Letter to the Editor: Impact of the intensivist at the bedside - the case of rational use of benzodiazepines

Abstract

The detrimental effects associated with prolonged benzodiazepine infusion have long been recognized, and precipitated a transformation in the management of sedation and analgesia in critically ill patients. This transformation emphasizes the need to reduce the continuous use of benzodiazepines. Achieving an appropriate sedo-analgesia target tailored to the patient’s context requires clinical staff to possess knowledge and considerable experience in this management. The study published in World Journal of Critical Care Medicine by Nestoiter et al exemplified this scenario. The authors identified an association between the continuous use of midazolam and the absence of a critical care team managing patients at the bedside. The use of continuous midazolam, as an indicator of good clinical practice, was associated with unfavorable clinical outcomes, such as increased days in coma and delirium. These results reinforce the fact that effective management of sedation and analgesia is a critical area where the fundamental role of the intensivist in the care of critically ill patients is evident. These findings should not be interpreted in isolation but rather within a set of organizational aspects that characterize a high-performing intensive care unit, such as an adequate patient-to-nurse ratio, the presence of an intensivist-led team, and the development of clinical protocols in sedation and analgesia management.

Key Words: Intensive care unit; Sedation; Benzodiazepines; Midazolam; Critical care team

Core Tip: Continuous infusion of benzodiazepines, such as midazolam, is associated with worse outcomes in critically ill patients. This study indicates that management by a dedicated critical care team (CCT) significantly reduces the use of midazolam, thereby reducing the risk of delirium and coma. CCT is especially effective when combined with organizational strengths, such as low patient-to-nurse ratios. Ultimately, a “virtuous circle” of care, in which CCT is an important player, is essential for improving outcomes through precise patient-centered sedo-analgesia.

TO THE EDITOR

The adverse effects associated with the extended administration of benzodiazepines, both in the short and long term, have been acknowledged for a considerable duration[1]. This recognition has led to a significant shift in the approach to sedation and analgesia management in critically ill patients over the past two decades. This shift emphasizes prioritizing analgesia over sedation, utilizing lower cumulative doses of analgesics and sedatives, and notably reducing the continuous use of benzodiazepines - particularly midazolam, the most commonly used drug in this class. Achieving an appropriate sedo-analgesia target tailored to the patient’s context - ensuring comfort, analgesia, and adequate interaction with the environment and supportive therapies, while minimizing the risk of delirium and coma - presents a complex challenge. These practical skills are part of a high-performance care context in an intensive care unit (ICU). It requires that the critical care team (CCT) possesses extensive knowledge and considerable experience in managing these patients[2].

The study published in World Journal of Critical Care Medicine by Nestoiter et al[3] serves as a pertinent example of this scenario. In this retrospective cohort analysis, the authors identified a statistically and clinically significant association between the continuous administration of midazolam and the absence of a CCT managing these patients at the bedside. The continuous use of midazolam, as an indicator of care delivery, was correlated with adverse clinical outcomes, such as prolonged periods of coma and delirium, thereby underscoring the significance of the study’s findings. A major limitation of the study lies in the fact that patients who were not treated by a CCT had more comorbidities, as assessed by the Charlson comorbidity index, and greater organ failures, as evaluated by the Sequential Organ Failure Assessment score. More severely ill patients with more comorbidities may, at least theoretically, have a higher risk of receiving midazolam infusion. Although the study is subject to potential selection bias due to its observational design and these imbalances between the population managed by a CCT and those not managed by a CCT, the results of the multivariate analysis robustly indicate an association between midazolam use and the presence of a CCT in patient management. Similar findings have been recently reported, demonstrating that intensivists administer lower doses of sedatives in continuous infusion, reduced quantities of benzodiazepines, and to fewer patients, compared to emergency physicians in the management of patients on invasive mechanical ventilation[4].

These data highlight that effective management of sedation and analgesia is a critical domain where the essential role of the intensivist in the care of critically ill patients is evident. We subsequently find similar conclusions in other areas of practice in the ICU, such as hemodynamic management, protective mechanical ventilation, rational fluid use, effective communication with patients and relatives, and nutritional support. Nonetheless, when evaluating the proper practice of sedation and analgesia in ICU patients, the presence of an intensivist should not be seen as an isolated event. Organizational characteristics of the ICU also play a role in this context, such as a low patient-to-nurse ratio, which is associated with better outcomes in the management of analgesia for critically ill patients[5]. This type of organizational care is usually associated with the presence of an intensivist-led team, creating a “virtuous circle”, in which it may be difficult to distinguish the individual impact of each measure.

For instance, high-intensity staffing by an intensivist-led team is associated with reduced hospital and ICU mortality, along with significant decreases in ICU and hospital length of stay[6]. These findings are justified by a set of practices characteristic of the technical skills of a CCT. Thus, the findings of Nestoiter et al[3], when evaluating one of the most sensitive topics in the care of critically ill patients, also align with this perspective. However, these findings should not be interpreted in isolation, but rather within a set of organizational aspects that characterize a high-performing ICU.