Fact vs. Fallacy: Sedation in the ICU

“If I’m ever intubated, I’d better be SEDATED!” 

This is the common phrase said by providers throughout the ICU for decades. 

I believe this is rooted in what we see when we finally turn sedation off after patients have been sedated into drug-induced comas for days to weeks. 

Agitation, thrashing, self-extubation, discomfort, terror, anger, panic, agony, etc. are common responses that clinicians witness at the bedside with patients that are emerging from sedation. 

….but why? 

The myth passed down throughout generations of clinicians is that:

1. This behavior is due to the discomfort of the endotracheal tube. 

2. We spare patients awareness, pain, and trauma of the tube when they are sedated.

3. The less intubated patients move, the less PTSD they will have. 

4. Patients are peacefully sleeping while sedated. 

5. It is inhumane to have patients awake and aware of their surroundings. 

If we are to bring practices into alignment with current evidence, it is imperative that we confront uncomfortable truth. 

Until ICU clinicians hear from survivors what they actually endure while chemically restrained under sedation, the ABCDEF Bundle will never become standard practice. 

I have interviewed dozens of survivors for the podcast, “Walking Home From the ICU”. They have illuminated the disturbing impact of sedation and immobility. Here are a few of their powerful accounts:

"I was trapped in my body, lost in a nightmare. My reality was filled with horror—patients were screaming, and no one could hear me." - Drew Brophy

Many patients find that the line between reality and delirium blurs. Susanne shared her experience of feeling transformed: “I was convinced I was being sold for research, and that my hair was falling out because they were preparing me for this transformation.” She describes the panic of believing she was “going to be thrown into the ocean as a fish” and lamented, "If I pull out the tube, maybe I can escape this nightmare."

Chuck eloquently recounted waking up and realizing he was being cannibalized by his deceased father: “In my delirium, I was convinced my father was trying to kill me, feeding on me while I lay there helpless.” He shared the agonizing helplessness of feeling trapped: “I was aware of everything happening to me, paralyzed, unable to speak. I could hear the conversations around me, and it drove me to despair.”

Survivors often recount hearing their loved ones and the chaos around them, only to have that experience twisted by confusion. 

One survivor shared, “I could hear my parents talking, but it felt like they were choosing not to save me. I was terrified that they had abandoned me.” 

Another added, “I remember the nurses talking about my family in front of me, decisions being made. I thought, ‘Why are they discussing me like I’m not here? Don’t they care?’”

Drew expressed similar feelings: “The pressure on my chest was unbearable. I was aware, but terrified. I thought my family had forgotten about me in a dark room where I lay, and nobody came to help.” 

This isolation compounded their fear, leaving them feeling as if they were not only fighting a life-threatening illness but also the perceived abandonment by their loved ones.

The consequences of these experiences extend far beyond the ICU. Survivors often grapple with cognitive impairments and post-ICU PTSD:

“I can’t shake the fear that I might die every time I go into a medical facility.” - Survivor “Every time I have an IV inserted, I’m overwhelmed with dread because I know what comes next.” - Survivor

“It's been two years, but I still have vivid memories of people screaming in agony—those memories won’t fade.” - Survivor

The emotional toll is further exemplified by Susanne, who explained: “I hear my own breath, but my reality keeps fading away. I feel trapped in a dream, unsure of what’s real.”

Patients often emerge from their critical illnesses deeply impacted—physically, mentally, and emotionally. The stories shared highlight an urgent need for transformation within our critical care practices. We must recognize that sedation may not protect our patients from trauma but can, in fact, inflict severe psychological scars.

It is evident that decades of talking about awakening and breathing trials and focusing on tasks and documentation is not enough to protect patients from sedation. Until ICU clinicians understand patients' reality during sedation and the life-long damage it can cause we will forever lose the battle again antiquated sedation culture.

To change this narrative, it is crucial that as healthcare professionals, we prioritize:

1. Informed Consent: Patients and families must be adequately informed about the risks and potential long-term consequences of sedation, including the possibility of experiencing delirium, cognitive impairments, or post-ICU PTSD.
2. Awake and Walking ICU Protocols: We must focus the ABCDEF Bundle to be for the PREVENTION and treatment of delirium and ICU-acquired weakness. Not just for charting compliance. We must all be striving to keep patients as awake, communicative, autonomous, and mobile as possible.
3. Psychological Support: Implement post-ICU therapy options to help patients process their experiences and integrate their trauma, ultimately promoting recovery.
4. Family Inclusion: Families should be engaged in the care process— their support can help patients feel less isolated and more grounded.

As we move forward in critical care, we must remember that the real horror of sedation and immobility lies in the lived experiences of our patients. Let us be champions of change, ensuring we advocate for practices that prioritize both physical and mental health in the ICU.

"This isn’t just about survival; it’s about the quality of life after ICU.” - Survivor