A national survey on routines regarding sedation in Swedish intensive care units


ARTICLE

A national survey on routines regarding sedation in Swedish
intensive care units

Oskar Talsia, Ritva Kiiski Berggrena,b, G€oran Johanssona and Ola Wins€oa

aDepartment of Surgical and Perioperative Sciences, Anaesthesiology and Intensive Care Medicine, Umeå University, Umeå, Sweden;
bSwedish National Quality Registry for Intensive Care (SIR), Karlstad, Sweden

ABSTRACT
Background: Previous studies concerning sedation in Swedish intensive care units (ICU) have shown
variability in drug choices and strategies. Currently, there are no national guidelines on this topic. As
an update to a Nordic survey from 2004, and as a follow-up to a recently introduced quality indicator
from the Swedish Intensive Care Registry, we performed a national survey.
Methods: A digital survey was sent to the ICUs in Sweden, asking for sedation routines regarding hyp-
nosedatives, analgosedatives, protocols, sedation scales, etc.
Results: Fifty out of 80 ICUs responded to the survey. All units used sedation scales, and 88% used
the RASS scale; 80% used written guidelines for sedation. Propofol and dexmedetomidine were the
preferred short-term hypnosedatives. Propofol, dexmedetomidine, and midazolam were preferred for
long-term hypnosedation. Remifentanil, morphine, and fentanyl were the most frequently used agents
for analgosedation.
Conclusions: All ICUs used a sedation scale, an increase compared with previous studies. Concerning
the choice of hypno- and analgosedatives, the use of dexmedetomidine, clonidine, and remifentanil
has increased, and the use of benzodiazepines has decreased since the Nordic survey in 2004.

ARTICLE HISTORY
Received 19 February 2019
Revised 15 April 2019
Accepted 3 May 2019

KEYWORDS
Analgesics; intensive care;
mechanical ventilation;
sedation scale; sedatives

Introduction

Sedation is crucial for treatment in the intensive care unit
(ICU). The concept is wide and includes everything from light
sedation with patients being awake and able to communi-
cate, to heavy sedation where patients cannot manage their
own respiration. The purpose of sedation from the patient
perspective is relief of pain and anxiety, which means that
nursing care, communication, and drugs interact to achieve
these goals. Nowadays, the general opinion on sedation
among ICU staffs and recent studies is pointing towards less
sedation. Today more focus is directed on analgesia, since
heavy sedation has been reported to prolong the length of
stay (LOS) at the ICU and to increase the rate of complica-
tions (1–5). Lower levels of sedation also permit easier evalu-
ation of disease progress, easier follow-up of analgesic
therapy, and they simplify clinical examinations.

Previous studies have shown that the level of sedation in
the ICU has a tendency to be too deep and that the anal-
gesic therapy is insufficient (6). Nowadays it is well known
that monitoring of sedation levels and utilization of validated
sedation scales, with or without a sedation protocol, give a
more accurate sedation level. More accurate and lighter sed-
ation gives shorter LOS, shorter time on mechanical ventila-
tion, and fewer complications in the ICU (7,8). Too heavy

sedation can also contribute to an increase of post-traumatic
stress disorder (PTSD) symptoms in ICU survivors, though
many aspects are involved (9). Earlier Swedish and Nordic
observational studies from 2003 and 2004 have shown vary-
ing results in usage of sedation scales and goals, ranging
from 16% to about 50% (10,11). Similar studies in Europe
and North America show data comparable to the use of sed-
ation scales in the Nordic countries (12–14).

Subjective scales evaluating the level of sedation are con-
sidered more accurate than objective measures of brain
activity, e.g. bispectral index (BIS) (1). There are multiple sed-
ation scales in clinical use, though a ‘gold standard’ has not
been identified. The recommendations today promote the
use of a validated scale, e.g. the Richmond Agitation
Sedation Scale, which is one of the most frequently used
sedation scales in Europe (1,15–18).

ICU care is expensive, and the number of beds is often
very limited. It is therefore relevant, both for patients and
hospitals, that knowledge on strategies which can reduce
LOS and complications is used. Utilization of sedation scales
and definition of sedation goals are some of the Swedish
Intensive Care Registry’s eight quality indicators, but there
are currently no national guidelines on which sedation scale
to use. Moreover, there are no recent Swedish studies on the
compliance to this new quality indicator.

CONTACT Ola Wins€o ola.winso@umu.se Department of Surgical and Perioperative Sciences, Anesthesiology and Intensive Care Medicine, Umeå
University, Umeå, Sweden
� 2019 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use,
distribution, and reproduction in any medium, provided the original work is properly cited.

