Sedatives, analgesics, and antipsychotics in tracheostomised intensive care unit patients – Is less more?

Background: Sedation and anaesthesia are used universally to facilitate mechanical ventilation – with larger cumulative doses being used in those with prolonged ventilation. Transitioning from an endotracheal to a tracheostomy tube enables the depth of sedation to be reduced. Early use of speaking valves with tracheostomised patients has become routine in some intensive care units (ICUs). The return of verbal communication has been observed to improve ease of patient care and increase patient and family engagement, with a perceived reduction in patient agitation. Objectives: The objective of this study was to investigate the potential impact of speaking valve (SV) use on requirements of sedatives, analgesics, and antipsychotics in ICU patients with a tracheostomy tube. Methods: A retrospective data audit was undertaken for all tracheostomised patients in a cardiorespiratory ICU from 2011 to 2014. Use of sedative, analgesic, and antipsychotic drugs was captured for endotracheal tube, tracheostomy tube, and SV periods, including patient demographics, disease specifics, and severity. Results: A total of 145 patients received an SV, and 115 did not. There were significantly less (p < 0.001) analgesic drugs used after introduction of SVs into the ICU (2011 vs 2012–2014). In the final adjusted multivariable model, analgesic dose was associated with age, positive extracorporeal membrane oxygenation (ECMO) status, and attendance to operating theatre during ICU admission. The only variable associated with sedative dose was age. Receiving any antipsychotics was associated with gender (less likely in females: odds ratio, 0.4; 95% confidence interval, 0.3–0.7), length of stay [more likely with stay over 25 days (odds ratio, 3.1; 95% confidence interval, 1.4–0.8) compared with 5–11 days], and survival. Conclusions: There was significantly fewer analgesics used after the introduction of SVs. However, SV use in patients with tracheostomy tube was not found to be associated with reduced dose of sedatives or antipsychotics, despite the clinical impression. Future prospective studies are needed to more adequately investigate the association between drugs and patients' ability to verbally participate in their care.