Adherence to Sedation Protocol Recommendations in Intubated ICU Patients

Sedation in critically ill children is a complex challenge. Both inadequate sedation and oversedation are undesirable and carry consequences. Standardized sedation protocols aim to reduce practice variability, minimize drug exposure, and improve outcomes. Although widely used, adherence to sedation protocols remains poorly studied. We quantified the alignment between sedation protocols and infusion titration practices in a large single-center cohort.

Retrospective cohort study.

Three PICUs within a single-tertiary care children's hospital.

Patients admitted between January 1, 2011, and December 31, 2023 who received mechanical ventilation for greater than 24 hours and at least one sedative infusion.

None.

A total of 8,108 patients across 9,670 encounters, representing 172,136 ICU patient days were included. Adherence to five metrics was calculated as the proportion of protocol-defined titration opportunities in which the recommended action was taken. Protocol adherence was consistently low across all ICUs. Infusions were rarely increased when indicated (92.5% missed [95% CI, 92.4-92.6%]) and were often not decreased when recommended (95.5% missed [95.4-95.6%]). Increases in infusion dose were premature (i.e., not indicated by the protocol) in 54.7% (95% CI, 54.3-55.2%). Titration opportunities, determined by the protocols-defined titration recommendations using the number of as-needed doses, varied in frequency across encounters with a median of 3.0 (interquartile range [IQR], 1.1-7.6) increase opportunities and 2.4 (IQR, 1.6-3.6) decrease opportunities per infusion day. Only 16.2% (95% CI, 15.1-17.2%) of eligible short-duration infusions were discontinued when recommended. Infusions of greater than 5 days duration were weaned per protocol in 74.5% (74.0-75.1%) of opportunities.

Sedation titration in PICUs frequently deviates from protocol recommendations, leading to missed opportunities for active titration. Given the well-documented risks of prolonged sedation, including neurodevelopmental impact, iatrogenic withdrawal, and delirium, as well as the evidence that protocols diminish sedative exposure, improving adherence to sedation protocols is a key target for quality improvement. Future work should focus on identifying barriers to adherence and developing interventions, such as clinical decision support tools, to enhance compliance with evidence-based sedation management.