Sedation and analgesia in ICU

AHMAD F. MADY MD
Lecturer of Anesthesia &ICU, Tanta university hospitals,Tanta,Egypt Senior registrar,ICU,KSMC

Objectives
Algorithm for Sedation Technique Application
Clinical practice guidelines for the sustained use of sedatives and analgesics in the critically ill adult

introduction
In critically ill patients there are three rationales for adequate analgesia and sedation (A&S). Firstly, A&S ensure an optimal level of comfort; the patient should have no more than moderate pain and should be calm and alert. Secondly, A&S are thought to reduce the stress response that is related to inflammation and trauma. Thirdly, A&S facilitate diagnostic and therapeutic procedures, as well as nursing care.

Analgesia is the act of blunting pain, through administration of drugs, but also through positioning of the patient, stabilising fractures and minimising harmful physical stimulation .
4582% of critically ill patients suffer from pain depending on their degree of activity . They are exposed to numerous noxious stimuli

Bernhard Walder, Martin R. Tramr SWISS MED

WKLY 2004;134:333346 www.smw. c h
Sedation in critical care is the act of calming, especially through administration of centrally acting drugs, but also through reassurance, information and music. 71% of critically ill patients have been shown to suffer from anxiety, confusion and agitation

INDICATIONS FOR A&S

1- Pain, MV. trauma, invasive operations, routine nursing care, ETT suctioning, and prolonged immobility. 2- Anxiety & agitation life-threatening illness, Inadequately controlled pain, sleep deprivation, isolation, and the presence of invasive tubes and catheters are frequently listed as sources of stress and anxiety 3- Delirium: 4- Facilitate Patient Care 5- Decrease Oxygen Consumption particularly important in patients suffering from acute lung injury or shock. 6- Reduction of seizures: Sedation appears to be an attractive option

in reducing seizures in the NICU

7-amnesia Some studies have shown that patients with a greater recall of adverse experiences may be likely to develop posttraumatic stress disorder (PTSD), leading some to suggest that deep sedation be routinely used to blunt patient awareness of the ICU experience More recently,investigators have demonstrated that patients who were most awake, or the most unresponsive, during mechanical ventilation had the lowest PTSD-like symptoms.

Weinert CR, Sprenkle M. Post-ICU consequences of patient wakefulness and sedative exposure during mechanical ventilation. Intensive Care Med 2008; 34(1):8290.

8- Weaning from Mechanical Ventilation It is now well known that patients being weaned from MV require appropriate sedation for a successful outcome. Non pharmacologic intervention at the time of weaning may relieve mild anxiety. Such interventions include changing the environment, using relaxation techniques, reassuring the patient, and providing adequate rest and psychological support. However, for patients who do not respond to these interventions, pharmacologic therapy should be instituted

Cohen IL, Gallagher TJ, Pohlman AS, Dast JF, Abraham E, Papadakos PJ:The management of the agitated ICU patient. Crit Care Med 2002; 30: 97125.

GOALS FOR S&A

To minimise physical discomfort or pain for procedures

To control behaviour, particularly movement To minimise psychological disturbance & distress To maximise the potential for amnesia

To guard patient safety

Clinical practice guidelines for the sustained use of sedatives and analgesics in the critically ill adult(1995,2002,2005)
American College of Critical Care Medicine (ACCM) the Society of Critical Care Medicine (SCCM) the American Society of Health-System Pharmacists (ASHP) the American College of Chest Physicians
Judith Jacobi, PharmD, FCCM, BCPS; Gilles L. Fraser, PharmD, FCCM; Douglas B. Coursin, MD; Richard R. Riker, MD; Dorrie Fontaine, RN, DNSc, FAAN; Eric T. Wittbrodt, PharmD; Donald B. Chalfin, MD, MS, FCCM; Michael F. Masica, MD, MPH; H. Scott Bjerke, MD; William M. Coplin, MD; David W. Crippen, MD, FCCM; Barry D. Fuchs, MD; Ruth M. Kelleher, RN; Paul E. Marik, MDBCh, FCCM; Stanley A. Nasraway, Jr, MD, FCCM; Michael J. Murray, MD, PhD, FCCM; William T. Peruzzi, MD, FCCM; Philip D. Lumb, MB, BS, FCCM

Grades of Recommendations
(A) Methods strong, results consistent, prospective, randomized, controlled trials, no heterogeneity Methods strong, results inconsistent, prospective, randomized, controlled trials, heterogeneity present Methods weak, observational studies

(B)

(C)

ANALGESIA
ICU patients commonly have pain and physical discomfort from obvious factors, such as preexisting diseases, Invasive procedures, or trauma. Monitoring and therapeutic devices (such as catheters, drains, noninvasive ventilating devices, and endotracheal tubes) Routine nursing care (such as airway suctioning, physical therapy, dressing changes, and patient mobilization) prolonged immobility

Unrelieved pain may contribute to inadequate sleep, possibly causing exhaustion and disorientation. Agitation. Stress response characterized by tachycardia, increased myocardial oxygen consumption, hypercoagulability, immunosuppression, and persistent catabolism, pulmonary dysfunction.

