed consent: Data management, monitoring, and reporting of the study were performed according to the International Conference on Harmonization Good Clinical Practice Guidelines. Approval to enroll patients in ENIO was obtained from the institutional review board of the promoter center (Groupe Nantais d’Ethique dans le Domaine de la Santé, institutional review board no. 7/11/2017), and then from each participating site. Informed consent was obtained in accordance with local regulations.

References

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1. Paul BS, Paul G. Sedation in neurological intensive care unit. Ann Indian Acad Neurol. 2013;16(2):194–202. https://doi.org/10.4103/0972-2327.112465 . - DOI
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1. Pham T, Heunks L, Bellani G, et al. Weaning from mechanical ventilation in intensive care units across 50 countries (WEAN SAFE): a multicentre, prospective, observational cohort study. Lancet Respir Med. 2023;11(5):465–76. https://doi.org/10.1016/S2213-2600(22)00449-0 . - DOI
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Sedation Practices in Mechanically Ventilated Neurocritical Care Patients from 19 Countries: An International Cohort Study

Affiliations

Sedation Practices in Mechanically Ventilated Neurocritical Care Patients from 19 Countries: An International Cohort Study

Authors

Affiliations

Abstract

Conflict of interest statement

References

Publication types

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LinkOut - more resources

Full Text Sources

Medical