Daily stopping of sedation may reduce ventilator time and mortality in critically ill patientsDaily stopping of sedation may help patients breathe on their own

Rationale Daily sedation interruption (DSI) aims to limit drug accumulation and promote a more awake state, thereby reducing the duration of mechanical ventilation and its associated complications. This is an update of a Cochrane review first published in 2014. Objectives To assess the effects of DSI versus sedation management without DSI on the duration of invasive mechanical ventilation, mortality, intensive care unit (ICU) length of stay, adverse events related to under‐ or oversedation (including accidental removal of endotracheal tube and tracheostomy), total doses of sedative and analgesic drug administered, and health‐related quality of life, for critically ill people requiring intravenous sedation. Search methods We used CENTRAL, MEDLINE All, Embase Classic+Embase, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Web of Science Core Collection, and two trial registers, together with reference checking, citation searching, and contact with study authors to identify the studies included in the review. The latest search date was 8 October 2025. Eligibility criteria We included randomised controlled trials (RCTs) comparing DSI with sedation strategies that did not include DSI (protocolised sedation, non‐protocolised usual care (clinician discretion), or analgesia first/no sedation) in mechanically ventilated, critically ill people (adults and infants or children under 18 years of age). Outcomes Our critical outcomes were duration of mechanical ventilation (from randomisation to successful extubation or death), mortality, and ICU length of stay (LOS). Our important outcomes included hospital LOS, adverse events related to under‐ or oversedation (e.g. accidental removal of endotracheal tube or other lines or catheters, tracheostomy, new onset of delirium occurrence, use of physical restraint, and cardiac events), total drug doses, and health‐related quality of life (HRQoL). Risk of bias We used the original Cochrane tool, RoB 1, to assess bias in the RCTs. Synthesis methods We synthesised results for each outcome using meta‐analysis (random‐effects modelling). We conducted subgroup and sensitivity analyses according to pre‐defined criteria. We used GRADE to assess the certainty of evidence. Included studies This update included 23 trials (one cluster‐randomised trial; 18 RCTs in adults, five in children) with 5987 (4910 adjusted) participants (3238 adults, 2750 (1673 adjusted) children). Nine trials used a sedation protocol comparator, nine used ‘usual sedation practices’ with sedative and analgesic drugs at the clinical team’s discretion, and five used analgesia‐first or no‐sedation comparators. Synthesis of results Daily sedation interruption may reduce the duration of mechanical ventilation compared with sedation strategies that do not include DSI (mean difference (MD) −0.15 log days, 95% confidence interval (CI) −0.29 to −0.01; I2 = 88%; 18 studies, 3815 participants; low‐certainty evidence). These data translate to a relative reduction of 14% (95% CI 1% to 25%). Daily sedation interruption probably reduces mortality compared with sedation strategies that do not include DSI (relative risk (RR) 0.88, 95% CI 0.77 to 0.99; I2 = 0%; 18 studies, 4057 participants; 725 events; moderate‐certainty evidence). Daily sedation interruption probably reduces ICU LOS (MD −0.12 log days, 95% CI −0.22 to −0.02; I2 = 72%; 18 studies, 4477 participants; moderate‐certainty evidence). These data translate to a relative reduction of 11% (95% CI 2% to 20%). Daily sedation interruption probably reduces hospital LOS (MD −0.12 log days, 95% CI −0.22 to −0.02; I2 = 39%; 13 studies, 3589 participants; moderate‐certainty evidence). These data translate to a relative reduction of 11% (95% CI 2% to 20%). For adverse events related to under‐ or oversedation, DSI may result in little to no difference in the rate of self/accidental removal of the endotracheal tube (RR 0.88, 95% CI 0.66 to 1.19; P = 0.41, I2 = 0%; 16 studies, 4342 participants; 171 events; low‐certainty evidence) or self/accidental removal of lines or catheters (RR 1.44, 95% CI 0.80 to 2.57; P = 0.22, I2 = 0%; 7 studies, 1536 participants; 42 events; low‐certainty evidence). DSI probably reduces rates of tracheostomy (RR 0.68, 95% CI 0.55 to 0.85; P < 0.001, I2 = 0%; 8 studies, 2503 participants; 263 events; moderate‐certainty evidence). It may result in little to no difference in the rate of delirium occurrence, but the evidence is very uncertain (RR 0.92, 95% CI 0.74 to 1.15; P = 0.48, I2 = 59%; 4 studies, 1009 participants; 520 events; very low‐certainty evidence). Compared with sedation management without DSI, DSI may result in little to no difference in the total dose of benzodiazepines, fentanyl, or propofol administered over the ICU admission. However, the evidence is very uncertain. Daily sedation interruption probably increases the total dose of morphine administered over the ICU admission (MD 0.07 log mg, 95% CI 0 to 0.13; P = 0.05, I2 = 0%; 4 studies, 404 participants; moderate‐certainty evidence). These data translate to a relative increase of 7% (95% CI 0% to 14%). DSI may result in little to no difference in HRQoL compared with sedation management without DSI, with evidence in the mental health domain being very uncertain. Evidence certainty is limited by inconsistency (statistical heterogeneity) and imprecision due to wide CIs, including CIs that encompass both benefit and harm for some outcomes. Authors' conclusions Based on low‐ and moderate‐certainty evidence from 23 trials including nearly 6000 critically ill people, we found that DSI may reduce the duration of mechanical ventilation and probably reduces mortality, intensive care LOS, and hospital LOS compared with other sedation methods. Daily sedation interruption may have little to no effect on the adverse outcomes of accidental removal of the endotracheal tube or other