Recommendation: All critically ill patients have the right to adequate analgesia and management of their pain. (C)

Because patients can complete the NRS by writing or speaking, and because it is applicable to patients in many age groups, NRS may be preferable to VAS in critically ill patients.

Pain Assessment
The most reliable and valid indicator of pain is the patients selfreport. The location, characteristics, aggravating and alleviating factors, and intensity of pain should be evaluated. Assessment of pain intensity may be performed with unidimensional tools, such as verbal rating scale (VRS), visual analogue scale (VAS), and numeric rating scale (NRS)

Recommendations The level of pain reported by the patient must be considered the current standard for assessment of pain and response to analgesia whenever possible. Use of the NRS is recommended to assess pain.(B)

As critically ill patients are often unable to communicate their level of pain if sedated, anesthetized, or receiving neuromuscular blockade. Neither the VAS nor the NRS will resolve this problem as they rely on the patients ability to communicate with the care provider
Recommendations

Patients who cannot communicate should be assessed through subjective observation of pain-related behaviors (movement, facial expression, and posturing) and physiological indicators (heart rate, blood pressure, and respiratory rate) and the change in these parameters following analgesic therapy. (B)

Recommendations:

Pain assessment and response to therapy should be performed regularly by using a scale appropriate to the patient population and systematically documented. (C) The level of pain reported by the patient must be considered the current standard for assessment of pain and response to analgesia whenever possible. Use of the NRS is recommended to assess pain.(B) Patients who cannot communicate should be assessed through subjective observation of pain-related behaviors (movement, facial expression, and posturing) and physiological indicators (heart rate, blood pressure, and respiratory rate) and the change in these parameters following analgesic therapy. (B)

Analgesia Therapy
NONPHARMACOLOGIC TREATMENT Stabilization of fractures Encouragement of patients to communicat. Music Minimizing irritating stimuli, such as traction on the ETT. Proper positioning of patients.

Prompt treatment of anxiety and delirium

PHARMACOLOGIC TREATMENT

opioids, NSAIDs, PCM

In critically ill patients opioids are most often used for acute pain treatment Opioids mediate analgesia by interacting with a variety of central and peripheral opioid receptors and . The analgesic agents most commonly used in ICU patients (fentanyl, morphine, and hydromorphone)

Intravenous opiates can be delivered in three different modes: Bolus intravenous injections are often used for moderate pain, with doses titrated to analgesic requirements and the avoidance of respiratory depression and hemodynamic instability . Continuous intravenous infusions of opiates are used for moderateto-severe pain which is poorly controlled with repeated bolus injections. After an initial bolus dose, a low continuous infusion rate is set with subsequent adjustment for adequate analgesia . Patient-controlled analgesia (PCA) may be preferable in conscious patients, particularly in the postoperative setting .This technique allows self-dosing with opiates up to a predetermined limit set by the clinician.

Recommendations: A therapeutic plan and goal of analgesia should be established for each patient and communicated to all caregivers to ensure consistent analgesic therapy. (Grade of recommendation C) If intravenous doses of an opioid analgesic are required, fentanyl, hydromorphone, and morphine are the recommended agents. (Grade of recommendation C) Scheduled opioid doses or a continuous infusion is preferred over an as needed regimen to ensure consistent analgesia. A PCA device may be utilized to deliver opioids if the patient is able to understand and operate the device. (Grade of recommendation B) Fentanyl is preferred for a rapid onset of analgesia in acutely distressed patients. (Grade of recommendation C) Fentanyl or hydromorphone are preferred for patients with hemodynamic instability or renal insufficiency. (Grade of recommendation C) Morphine and hydromorphone are preferred for intermittent therapy because of their longer duration of effect. (Grade of recommendation C)

Recommendations: NSAIDs or acetaminophen may be used as adjuncts to opioids in selected patients. (Grade of recommendation B) Ketorolac therapy should be limited to a maximum of five days, with close monitoring for the development of renal insufficiency or gastrointestinal bleeding. Other NSAIDs may be used via the enteral route in appropriate patients. (Grade of recommendation B)

SEDATION
Sedation in critical care is the act of calming, especially through administration of centrally acting drugs, but also through reassurance, information and music. 71% of critically ill patients have been shown to suffer from anxiety, confusion and agitation

Bernhard Walder, Martin R. Tramr SWISS MED WKLY 2004;134:333346

GOALS
the optimal depth of sedation (or sedation score) must be individualized. Some patients can be well ventilated without sedation or analgesia, while others require deep sedation to avoid ventilator asynchrony or significant agitation. The optimal target sedation score is best established by frequent assessments while titrating the sedative dose downward. The guiding principle should be to provide just enough medication to minimize patient discomfort, agitation, and ventilator asynchrony.