UPSALA JOURNAL OF MEDICAL SCIENCES
2019, VOL. 124, NO. 3, 199–202
https://doi.org/10.1080/03009734.2019.1616339

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Since there are no written national guidelines on this sub-
ject in Sweden, the type of treatment varies between hospi-
tals. Previous studies have shown that propofol and
midazolam were the most frequently used hypnosedatives in
Sweden (10). Recently, the use of dexmedetomidine was pro-
moted due to the shorter time on mechanical ventilation
and shorter LOS at the ICU (19).

The aim of this study was to investigate the current sed-
ation practice in Sweden based on a national survey. Focus
in the survey was on the use of sedation scales, drug admin-
istration methods, and choice of pharmacological agents for
sedation and analgesia.

Material and methods

A national survey was created in cooperation with the
Swedish National Quality Registry for Intensive Care (SIR).
The survey was sent out on 12 April 2017 to 80 ICUs in
Sweden, through SIR’s member register. The survey was an
electronic questionnaire consisting of multiple-choice ques-
tions, with a possibility to add written answers at the end. In
the survey, we asked for routines regarding the use of sed-
ation scales, sedation goals, and preferred analgosedatives
and hypnosedatives (see Appendix). The respondent was
asked to rank the three most frequently used hypnosedatives
and analgosedatives. Additional data were assembled
through email.

Ethics

It was voluntary to participate in the study, and a written
reply was considered as informed consent. The principal
study concept was approved by the local ethical committee
on 10 April 2018 (EPN 2018/13-31).

Statistical analysis

IBM SPSS Statistics (version 24.0) was used. The
Mann–Whitney test and the Kruskall–Wallis test were used
for statistical calculations; 95% confidence interval was used,
and significance level was set at P < 0.05.

Results

The total number of responders was 50 out of 80 (63%) sur-
veys sent out. The responding units were categorized accord-
ing to the Swedish Intensive Care Society (SIS) classification
from 1 to 3, where 3 is the most advanced level of ICU. Eight
of the responders were from category 1; 29 from category 2;
and 13 from category 3. Median number of ventilators pos-
sible to use simultaneously per ICU was 8 (min. 2, max. 18).

All the responding units used a sedation scale. Forty-four
(88%) of the units used the RASS scale, making it the pre-
dominantly used sedation scale. The Motor Activity
Assessment Scale (MAAS) was used by four units; one paedi-
atric ICU used the Comfort B scale; and one unit used an
unspecified scale. Local written guidelines were used by 80%
of the responding ICUs, and 10% were working on such

guidelines. Daily ‘wake-up calls’ were used in 58% of
the units.

The two most frequently used hypnosedatives for short-
term sedation (<24 h) were propofol (78%) and dexmedeto-
midine (20%). The most popular combination was to use pro-
pofol as first choice and dexmedetomidine as second choice.
For long-term hypnosedation (>24 h) propofol (52%) was the
most frequently used agent. The most popular combination
was to use propofol as first choice and dexmedetomidine as
second choice. There is one more first choice than respond-
ers in the category long-term sedation, because one
respondent gave two drugs as first choice (Table 1). For anal-
gosedation remifentanil (36%), morphine (30%), and fentanyl
(26%) were the preferred agents. The most popular combin-
ation of analgosedatives was to use remifentanil or morphine
as first choice and ketobemidon or fentanyl as second choice
(Table 2). In one part of the survey we asked for the use of
alpha-2-agonists. All the responding units use dexmedetomi-
dine. The most common indications for dexmedetomidine
were non-invasive ventilation (88%), shallow sedation (88%),
and nightly sedation (80%). The most common indications
for clonidine were shallow sedation (RASS > -2) (64%), non-
invasive ventilation (46%), nightly sedation, and deep sed-
ation (RASS < -2) (32%) (Table 3).

Continuous infusion was the preferred administration
method for all the responding units (50/50) in the category
hypnosedation. Thirty-one out of 50 used intermittent

Table 1. Hypnosedation, short- and long-term use.

Choice First Second Third

Short term use, <24 hours
Propofol 39 10 0
Dexmedetomidine 10 31 6
Clonidine 1 5 10
Diazepam 0 1 0
Esketamine 0 0 6
Lorazepam 0 0 0
Midazolam 0 1 18
Other 0 2 4

Long term use, >24 hours
Propofol 26 15 6
Dexmedetomidine 16 16 5
Midazolam 7 8 12
Clonidine 2 7 14
Diazepam 0 0 0
Esketamine 0 1 2
Lorazepam 0 1 2
Thiopental 0 0 2
Other 0 0 2

Data presented as preferred choices from the participating national
Swedish ICUs.

