Rationale: Intravenous sedation is an important tool for managing invasively ventilated patients, yet excess sedation is harmful, and dosing could be influenced by implicit bias. Objective: To measure the association between sex, race and ethnicity, and sedation practices. Methods: We performed a retrospective cohort study of adults receiving invasive ventilation for 24 hours or more using the MIMIC-IV (2008-2019) database from Boston, USA. We used a repeated-measures design (4-hour time intervals) to study the association between patient sex (female, male) or race and ethnicity (Asian, Black, Hispanic, White) and sedation outcomes. Sedation outcomes included sedative use (propofol, benzodiazepine, dexmedetomidine) and minimum sedation score. We divided sedative use into five categories: no sedative given, then lowest, second, third, and highest quartiles of sedative dose. We used multilevel Bayesian proportional odds modeling to adjust for baseline and time-varying covariates and reported posterior odds ratios with 95% credible intervals [CrI]. Results: We studied 6,764 patients: 43% female; 3.5% Asian, 12% Black, 4.5% Hispanic and 80% white. We analyzed 116,519 4-hour intervals. Benzodiazepines were administered to 2,334 (36%) patients. Black patients received benzodiazepines less often and at lower doses than White patients (OR 0.66, CrI 0.49 to 0.92). Propofol was administered to 3,865 (57%) patients. Female patients received propofol less often and at lower doses than male patients (OR 0.72, CrI 0.61 to 0.86). Dexmedetomidine was administered to 1,439 (21%) patients, and use was largely similar across sex or race and ethnicity. As expressed by sedation scores, male patients were more sedated than female patients (OR 1.41, CrI 1.23 to 1.62), and White patients were less sedated than Black patients (OR 0.78, CrI 0.65 to 0.95). Conclusion: Among patients invasively ventilated for at least 24 hours, intravenous sedation and attained sedation levels varied by sex and race and ethnicity. Adherence to sedation guidelines may improve equity in sedation management for critically ill patients.

The authors have declared no competing interest.

Sarah Walker was funded by the Temerty Centre for AI Research and Education in Medicine Summer Research Studentship. Dr Yarnell was funded by the Canadian Institutes for Health Research Vanier Scholar program, the Eliot Phillipson Clinician Scientist Training Program, and the Clinician Investigator Program of the University of Toronto. Funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; nor in the decision to submit the manuscript for publication. The opinions, results and conclusions reported in this paper are those of the authors and are independent from the funding sources. No endorsement by any of the funding agencies is intended or should be inferred.

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The details of the IRB/oversight body that provided approval or exemption for the research described are given below:

We used deidentified patient data from the Medical Information Mart for Intensive Care version IV (MIMIC-IV) database. It contains intensive care unit (ICU) admissions from an academic quaternary centre in Boston, USA, between 2008 and 2019. It is approved for database research by the Beth Israel Deaconess Medical Center (2001-P-001699/14) and the Massachusetts Institute of Technology (0403000206). MIMIC-IV is available from https://physionet.org/content/mimiciv/.

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