GOALS
The appropriate target level of sedation will primarily depend on a patients acute disease process and any therapeutic and supportive interventions required. A common target level of sedation in the ICU is a calm patient that can be easily aroused with maintenance of the normal sleep-wake cycle, but some may require deep levels of sedation to facilitate MV. The desired level of sedation should be defined at the start of therapy and reevaluated on a regular basis as the clinical condition of the patient changes.

Goals
those ventilated by a spontaneous breathing mode needed significantly less midazolam and sufentanil compared with those on controlled mechanical ventilation. Patients with spontaneous breathing also had a significantly shorter mean duration of ventilation (15 vs 21 days) and of ICU stay (23 vs 30 days).

Putensen C, Zech S, Wrigge H, Zinserling J, Stuber F, Von Spiegel T, et al. Long-term effects of spontaneous breathing during ventilatory support in patients with acute lung injury. Am J Respir Crit Care Med 2001;164:439.

GOALS
Mechanical ventilation Pressure support ventilation, CPAP, SIMV good pt cooperation Ramsay 2, GCSC 13-15, SAS 4, RASS 0 Assisted controlled Ramsay 3, GCSC 8-12, SAS 3, RASS -1~-3 Pressure controlled Ramsay 4-5, GCSC 8-12, SAS 2, RASS -4 Agitation and delirium Ramsay 2-3, SAS 3-4, RASS 0~-2 IICP Ramsay 5, SAS 1, RASS -5

On-target sedation: Decreases weaning period Is not associated with muscular atrophy1 Decreases LOS and cost2 Provides cardiovascular1 and intraoperative hemodynamic stability3 Improves patient safety1,3

Facilitates neurological assessment

1McGaffigan PA. Crit Care Nursing. 2002;Feb Suppl:29-36. 2Dasta et al. Pharmacotherapy. 2006;26:798-805. 3Arbour R. Am J Crit Care Nursing. 2004;13:66-73.

Incidence of Inadequate Sedation

Dasta JF, et al. Crit Care Med. 2005;33:1266-1271.

Recommendation: Sedation of agitated critically ill patients should be started only after providing adequate analgesia and treating reversible physiological causes. (Grade of recommendation C)

Pain control in ICU

An ideal sedation scale

Good reliability and validity
determination of the degree of sedation and agitation, behavioral descriptors,

Applicability
require minimal training easy to score For diverse patient population

guide the titration of therapy to a defined sedation endpoint

Many scales are available, but a true

Subjective methods
The Ramsay Scale The Glasgow Coma Scale modified by Cook and Palma, GCSC The Sedation Agitation Scale, SAS The Richmond Agitation and Sedation Scale, RASS The Bloomsbury sedation scale the Adaptation to the Intensive Care Environment (ATICE) scale The Avripas sedation scale the Comfort scale for pediatric patients.

Objective Assessment of Sedation

Ramsay Scale
The most commonly scale used today

BIS
Recommending results
good relationship with subjective monitoring tools a decreased use of opioids and analgesics using BISguided sedation therapy

Conflicting results

poor correlation with subjective monitoring tools intra-individual variation in BIS values even in chemically paralyzed patients underestimation of sedation in non-chemically paralyzed patients.

the use of the BIS monitor in the ICU is still unclear.

Recommendations: A sedation goal or

endpoint should be established and regularly redefined for each patient. Regular assessment and response to therapy should be systematically documented. (Grade of recommendation C) The use of a validated sedation assessment scale (SAS, MAAS, or VICS) is recommended. (Grade of recommendation B) Objective measures of sedation, such as BIS, have not been completely evaluated and are not yet proven useful in the ICU. (Grade of recommendation C)