Table 2. Analgosedation.

Choice First Second Third

Remifentanil 18 6 9
Morphine 15 6 11
Fentanyl 13 12 3
Ketobemidone 3 9 5
Alfentanil 0 4 6
Esketamine 0 1 5
Clonidine 0 6 5
Sufentanil 0 0 0
Other 1 4 1

Data presented as preferred choices from the participating national
Swedish ICUs.

200 O. TALSI ET AL.



intravenous injections as second choice. In the category anal-
gosedation, 45 out of 50 (90%) used continuous infusions as
first choice, and four out of 50 units (8%) used intermittent
injections as first choice. The most frequently used method
for follow-up on sedation level was that nurses and assistant
nurses examined the patient (40/50, 80%). In this group of
40 answers, 31 (78%) made a note in the patient chart and
reported at rounds; five units only made a note in the
patient chart; and four units (10%) only reported at rounds.

Discussion

Of the responding units 80% used written guidelines for sed-
ation, an increase from 44% in 2004 (10). All the responding
ICUs used a sedation scale, which also is an increase from 2004
when 54% of Swedish ICUs responded that they used a sed-
ation scale; 100% is a high number and might not fully repre-
sent the situation nationwide, since there were 30 units missing
in the survey. But comparable numbers have been observed in
a recent similar study from Great Britain (20). Eighty-eight per
cent of the ICUs used the RASS scale, making it the predomin-
antly used sedation scale. This is a change from the 2004 sur-
vey, where MAAS was the most frequently used scale (58%)
and no use of the RASS scale was registered. Most probably,
the increase in usage of sedation scales reflects the current
state of knowledge on sedation in ICU settings. Furthermore,
the increase in utilization of the RASS scale might be due to
ease of use and that it perhaps is more detailed in the span of
light sedation. The RASS scale is recommended in both
American and German guidelines and was the most frequently
used sedation scale in a recent British ICU survey (1,18,20).

In our survey, it was possible to identify two favourite
drugs in the category hypnosedation, propofol and dexmede-
tomidine. These drugs were preferred in both the category
short- and long-term sedation. However, in the category long-
term sedation, midazolam was preferred as first choice by
14% of the responders. The change of use in both short- and
long-term hypnosedation reflects recent studies, promoting a
lighter level of sedation and supporting a non-benzodiazepine
sedation strategy (18,19). This pattern has also been observed

in recent studies and guidelines, where deep sedation is rec-
ommended only in specific patient groups (1,18).

It was difficult to identify a clear favourite in the category
analgosedation, but remifentanil was preferred by most res-
ponders. This is a change from 2004 when no use of remifen-
tanil was registered (10), partially because it was a relatively
new drug at that time. Due to its pharmacokinetic properties,
remifentanil is mostly administered as an infusion. Because of
its short-acting nature, it needs to be withdrawn carefully. The
short-acting nature makes it practical for patients with renal
or hepatic failure, which is often the case in the ICU (21).
Remifentanil is also well tolerated by ICU patients, facilitates a
fast and predictable extubation, and may shorten ICU LOS
and time on mechanical ventilation (22).

Continuous infusions were preferred by all ICUs in the cat-
egory hypnosedation and by most responders in the cat-
egory analgosedation, even though continuous infusions
have certain drawbacks. Thus, continuous infusions of benzo-
diazepines have been associated with higher risk of delirium
(1,23). Continuous intravenous sedation has also been linked
to prolonged ICU LOS and increased duration of mechanical
ventilation and hospitalization (24). One explanation to the
high reported use of continuous infusions might be the
increased use of remifentanil and dexmedetomidine, drugs
only administered as intravenous infusions.

The responses in the survey reflect the current state in
Swedish ICUs. The response rate (63%) is comparable to simi-
lar studies elsewhere in Europe (10,13,17,25). However, this
survey does not say anything about quantities of the drugs
used and actual compliance to sedation scales and local
guidelines. Our survey was filled out by one physician for
each ICU, and there might be a discrepancy from the actual
clinical practice. A similar survey carried out in 2013 (25), sent
out to ICU nurses in Europe, recorded no answers with dex-
medetomidine as the preferred first choice sedative. This raises
questions on whether there has been a shift in drug choice
over a short period of time or if the answers in this or previ-
ous studies over- or underestimate the use of dexmedetomi-
dine. To get a more representative picture of the current
practice in Swedish ICUs, prospective multicentre studies or
point prevalence studies on site need to be performed.

