Article published online: 2023-03-01

THIEME
Correspondence

Sedation Vacation in Neurocritical Care:

A Proposal Algorithm
Luis Rafael Moscote-Salazar1 William A. Florez-Perdomo1 Tariq Janjua2

1 Department of Critical Care Medicine, Physician Regional Medical Address for correspondence Luis Rafael Moscote-Salazar, MD,
Center, Naples, Florida, United States Colombian Clinical Research Group in Neurocritical Care, Bogota
2 Colombian Clinical Research Group in Neurocritical Care, Bogota, 250251, Colombia (e-mail: [email protected]).
Colombia

Indian J Neurotrauma

Abstract Daily sedation interruption or sedation vacation is a strategy for neurological

evaluation, respiratory mechanics, cardiac stability, and eventual weaning to
Keywords extubation. However, its application has safety aspects such as pulmonary, cardiac,
► critical care and neurological complications.
► neurocritical care A protocol-driven sedation vacation in the medical intensive care helps with the
► neurosurgery reduction in the intensive care length of stay and increase in ventilator-free days.1,2
► neurotrauma The same approach can be used in neurointensive care with alterations based upon the
► sedation neurocritical care progression.

Daily sedation interruption or sedation vacation is a strategy of new focal injury where sedation reduction or vacation can
for neurological evaluation, respiratory mechanics, cardiac help with bedside neurological examination.
stability, and eventual weaning to extubation. However, its Sedation vacation for neurocritical care patients can be done
application has safety aspects such as pulmonary, cardiac, when the original injury is stable and ventilator weaning is
and neurological complications. required. Another aspect as mentioned above is to look for any
A protocol-driven sedation vacation in the medical new focal deficit. The elements to consider before sedation
intensive care helps with the reduction in the intensive vacation include cardiopulmonary stability, no urgent plan for
care length of stay and increase in ventilator-free days.1,2 any procedure or tests, and an underlying condition is improving.
The same approach can be used in neurointensive care with Gradual reduction in sedation is the best option, although
alterations based upon the neurocritical care progression. cessation of a solitary infusion of sedative in a stable patient
In the protocol published by Kress et al,3 the daily dose of also will help. These agents are usually an infusion of propofol,
sedation was reduced under close clinical monitoring by 50%. dexmedetomidine, or fentanyl. A protocol-driven approach is
This approach was for medical intensive care patients. It is better so all the team members can follow this protocol ►Fig 1.
important to mention that the progressive reduction in The team members for this purpose include intensivists, bedside
sedation allowed in these trials for close neurological staff, respiratory therapists, pharmacists, and others.
status.4,5 This approach can be translated to neurocritical In conclusion, a sedation vacation approach is feasible
care patients. The key aspect is to have neurological stability and a protocol implementation in neurocritical care
for the sedation vacation in these patients. Another aspect can help with the progression of care. Full team effort is
that requires attention is an acute brain injury and suspicion needed to start and continue the process. Further research

DOI https://doi.org/ © 2023. The Author(s).

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Sedation Vacation in Neurocritical Care Moscote-Salazar et al.

Fig. 1 Sedation vacation pathway in neurocritical care. CPP, cerebral perfusion pressure; MAP, mean arterial pressure; PaO2, arterial oxygen
tension; PaCO2, arterial carbon dioxide tension; PtiO2, brain tissue oxygen.

Indian Journal of Neurotrauma © 2023. The Author(s).

 Sedation Vacation in Neurocritical Care Moscote-Salazar et al.

based on common diagnoses in neurocritical can elucidate 2 Strøm T, Martinussen T, Toft P. A protocol of no sedation for
the limitations and further refinements. critically ill patients receiving mechanical ventilation: a
randomised trial. Lancet 2010;375(9713):475–480
3 Kress JP, Pohlman AS, O’Connor MF, Hall JB. Daily interruption of
Conflict of Interest
sedative infusions in critically ill patients undergoing mechanical
None. ventilation. N Engl J Med 2000;342(20):1471–1477
4 Mehta S, Burry L, Cook D, et al; SLEAP Investigators Canadian
Acknowledgments Critical Care Trials Group. Daily sedation interruption in
None. mechanically ventilated critically ill patients cared for with a
sedation protocol: a randomized controlled trial. JAMA 2012;308
(19):1985–1992
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1 Girard TD, Kress JP, Fuchs BD, et al. Efficacy and safety of a paired Canadian Critical Care Trials Group. Recall of ICU stay in
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Indian Journal of Neurotrauma © 2023. The Author(s).