Sedation Therapy
Benzodiazepines Propofol. Central -Agonists

Pharmacology of selected sedatives

Rapid onset of action Easily titratable level of adequate sedation Short acting, allowing patient assessment, rapid recovery following discontinuation, easy weaning from MV, and early extubation. No or few adverse effects. No anaphylaxis or allergic reaction. No nausea, vomiting, or phlebitis. Minimal metabolism; not dependent on normal hepatic, renal, or pulmonary function Minimal respiratory depression. Minimal effect on cardiovascular function No pain on injection. No active or toxic metabolites. No suppression of cortisol production by the adrenal cortex. No or minimal interactions with other commonly prescribed ICU drugs Ease of administration. Lack of accumulation with prolonged administration Does not promote growth of pathogens. No tolerance and withdrawal of pathogens Cost effective. Easily prepared and long shelf-life. Safe for all ages with no age-related changes in pharmacokinetics. Provides facilitation of ventilator synchrony and the performance of various procedures and nursing interventions Lack of abuse potential

Cohen et al., 2002)

Recommendations: Midazolam or diazepam should be used for rapid sedation of acutely agitated patients. (Grade of recommendation C) Propofol is the preferred sedative when rapid awakening (e.g., for neurologic assessment or extubation) is important. (Grade of recommendation B) Midazolam is recommended for shortterm use only, as it produces unpredictable awakening and time to extubation when infusions continue longer than 4872 hours. (Grade of recommendation A) Lorazepam is recommended for the sedation of most patients via intermittent i.v. administration or continuous infusion. (Grade of recommendation B) The titration of the sedative dose to a defined endpoint is recommended with systematic tapering of the dose or daily interruption with retitration to minimize prolonged sedative effects. (Grade of recommendation A) Triglyceride concentrations should be monitored after two days of propofol infusion, and total caloric intake from lipids should be included in the nutrition support prescription. (Grade of recommendation B) The use of sedation guidelines, an algorithm, or a protocol is recommended. (Grade of recommendation B

Recommendation: The potential for opioid, benzodiazepine, and propofol withdrawal should be considered after high doses or more than approximately seven days of continuous therapy. Doses should be tapered systematically to prevent withdrawal symptoms. (Grade of recommendation B)

 Recommendations :

A therapeutic plan and goal of analgesia should be established for each patients and communicated to all caregivers to ensure consistent analgesic therapy.

( Grade of recommendation = C )

If intravenous doses of opioid analgesic are required, fentanyl, hydromorphone, and morphine are the recommended agents.

( Grade of recommendation = C )

Scheduled opioid doses or a continuous infusion is preferred. A PCA device may be utilized to deliver opioid if patient is able to understand and operated the device.

( Grade of recommendation = B )

 Fentanyl is preferred for a rapid onset of analgesic

in acutely distressed patients.

( Grade of recommendation = B )>>>>>c

Fentanyl or hydromorphone are preferred for patients with hemodynamic instability or renal insufficiency

( Grade of recommendation = B )>>>>>>>>>>>>>>c

Morphine and hydromorphone are preferred for intermittent therapy because of their longer duration of effect.

( Grade of recommendation = B )>>>>>>>>>>>>c

NSAIDs or acetaminophen may be used as adjuncts to opioids in selected patients.

( Grade of recommendation = B )
Ketorolac therapy should be limited to a maximum of 5 days, with close monitoring for the development of renal insufficience or GI bleeding. Other NSAIDs may be used via the enteral route in appropriate patients.

( Grade of recommendation = B )

A sedation goal or endpoint should be established and regularly refined for each patient. Regular assessment and response to therapy should be systematically documented.

( Grade of recommendation = C )

The use of a validated sedation assessment scale ( SAS, MAAS, or VICS ) is recommended.

( Grade of recommendation = B )

Objective measures of sedation, such as BIS, have not been completely evaluated and are not yet proven useful in the ICU.

( Grade of recommendation = C )

RAMSAY SEDATION SCORE

Ramsay Sedation Scale Addenbrookes Sedation Scale Rikers Sedation-Agitation Scale SAS Motor Activity Assessment Scale MAAS Level Response 1 Anxious, and agitated or restless, or both 2 Co-operative, orientated and tranquil 3 Responds to commands only 4 Asleep, but brisk response to glabellar tap or low auditory stimulation 5 Asleep, sluggish response to glabellar tap or loud auditory stimulus 6 No response

Recommendations :
Midazolam or diazepam should be used for rapid sedation of acutely agitated patients.

( Grade of recommendation = C )

Propofol is the preferred sedative when rapid awakening ( e.g. for neurologic assessment) is importment.

( Grade of recommendation = B )

Midazolam is recommended for short term use only, as it produces unpredictable awakening and time to extubation when infusions continue longer than 48-72 hours.

( Grade of recommendation = A )

Lorazepam is recommended for the sedation of most patients via intermittent i.v. administration or continuous infusion.

