Sedation Depth in Acute Respiratory Distress Syndrome Patients Receiving Neuromuscular Blockade: A Prospective...

The primary objective of this study was to evaluate sedation depth using processed electroencephalography (pEEG) in adults with acute respiratory distress syndrome (ARDS) receiving continuous neuromuscular blockade (NMBA). SECONDARY OBJECTIVES INCLUDED: (1) to estimate the prevalence of potential inadequate and excessive sedation; (2) to describe 24-hour temporal trends in Patient State Index (PSI) and spectral edge frequency (SEF; right [SEF-R] and left [SEF-L]) (T0-T24); and (3) to explore associations with sedative regimens.

Prospective observational study.

Tertiary intensive care unit (ICU).

Sixty adult patients with ARDS receiving continuous NMBA infusions for at least 24 hours.

Sedation was achieved with propofol and/or midazolam, with fentanyl used as an analgesic adjunct. pEEG monitoring was applied using PSI, SEF-R, and SEF-L.

PSI, SEF-R, and SEF-L values were recorded at seven time points over 24 hours (T0-T24). PSI values were categorized as deep (<25), adequate (25-50), and potentially inadequate (>50) sedation. The median PSI value was 53.3; 50% of patients had a PSI >50, and 16.7% had a PSI >75, indicating potentially inadequate sedation despite continuous infusion. No significant hemodynamic differences were observed between adequately and inadequately sedated patients. Patients receiving propofol plus midazolam had significantly lower PSI values compared with those in the single-agent groups (p < 0.001). Across predefined time points (T0-T24), PSI decreased significantly from T0 to subsequent time points (overall p < 0.001), and SEF-R and SEF-L also showed significant time effects; pairwise comparisons involving T0 were consistently significant (see Supplementary Table 1).

Among paralyzed ICU patients receiving NMBA, a substantial proportion demonstrated indices consistent with potential inadequate sedation despite standard protocols; explicit awareness was not assessed. pEEG monitoring should be interpreted cautiously and as an adjunct to clinical assessment, it may provide real-time information to support individualized, brain-focused sedation management.