To conclude, we observed a few changes from the study
published in 2004 (10). All the responding units use sedation
scales, and the preferred scale is RASS. Similar changes are
reported from other countries, e.g. the UK (17,20), and are sup-
ported by international guidelines (1,18). Dexmedetomidine and
clonidine are used regularly. Remifentanil was reported as the
first-choice analgesic agent, even though a clear favourite in
this category was not possible to identify.

Disclosure statement

The authors report no conflicts of interest.

Acknowledgements

The authors would like to acknowledge Gunnar Malmqvist for valu-
able input.

Table 3. Indications for the use of dexmedetomidine and clonidine.

n

Dexmedetomidine
Non-invasive ventilation 44
Sedation (RASS > -2) 44
Nightly sedation 40
Sedation (RASS < –1) 7
Short procedures 6
Other 5

Clonidine
Sedation (RASS > –2) 32
Non-invasive ventilation 23
Nightly sedation 18
Sedation (RASS < –1) 16
Abstinence 9
Weaning 6
Short procedures 5
Do not use 4
Hypertension 3
Other 2

Data presented as preferred choices from the participating national
Swedish ICUs.

UPSALA JOURNAL OF MEDICAL SCIENCES 201



Funding

This work was supported by the Department of Surgical and
Perioperative Sciences, Anaesthesiology, and Intensive Care Medicine,
Umeå University, Umeå, Sweden.

Notes on contributors

Oskar Talsi conducted this study as a mandatory thesis project during
his medical studies in Umeå. He has now finished his studies and is cur-
rently working as a physician. The work was performed in collaboration
with the Swedish intensive Care Registry, represented by Ritva
Kiiski Berggren.

Ritva Kiiski Berggren is a Senior Consultant, working as anaesthesiolo-
gist at Umeå University Hospital, Umeå.

G€oran Johansson is a research engineer. He has for several years helped
medical students and others with data analyses and staristical
calculations.

Ola Wins€o is currently Professor emeritus, since he has retired from the
work as Professor in Anaesthesiology and Intensive Care Medicine at
Umeå University.

References

1. Barr J, Fraser GL, Puntillo K, Ely EW, Gelinas C, Dasta JF, et al.
Clinical practice guidelines for the management of pain, agitation,
and delirium in adult patients in the intensive care unit. Crit Care
Med. 2013;41:263–306.

2. Bassett R, Adams KM, Danesh V, Groat PM, Haugen A, Kiewel A,
et al. Rethinking critical care: decreasing sedation, increasing delir-
ium monitoring, and increasing patient mobility. Jt Comm J Qual
Patient Saf. 2015;41:62–74.

3. Brook AD, Ahrens TS, Schaiff R, Prentice D, Sherman G, Shannon
W, et al. Effect of a nursing-implemented sedation protocol on
the duration of mechanical ventilation. Crit Care Med. 1999;27:
2609–15.

4. Sessler CN, Varney K. Patient-focused sedation and analgesia in
the ICU. Chest. 2008;133:552–65.

5. Strom T, Martinussen T, Toft P. A protocol of no sedation for critic-
ally ill patients receiving mechanical ventilation: a randomised
trial. Lancet. 2010;375:475–80.

6. Wiatrowski R, Norton C, Giffen D. Analgosedation: improving
patient outcomes in ICU sedation and pain management. Pain
Manag Nurs. 2016;17:204–17.

7. Botha JA, Mudholkar P. The effect of a sedation scale on ventila-
tion hours, sedative, analgesic and inotropic use in an intensive
care unit. Crit Care Resusc. 2004;6:253–7.

8. Brattebo G, Hofoss D, Flaatten H, Muri AK, Gjerde S, Plsek PE.
Effect of a scoring system and protocol for sedation on duration
of patients’ need for ventilator support in a surgical intensive care
unit. BMJ. 2002;324:1386–9.

9. Jones C, Griffiths RD, Humphris G, Skirrow PM. Memory, delusions,
and the development of acute posttraumatic stress disorder-
related symptoms after intensive care. Crit Care Med. 2001;29:
573–80.

10. Guldbrand P, Berggren L, Brattebo G, Malstam J, Ronholm E,
Winso O, et al. Survey of routines for sedation of patients on con-
trolled ventilation in Nordic intensive care units. Acta Anaesthesiol
Scand. 2004;48:944–50.

