Daily sedation interruption: mortality RR 0.88 across 23 trials

Design

Cochrane systematic review and meta-analysis of 23 randomised trials

Population

5,987 mechanically ventilated, critically ill adults and children

Primary outcome

Duration of ventilation, mortality and ICU length of stay

Effect

Mortality RR 0.88 (95% CI 0.77 to 0.99); ventilation about 14% shorter; tracheostomy RR 0.68 (0.55 to 0.85)

An updated Cochrane review (7 October) included 23 randomised trials of daily sedation interruption in 5,987 mechanically ventilated adults and children, compared with protocolised sedation, usual care or analgesia-first approaches.

Sedation interruption probably reduced mortality (RR 0.88, 95% CI 0.77 to 0.99; moderate certainty, no heterogeneity) and ICU and hospital stay by about 11% each, and probably reduced tracheostomy (RR 0.68). It may shorten mechanical ventilation by about 14%, though with high heterogeneity. Accidental extubation did not clearly differ (RR 0.88, 0.66 to 1.19). Total opioid use, measured as morphine, was probably slightly higher. Effects on delirium were very uncertain.

Many ICUs have moved to light sedation targets without a formal daily hold, and some have dropped the hold altogether. This review supports keeping a daily interruption, or an equivalent daily assessment of whether sedation can stop, as a standard step. The mortality benefit is modest and its interval close to 1, so the strongest message is that interruption is safe and probably beneficial, not that it transforms survival.

• Build a daily sedation interruption or spontaneous awakening trial into the ventilated patient's routine.
• Pair the interruption with a spontaneous breathing trial when the patient is ready.
• Monitor closely during interruption; accidental extubation did not clearly increase but vigilance is still needed.
• Review analgesia during interruption, as opioid use may rise slightly.
• Exclude patients for whom interruption is unsafe, such as those with raised intracranial pressure or on neuromuscular blockade.

Why it matters

It gives moderate-certainty evidence to keep a step some units have quietly dropped in favour of light sedation alone.

Don't overread it

The mortality interval reaches 0.99, and the ventilation result is low certainty with high heterogeneity.

The statistics, in plain English

A relative risk of 0.88 means about 12% lower risk of death, but the interval (0.77 to 0.99) runs almost to no effect. I² of 0% for mortality means the trials agreed; I² of 88% for ventilation time means they disagreed a lot, which is why that result is rated low certainty.

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