The standard of care of patients with ARDS: ventilatory settings and rescue therapies for refractory hypoxemia

Bein, Thomas; Grasso, Salvatore; Moerer, Onnen; Quintel, Michael; Guerin, Claude; Deja, Maria; Brondani, Anita; Mehta, Sangeeta

Sedation management during the early phase of ARDS is managed according to the need for neuromuscular blocking agents and to promote lung-protective ventilation. There are no randomized trials suggesting clinical advantages of any particular sedative. However, propensity score analysis of a large multicenter ICU database suggested that benzodiazepine infusions were independently associated with higher mortality and longer durations of ICU stay and ventilator support compared with propofol [76] . If the ARDS patient does not meet criteria for continuous muscle paralysis or as soon as neuromuscular blocking agents are no longer required, clinicians should target light sedation, with frequent assessment of pain and sedation, using validated scales. Sedation should be managed according to the approach proposed in the 2013 guidelines for management of pain, agitation, and delirium [77] . A randomized trial by Mehta and colleagues found that daily sedation interruption (DSI) provided no additional benefit when a nurse-directed sedation protocol is used [78] ; a systematic review of nine trials and 1282 patients also concluded there is no strong evidence that DSI alters the duration of mechanical ventilation, mortality, or length of ICU or hospital stay [79] . Although the evidence for light or no sedation in mechanically ventilated critically ill patients is likely to be enhanced in the future, there are no data regarding sedation management in patients with severe hypoxemia, but in these critical situations a deep sedation within 48 h after onset might be advantageous.