Both Spontaneous Awakening Trials and Spontaneous Breathing Trials

Reducing the duration of ventilation time is an important goal because prolonged mechanical ventilation can lead to undesirable outcomes.

Within the ABCDEF bundle, the B component, Both Spontaneous Awakening Trials (SAT) and Spontaneous Breathing Trials (SBT), focuses on setting a time(s) each day to stop sedative medications, orient the patient to time and day, and conduct an SBT in an effort to liberate the patient from the ventilator.

ICU sedation can help reduce anxiety and agitation for patients, facilitate mechanical ventilation, and decrease traumatic memories. But deep sedation has been found to reduce six-month survival and increase hospital mortality, ICU lengths of stay, ventilator duration and physiologic stress.

Studies have shown that using SAT and SBT synergistically helps decrease mechanical ventilation days, hospital lengths of stay and delirium.


Implementation Tools
Implementing the B component of the ABCDEF Bundle
Wake Up and Breath Protocol

Both SATs and SBTs are incorporated into the Wake Up and Breathe Protocol, a two-step process that focuses on creating a synergy between SAT and SBT protocols. These protocols typically incorporate safety screens and failure criteria.

The SAT safety screen includes the absences of seizures, alcohol withdrawal, paralysis and increased intracranial pressure. SAT failure criteria focus attention on the signs of pain, agitation and delirium (PAD), along with signs common to respiratory distress in aroused patients.

The SBT safety screen includes evaluation of the need for ventilator support; this helps facilitate ventilation weaning and decreases reintubation rates.

To enable successful implementation of SATs and SBTs, it is important to create an interprofessonal team. The ABCDEF bundle is most effective when implemented by a team that includes a physician, a nurse, a respiratory therapist, and a physical therapist at all levels of care.

The PAD guidelines recommend that:

  • Depth and quality of sedation should be routinely assessed in all ICU patients.
  • The Richmond Agitation-Sedation Scale (RASS) and the Sedation-Agitation Scale (SAS) are the most valid and reliable scales for assessing quality and depth of sedation in ICU patients.
  • Objective measures of brain function should be used adjunctively to monitor sedation in patients receiving neuromuscular blocking agents.
  • EEG monitoring should be used to either monitor nonconvulsive seizure activity in ICU patients at risk for seizures or titrate electrosuppressive medication to achieve burst suppression in ICU patients with elevated intracranial pressure.
 

 Additional Reading

 

Ely EW, Baker AM, Dunagan DP, et al. Effect on the duration of mechanical ventilation of identifying patients capable of breathing spontaneously. N Engl J Med. 1996 Dec;335(25):1864-1869.

Riker RR, Picard JT, Fraser GL. Prospective evaluation of the Sedation-Agitation Scale for adult critically ill patients. Crit Care Med. 1999 Jul;27(8):1325-1329.

Kress JP, Pohlman AS, O’Connor MF, et al. Daily interruption of sedative infusions in critically ill patients undergoing mechanical ventilation. N Engl J Med. 2000 May;342(18):1471-1477.

Sessler CN, Gosnell MS, Grap MJ, et al. The Richmond Agitation-Sedation Scale: validity and reliability in adult intensive care unit patients. Am J Respir Crit Care Med. 2002 Nov;166(10):1338-1344.

Ely EW, Truman B, Shintani A, et al. Monitoring sedation status over time in ICU patients: reliability and validity of the Richmond Agitation-Sedation Scale (RASS). JAMA. 2003 Jun;289(22):2983-2991.

Girard TD, Kress JP, Fuchs BD, et al. Efficacy and safety of a paired sedation and ventilator weaning protocol for mechanically ventilated patients in intensive care (Awakening and Breathing Controlled trial): a randomised controlled trial. Lancet. 2008 Jan;371(9607):126-134.

Strøm T, Martinussen T, Toft P. A protocol of no sedation for critically ill patients receiving mechanical ventilation: a randomized trial. Lancet. 2010 Feb;375(9713):475-480.

Shehabi Y, Bellomo R, Reade MC, et al. Early intensive care sedation predicts long-term mortality in ventilated critically ill patients. Am J Respir Crit Care Med. 2012 Oct;186(8):724-731.

Balas MC, Vasilevskis EE, Olsen KM, et al. Effectiveness and safety of the awakening and breathing coordination, delirium monitoring/management, and early exercise/mobility bundle. Crit Care Med. 2014 May;42(5):1024-1036.

Bassett R, Adams KM, Danesh V, et al. Rethinking critical care: decreasing sedation, increasing delirium monitoring, and increasing patient mobility. Jt Comm J Qual Patient Saf. 2015 Feb;41(2):62-74.

Klompas M, Anderson D, Trick W, et al. The preventability of ventilator-associated events: The CDC Prevention Epicenters’ Wake Up and Breathe Collaborative. Am J Respir Crit Care Med. 2015 Feb;191(3):292-301.

Treggiari MM, Romand JA, Yanez ND, et al. Randomized trial of light versus deep sedation on mental health after critical illness. Crit Care Med. 2009 Sep;37(9):2527-2534.

Pandharipande PP, Shintani A, Peterson J, et al. Lorazepam is an independent risk factor for transitioning to delirium in intensive care unit patients. Anesthesiology. 2006 Jan;104(1):21-26.

Seymour CW, Pandharipande PP, Koestner T, et al. Diurnal sedative changes during intensive care: impact on liberation from mechanical ventilation and delirium. Crit Care Med. 2012 Oct;40(10):2788-2796.

Hager DN, Dinglas VD, Subhas S, et al. Reducing deep sedation and delirium in acute lung injury patients: a quality improvement project. Crit Care Med. 2013 Jun;41(6):1435-1442.

Shehabi Y, Bellomo R, Reade MC, et al. Early goal-directed sedation versus standard sedation in mechanically ventilated critically ill patients: a pilot study. Crit Care Med. 2013 Aug;41(8):1983-1991.

Shehabi Y, Chan L, Kadiman S, et al. Sedation depth and long-term mortality in mechanically ventilated critically ill adults: a prospective longitudinal multicenter cohort study. Intensive Care Med. 2013 May;39(5):910-918.

Tanaka LM, Azevedo LC, Park M, et al. Early sedation and clinical outcomes of mechanically ventilated patients: a prospective multicenter cohort study. Crit Care. 2014 Jul;18(4):R156.

Burry LD, Williamson DR, Rose L, et al. Analgesic, sedative antipsychotic, and neuromuscular blocker use in Canadian intensive care units: a prospective, multicenter, observational study. Can J Anaesth. 2014 Jul;61(7):619-630.

Minhas MA, Velasquez AG, Kaul A, Salinas PD, Celi LA. Effect of Protocolized Sedation on Clinical Outcomes in Mechanically Ventilated Intensive Care Unit Patients: A Systematic Review and Meta-analysis of Randomized Controlled Trials. Mayo Clin Proc. 2015 May;90(5):613-623.

Balzer F, Weiβ B, Kumpf O, et al. Early deep sedation is associated with decreased in-hospital and two-year follow-up survival. Crit Care. 2015 Apr;19:197.