CHEST Guidelines-Rebuttal-From-Dr-Kress

Rebuttal-From-Dr-Kress_chest

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Dr. John P. Kress's rebuttal emphasizes key considerations in the debate over sedation practices for mechanically ventilated ICU patients. He acknowledges Dr. Vinayak's arguments about minimizing sedation but highlights practical challenges. Kress references a study by Strøm et al. on a "no sedation" protocol, indicating that while promising, it involved using morphine as a foundational strategy—an opiate that provides calming effects—indicating sedative use indirectly. He points out that the study was conducted in Denmark with 1:1 nurse-to-patient ratios, an uncommon luxury in global ICUs, which impacts the feasibility of replicating the study elsewhere. Furthermore, not all patients tolerated the "no sedation" method, and ICU delirium wasn't measured, offering no conclusive insights on its effects.<br /><br />Kress expresses that continuous sedation agents like propofol and dexmedetomidine are preferred over benzodiazepines due to their low accumulation chances and reduced delirium risk. He notes that, according to emerging guidelines from the Society of Critical Care Medicine, benzodiazepines are becoming less favored. Continuous infusion sedatives allow for daily interruptions critical for patient mobility, an integral part of rehabilitation.<br /><br />While acknowledging the allure of an "opiates-only" strategy, Kress notes its testing limitations outside specialized settings. Ultimately, he argues that current evidence supports using continuous infusion of sedatives with daily interruptions as the most effective strategy for managing ICU sedation, necessary for effective patient care during mechanical ventilation. This comprehensive view reflects on feasibility, current standards, and emerging evidence in sedation management, emphasizing safety and patient outcomes.

Keywords

sedation practices

mechanically ventilated

ICU patients

morphine

no sedation protocol

nurse-to-patient ratio

ICU delirium

propofol

dexmedetomidine

continuous infusion sedatives