11. Samuelson KA, Larsson S, Lundberg D, Fridlund B. Intensive care
sedation of mechanically ventilated patients: a national Swedish
survey. Intensive Crit Care Nurs. 2003;19:350–62.

12. Payen JF, Chanques G, Mantz J, Hercule C, Auriant I, Leguillou JL,
et al. Current practices in sedation and analgesia for mechanically

ventilated critically ill patients: a prospective multicenter patient-
based study. Anesthesiology. 2007;106:687–95.

13. Soliman HM, Melot C, Vincent JL. Sedative and analgesic practice
in the intensive care unit: the results of a European survey. Br J
Anaesth. 2001;87:186–92.

14. Mehta S, Burry L, Fischer S, Martinez-Motta JC, Hallett D, Bowman
D, et al. Canadian survey of the use of sedatives, analgesics, and
neuromuscular blocking agents in critically ill patients. Crit Care
Med. 2006;34:374–80.

15. Jacobi J, Fraser GL, Coursin DB, Riker RR, Fontaine D, Wittbrodt ET,
et al. Clinical practice guidelines for the sustained use of sedatives
and analgesics in the critically ill adult. Crit Care Med. 2002;30:
119–41.

16. Schweickert WD, Kress JP. Strategies to optimize analgesia and
sedation. Crit Care. 2008;12(Suppl 3):S6.

17. Reschreiter H, Maiden M, Kapila A. Sedation practice in the inten-
sive care unit: a UK national survey. Crit Care. 2008;12:R152.

18. Martin J, Heymann A, Basell K, Baron R, Biniek R, Burkle H, et al.
Evidence and consensus-based German guidelines for the man-
agement of analgesia, sedation and delirium in intensive care –
short version. Ger Med Sci. 2010;8:Doc02.

19. Chen K, Lu Z, Xin YC, Cai Y, Chen Y, Pan SM. Alpha-2 agonists for
long-term sedation during mechanical ventilation in critically ill
patients. Cochrane Database Syst Rev. 2015;1:CD010269.

20. Richards-Belle A, Canter RR, Power GS, Robinson EJ, Reschreiter H,
Wunsch H, et al. National survey and point prevalence study of
sedation practice in UK critical care. Crit Care. 2016;20:355.

21. Westmoreland CL, Hoke JF, Sebel PS, Hug CC Jr, Muir KT.
Pharmacokinetics of remifentanil (GI87084B) and its major metab-
olite (GI90291) in patients undergoing elective inpatient surgery.
Anesthesiology. 1993;79:893–903.

22. Battershill AJ, Keating GM. Remifentanil: a review of its analgesic
and sedative use in the intensive care unit. Drugs. 2006;66:
365–85.

23. Zaal IJ, Devlin JW, Hazelbag M, Klein Klouwenberg PM, van der
Kooi AW, Ong DS, et al. Benzodiazepine-associated delirium in
critically ill adults. Intensive Care Med. 2015;41:2130–7.

24. Kollef MH, Levy NT, Ahrens TS, Schaiff R, Prentice D, Sherman G.
The use of continuous i.v. sedation is associated with prolongation
of mechanical ventilation. Chest. 1998;114:541–8.

25. Egerod I, Albarran JW, Ring M, Blackwood B. Sedation practice in
Nordic and non-Nordic ICUs: a European survey. Nurs Crit Care.
2013;18:166–75.

Appendix

The questionnaire sent to the ICUs was designed as a multiple-choice
form with the possibility to add written answers. Background data were
also asked for.

Questions:

1. Do you use written guidelines for sedation?
2. Which sedation scale do you use?
3. Do you use daily interruption of sedation, so-called ‘Wake

up-calls’?
4. How are drugs for hypnosedation administered?
5. How are drugs for analgosedation administered?
6. Which are the main drugs used for short-term hypnoseda-

tion (<24 h)?
7. Which are the main drugs used for long-term hypnoseda-

tion (>24 h)?
8. Which are the main drugs used for analgosedation?
9. To which patient groups/situations do you use dexmedetomidine?

10. To which patient groups/situations do you use clonidine?
11. Are you reporting data to SIR, according to SIR’s quality indicator

for sedation scales and sedation goals?

202 O. TALSI ET AL.


	Abstract
	Introduction
	Material and methods
	Ethics
	Statistical analysis

	Results
	Discussion
	Disclosure statement
	Acknowledgements
	Notes on contributors
	References