Published online Dec 9, 2025. doi: 10.5492/wjccm.v14.i4.111260
Revised: July 23, 2025
Accepted: October 17, 2025
Published online: December 9, 2025
Processing time: 155 Days and 15.8 Hours
Analgesia and sedation are commonly prescribed therapies within the intensive care unit (ICU) for patients receiving mechanical ventilation. Current guidelines recommend utilizing an analgesia-first approach to initially reach appropriate pain control, while potentially achieving sedation goals concurrently. Our system employs a guideline-based ICU sedation order-set that features an electronic medical record (EMR) integrated ICU checklist that combines analgesia and sedation.
To identify systems-based factors that are associated with the use of continuous midazolam infusion administration in mechanically ventilated patients.
We extracted EMR data from patients who received mechanical ventilation between January 1, 2021, and December 31, 2023. Subjects included were 18 years or older who received mechanical ventilation. “R” version 4.3.2 was used for data processing and statistical analysis. We performed a multivariable regression analysis to predict the administration of a continuous midazolam infusion with modified Sequential Organ Failure Assessment score, Charlson comorbidity index, and critical care medicine (CCM) primary service.
Of 3805 patients that underwent mechanical ventilation, 62% were male, with a mean age of 66.9 years. 3429 patients were treated by a provider team with a CCM attending, and 376 patients were managed by a non-CCM primary team with CCM consultative services. A midazolam infusion was used in 187 of 3429 (5%) patients with CCM as primary and in 166 of 376 (56%) patients with non-CCM primary (χ2 598.23, P < 0.001). Of the patients who received continuous midazolam, 117 (21%) died vs 236 (7%) survived hospitalization. Continuous midazolam was associated with more days with coma and more days with delirium (P < 0.0001).
Continuous midazolam infusion was more likely in patients admitted to the ICU under an open unit with a non-CCM physician with an intensivist consult available, despite guided order-sets and checklists integrated into the EMR.
Core Tip: Advancements have been made to improve outcomes among critically ill patients admitted to the intensive care units. Our study outlines the importance of adhering to guideline-based therapy when it comes to sedation, which is more commonly done in an intensivist staffing model. The choice of sedation has a strong impact on the overall care of the patient during their intensive care unit stay as well as the recovery period after they are discharged from the hospital.