lines or catheters, but probably reduces the need for tracheostomy. The evidence on sedation dosing is very uncertain; however, DSI probably increases opioid dosing. Given the evidence on the effect on sedation dosing is very uncertain, future trials should include data on total sedative and analgesic doses as well as delirium and health‐related quality of life, as these remain under‐evaluated. Funding This review received no funding. Registration Registration (CD009176) and previous version of the review: Cochrane Database of Systematic Reviews via DOI: 10.1002/14651858.CD009176.pub2. Protocol available via DOI 10.1002/14651858.CD009176.pub1. Plain language summary Does daily stopping of sedation reduce the time people spend on ventilators (breathing machines) in intensive care? Key messages Stopping sedation each day may reduce the time people spend on a ventilator, probably reduces the number who die, and probably reduces the time people spend in intensive care and hospital, compared to sedation methods that do not include daily stopping. Stopping sedation each day may make little or no difference to the risk of the breathing tube or other tubes being accidentally pulled out, and probably reduces the need for a breathing tube (tracheostomy) inserted in the neck. It may have little to no effect on the amount of sedative medication, but probably increases the amount of pain medication (morphine) people receive while in intensive care. We need more studies in children. Future studies should measure the total amount of sedation and pain medications given and people's quality of life. What is daily sedation interruption? Critically ill infants, children, and adults in intensive care may need a machine for breathing (mechanical ventilation), which requires a tube to be inserted into their windpipe (intubation). People receiving ventilation may also require sedative medication to help them tolerate the breathing tube and make them more comfortable. Sedatives are usually given as a drip into a vein. Because people's bodies may respond differently to medicine when they are critically ill, medications for sedation and pain can build up in the body. This can make it difficult to wake people when they are getting better and might extend the time they are on a ventilator. Stopping the sedative medication each day is done to see if a person wakes up and no longer needs sedation. People who are uncomfortable and still need sedation have medication restarted at a lower dose. If they are comfortable when awake and able to breathe safely without the ventilator, the healthcare team can assess whether the breathing tube can be removed. What did we want to find out? We wanted to know if stopping sedation each day was better than other sedation strategies for reducing: the length of time people require ventilation; death; the length of intensive care and hospital stays; sedation‐related unwanted events, including: the breathing tube (or other lines or tubes) being accidentally pulled out; being unable to come off the ventilator and needing a breathing tube (tracheostomy) inserted in the neck; or developing delirium (a sudden change in how a person thinks, understands things, and pays attention); the amount of sedation and pain medication given. We also wanted to know which was better at improving people's quality of life. What did we do? We looked for studies in adults and children that compared daily stopping of sedation with other sedation management methods that did not include daily stopping. We compared and summarised their results and rated our confidence in the evidence based on factors such as study methods and number of people included. What did we find? We found 23 studies involving 5987 people (3238 adults; 2750 children). Seven studies were conducted in North America; six in Europe; three in China; two in Egypt; and one each in Australia, Brazil, India, Indonesia, and Japan. Daily stopping of sedation was compared to: step‐by‐step guidelines on sedation management; usual management, where healthcare teams decide how to manage sedation; or a strategy that prioritises pain management and only uses sedation if someone is very uncomfortable and a risk to themselves. Main results Compared with other sedation management methods, daily stopping of sedation: may reduce the time on the ventilator by around 14%, or 1 day in adults and 0.4 days in children (18 studies, 3815 participants); probably reduces the number of people who die by around 3.5% (18 studies, 4057 participants); probably reduces intensive care length of stay by around 11%, or 1.1 days in adults and 0.5 days in children (18 studies, 4477 participants); may make little or no difference to the number of times someone's breathing tube (16 studies, 4342 participants) or other tubes or lines (7 studies, 1536 participants) are accidentally pulled out; probably reduces the need for tracheostomy (8 studies, 2503 participants). The evidence is very uncertain about the effect of daily sedation interruption on the amount of sedation medication people are given while in intensive care. It probably slightly increases the amount of pain medication (morphine) given. There may be little to no difference between sedation management strategies in terms of improving people's quality of life. What are the limitations of the evidence? We are moderately confident in the evidence about death and length of stay in intensive care and hospital, but have low confidence in the evidence about the length of time people required ventilation, occurrence of some unwanted events, and medication amounts given. Our confidence was reduced mainly because: the results sometimes varied between studies; they compared different ways of managing sedation; some outcomes were reported by too few studies to be certain about the size of the effect. How up to date is this evidence? This review updates our previous review. The evidence is current to 8 October 2025. Visual summary Unlock the full review Close Save citation to: RefWorks SciWheel