Sedation: “Vacation” is Over!

I have to admit, I wasn’t a fan of awakening trials at first. During my first two years in an Awake and Walking ICU, we rarely initiated sedation, so the need to get it off wasn’t a struggle for us. When sedation was necessary, we simply turned it off when we deemed it unnecessary.

It wasn’t until my third travel assignment—three years into my critical care journey—that I encountered awakening trials.

“Here, we do this annoying thing at 5 AM. You turn off sedation, and when you see them move, you turn it back on. That indicates they haven’t had a stroke and can't tolerate the ventilator. Just chart ‘failed awakening trial’ in this SAT category.”

At the time, it made no sense to me.

What was the objective? This wasn’t a full neuro exam. Why did patients react this way??

What did they need?

Despite my confusion, I had been worn down by demeaning responses to my previous questions about sedation, so I held my tongue and followed orders.

The stress of conducting these “awakening trials” at the end of my night shift was overwhelming. Often, I was alone, unaware of how or when the patient would emerge from sedation. Patients might remain quiet and then suddenly become agitated just as I was attending to others. In those moments, they often tried to pull out their tubes, and I had been directed to turn the sedation back on.

It baffled me. I had seen hundreds of patients fully awake, calm, compliant, and even unrestrained before. Why were these patients so “tube intolerant”? What made them different? Why was this experience so much more challenging than my first ICU?

I wish I had known these key points:

1. Delirium Increases Self-Extubation Risk: Delirium can increase the risk of self-extubation by 11.6 times, while continuous sedation raises the risk of delirium by 216%. Furthermore, more sedation correlates with increased severity of delirium. Most patients I encountered in my first ICU remained awake, calm, and unrestrained because they were free of sedation after intubation. They were quickly allowed to awaken, becoming oriented to their condition and tubes, which helped keep their movements safe. They could connect with family, communicate their needs, and get quality sleep—all factors that mitigate delirium.

Patients who are not delirious can better cope with the endotracheal tube, understanding its necessity for survival. They can articulate their needs and help respiratory therapists optimize comfort settings.

2. Awakening Trials Are Not Just an “On/Off Switch” for Sedation. In the early 1990s, spontaneous breathing trials showed that patients who were awake did better on ventilators, leading to the development of spontaneous awakening trials. Over time, terminology like “trials,” “interruption,” "holiday," "break," and “vacation” became common in ICU sedation discussions. Unfortunately, these terms suggest a temporary break from sedation rather than a reevaluation of its necessity, trapping clinicians in outdated practices.

3. The real purpose of awakening trials is to assess sedation needs.

?In the Awake and Walking ICU, we initiated this assessment promptly after intubation—unless specific conditions indicated sedation was necessary. We allowed patients to promptly awaken and communicate their needs via pen, paper, or even cell phones. If a patient was at a RASS of +3 or +4, we employed light sedation like dexmedetomidine to calm them down to a RASS of 0 or +1 to safely facilitate mobilization and communication. Our goal was to attempt discontinuation of sedation daily. For patients unable to oxygenate with movement due to severe ARDS, we would stop sedation each day to gauge their oxygen saturation during movement. If they maintained appropriate levels, sedation would remain off, allowing us to focus on mobility.

Listen to Mikita Fuchita , Dr. Brian Bellucci, Dr. Thomas Strom, and nurses share the improved ease in managing patients when they are awake shortly after intubation in episodes 133, 130, 91, 76, 114, and 114 of the podcast, "Walking Home From the ICU".

4. The ABCDEF Bundle’s Objective Is Critical.?

The aim is to keep patients as awake, communicative, autonomous, and mobile as possible even early on after ICU admission and intubation. Awakening trials are not solely to assess for extubation. They serve to ensure patients are only sedated when necessary, pushing for sedation cessation rather than a brief “interruption”.?

As Dr. Wes Ely says, "Awakening trials are for the rehumanization of the patient." This means we allow them to move, communicate, and be involved in their journey.

5. When to do Awakening Trials

I suspect that having SAT and SBT criteria on this same page has led to the myth that SATs are for SBTs. SATs should be done as soon as we suspect there is no longer an indication for sedation. For many patients, this can and should be once paralytics from intubation are no longer in effect. We do NOT need to wait until we are doing a breathing trial to do an awakening trial.

6. Clarification on “Failed” Trials:

Movement is not a “failed awakening trial”. This image above shows a common SAT and SBT algorithm. These prompts show valuable guidelines to help clinicians critically think, but I have witnessed in my own practice and within dozens of other teams that these prompts are misinterpreted.?

For example, “agitation” is listed as criteria for “failed awakening trial”. Yet we are seeing at the bedside that a RASS +1 in which a patient is restless is being determined as “agitated”, the awakening trial is “failed”, and sedation is being resumed. Instead, this kind of protocol should have objective RASS scores such as RASS >+2 as failed criteria.

7. How to respond to a true failed awakening trial If an awakening trial is deemed a failure, sedation should be resumed at half the previous rate. Despite being in most hospital policies, this strategy is often overlooked in clinical practice. Sedation resumption at the same or increased dose after a trial undermines the goals of maintaining patient wakefulness, autonomy, and mobility.

One awakening trial study showed that the awakening trial group ultimately received more sedation than the control group that never received any “breaks” from sedation. Just because awakening trials are required in the charting or even mentioned in rounds does not mean that they are being done properly.

8. A Strategic Approach to Stopping Sedation: Awakening trials can often be late, inconsistent, poorly executed, or yield low success rates due to insufficient education and strategy. My initial dread of these trials stemmed from the stress of managing a delirious, agitated patient alone during night shifts, making it a setup for failure.

All clinicians in the ICU must have a shared understanding of the risks associated with sedation and immobility. Together, we should aspire to keep patients awake, communicative, autonomous, and mobile shortly after intubation. When sedation is indicated, it is essential for our teams to collaborate and adopt a strategic approach to facilitate patients waking up and acclimating to the endotracheal tube.

Whenever a patient first opens their eyes, their loved ones should be present at the bedside. These family members play a crucial role in maintaining a calm environment, helping the patient understand the tube, assisting with communication through writing or texting, or simply being there as a reassuring presence. Care teams need to be competent in managing ventilator settings, securing the tube, and conducting pain assessments, all of which aid patients in adjusting to intubation.

If a patient shows signs of delirium, the nurse should be prepared to call in a "delirium SWAT team," which may include physical therapists, occupational therapists, and speech therapists.

Rather than resuming sedation at full dosage, nurses should strive to keep patients awake enough to engage in physical therapy and occupational therapy, working towards sitting on the edge of the bed and, potentially, standing or walking. This approach often results in patients becoming calmer, more oriented, and easier for the RN to manage after mobility efforts.

Conclusion

The "vacation" time for sedation needs to end. We must shift our semantics, culture, and perspective from automatic sedation for all and a quick on/off approach to actively working toward avoiding and minimizing sedation usage unless absolutely necessary.

It is crucial to recognize that sedation is NOT sleep. Prolonged sedation increases the risks of delirium, ICU-acquired weakness, mortality, long-term brain injury, and PTSD. Resuming sedation in response to signs of discomfort does not adequately address agitation or anxiety; it often plunges patients deeper into traumatic delirium.

It's time to move beyond the SAT and SBT culture of the 1990s.?

We need to embrace critical thinking and interdisciplinary collaboration to foster the development of Awake and Walking ICUs.