Overview
Sedative use disorder involves problematic patterns of using sedative medications leading to clinically significant impairment or distress 2.Diagnosis
Assess through clinical evaluation focusing on patterns of sedative use and associated impairment 2.
Utilize tools like the Indicator of Sedation Need (IOSN) for screening, though recognize its limitations and lack of specialty specificity 2.
Evaluate using validated sedation scales such as the Richmond Agitation-Sedation Scale (RASS) for monitoring levels of sedation 1.Management
Deprescribing initiatives, such as the EMPOWER program, can effectively reduce inappropriate sedative use in older adults, achieving higher cessation rates compared to historical controls 3.
Consider non-invasive routes for sedative administration, such as intranasal midazolam, which may offer higher efficacy and patient comfort compared to nebulized methods 4.
Monitor sedation levels rigorously; the Ramsay scale shows limited inter-rater reliability and may not be sufficiently reliable for consistent assessment 5.Special Populations
Elderly: Deprescribing programs like EMPOWER can be particularly effective in reducing inappropriate sedative use among older adults, with minimal reported worsening of sleep quality 3.
Pediatrics: Intranasal sufentanil and midazolam (IN-SM) demonstrate efficacy and better patient tolerance compared to intramuscular meperidine, promethazine, and chlorpromazine (IM-MPC) for sedation 8.Key Recommendations
Implement structured deprescribing programs, such as EMPOWER, to reduce inappropriate sedative use in elderly patients, particularly during hospitalization (Evidence: Strong 3).
Utilize non-invasive routes like intranasal administration for sedatives to enhance efficacy and patient comfort, especially in pediatric sedation (Evidence: Moderate 48).
Exercise caution with the Ramsay scale for sedation assessment due to its limited reliability; consider alternative monitoring tools like BIS, PSI, or Entropy for more accurate sedation level tracking (Evidence: Weak 5).References
1 Han L, Drover DR, Chen MC, Saxena AR, Eagleman SL, Nekhendzy V et al.. Evaluation of patient state index, bispectral index, and entropy during drug induced sleep endoscopy with dexmedetomidine. Journal of clinical monitoring and computing 2023. link
2 Shokouhi B, Kerr B. A review of the indicator of sedation need (IOSN): what is it and how can it be improved?. British dental journal 2018. link
3 Wilson MG, Lee TC, Hass A, Tannenbaum C, McDonald EG. EMPOWERing Hospitalized Older Adults to Deprescribe Sedative Hypnotics: A Pilot Study. Journal of the American Geriatrics Society 2018. link
4 McCormick AS, Thomas VL, Berry D, Thomas PW. Plasma concentrations and sedation scores after nebulized and intranasal midazolam in healthy volunteers. British journal of anaesthesia 2008. link
5 Olson D, Lynn M, Thoyre SM, Graffagnino C. The limited reliability of the Ramsay scale. Neurocritical care 2007. link
6 Robins EV. Nursing education, competency, and role in intravenous conscious sedation. International anesthesiology clinics 1999. link
7 Larson JS, Lunn JJ. Comparing drugs for short-term sedation. Contemporary internal medicine 1994. link
8 Bates BA, Schutzman SA, Fleisher GR. A comparison of intranasal sufentanil and midazolam to intramuscular meperidine, promethazine, and chlorpromazine for conscious sedation in children. Annals of emergency medicine 1994. link70274-8)