Should we Abandon Benzodiazepines from the ICU? / by Alawi Luetz

Sedation significantly worsens outcome in patients who are critically ill. In an observational study among 251 mechanically ventilated ICU patients, Shehabi and colleagues could show that early moderate to deep sedation was an independent predictor of 180-day mortality. Despite this fact, patients sometimes require deep sedation for a limited period of time to control, for example, intracranial hypertension. In particular in these cases, weaning from sedation is often challenging due to emerging agitation caused by severe anxiety and additional symptoms that may be associated with delirium.

Numerous studies revealed that especially the use of lorazepam increases the risk for prolonged sedation. The 2013 PAD guideline suggests that sedation strategies using nonbenzodiazepine sedatives may be preferred over sedation with benzodiazepines to improve clinical outcome. 

Our recently published research letter reports a case of severe and persisting agitation that was unresponsive to all available treatments. Ultimately, lormetazepam, which has recently become available for intravenous use in Germany resolved the problem by stress-reduction and anxiolysis without leading to measurable sedation.

Non-pharmacological interventions for the management of symptoms like anxiety or hallucination are preferable. Furthermore, conditions like insufficient analgesia or a beginning sepsis should be excluded. However, if symptoms persist, a pharmacological treatment is necessary. Benzodiazepines may continue to play an important role in treating persistent anxiety and agitation in critically ill patients. 

Maybe it is time to change the way how we use those drugs - not as sedatives but helping patients to stay awake without feeling anxious or stressed.

Download case report