( Grade of recommendation = B )

The potential for opioid, benzodiazepine, and propofol withdrawal should be considered after high doses or more than approximately 7 days of continuous therapy. Doses should be tapered systematically to prevent withdrawal symptoms.

( Grade of recommendation = B )

an acute, reversible organic mental syndrome with disorder of attention and cognitive function, increased or decreased psychomotor activity, and a disordered sleep-wake cycle

Delirium is an acute confusional state characterized by an alteration of consciousness with cognitive function. characterized by increased vigilance along with psychomotor and autonomic overactivity; these features are reflected in clinical manifestations such as agitation, tremulousness, and hallucinations. The most risk factors are underlying brain diseases such as dementia, stroke, or Parkinson disease, advanced age and sensory impairment (hearing and vision loss). Elderly patients are at the highest risk for delirium. Factors that may precipitate delirium include polypharmacy (particularly psychoactive drugs), infection, metabolic disturbances, dehydration, immobility, malnutrition.
ICU-related factors contributing to the development of delirium include sleep deprivation, sensory overload, lack of meaningful verbal or cognitive stimulation, and immobilization. inadequate analgesia ,Withdrawal of drugs such as opioids, sedatives,

An interesting characteristic of delirium is that the behavior of the patient can change dramatically within hours or even minutes. Drowsiness and lethargy can change to alertness and lucidity for a time, and then can quickly change to agitation and aggression

Delirium may be associated with confusion and different motoric subtypes: hypoactive, hyperactive, or mixed (179, 180). Hypoactive delirium, which is associated with the worst prognosis, is characterized by psychomotor retardation manifested by a calm appearance, inattention, decreased mobility, and obtundation in extreme cases. Hyperactive delirium is easily recognized by agitation, combative behaviors, lack of orientation, and progressive confusion after sedative therapy.

The confusion assessment method for the diagnosis of delirium in the ICU (CAM-ICU) (182, 185

Recommendation: Routine assessment for the presence of delirium is recommended. (The CAM-ICU is a promising tool for the assessment of delirium in ICU patients.) (Grade of recommendation B)

Suggested Criteria for Discharge Following Sedation and Analgesia (1,2022,34) 1. Patients should be easily aroused, alert and oriented, or returned to their baseline status (i.e. infants, cognitive impairment). 2. Vital signs should be stable and within acceptable limits 3. Patient is not at risk for resedation (i.e., sufficient time has elapsed since administration of reversal agents) 4. The patients protective reflexes have returned, and there is no risk for airway obstruction or aspiration 5. Pain is minimal and can be easily controlled in the post-discharge setting 6. Nausea is controlled and can be managed in the post-discharge setting 7. Outpatients should be discharged into the care of a responsible adult 8. Outpatients must be provided with written instructions regarding medications, activity, and emergency phone contacts

Delirium (acute, reversible) Dementia (chronic, irreversible) Depression (chronic, usually reversible)

Prevention of Delirium Consider developing protocolized approach Treat underlying infection and CHF Correct metabolic disturbances and hypoxemia Frequent reorientation of patient by nurse and family Goal directed sedation/analgesia and /or daily wake-up Stop the ventilator (SBT) each day to test readiness Early mobilization and physical therapy Attention to optimizing sleep pattern

Treatment of Delirium Identify etiologies Modify Risk Factors Control symptoms? No evidence that treatment reduces duration and

severity of symptoms

Typical and atypical antipsychotic agents Sedatives? - Particularly in combination with antipsychotic and for drug/alcohol withdrawal delirium No treatment FDA approved

Haloperidol Clinical Effects Hypnotic agent with antipsychotic properties1 For treatment of delirium in critically ill adults1 Does not cause respiratory depression Haloperidol Adverse Effects Dysphoria Adverse CV effects include QT interval prolongation, extrapyramidal symptoms, neuroleptic malignant syndrome (rare) Metabolism altered by drug-drug interactions

An analgesia-delirium-sedation protocol for critically ill trauma patients reduces ventilator days and hospital
length of stay
Pain Agitation Delirium visual/objective pain assessment scale Richmond Agitation-Sedation Scale RASS Confusion Assessment Method CAM-ICU.

CONCLUSION: An objective assessment- based protocol without daily interruption of medication infusion decreases ventilator days and hospital length of stay in critically ill trauma patients .
Robinson BR, J Trauma. 2008 Sep;65(3):517-26

Remifentanil-propofol analgo-sedation shortens duration of ventilation and length of ICU stay compared to a conventional regimen.
15 Dutch hospitals ,Patient cohorts were randomised to remifentanil based regimen (n = 96) with propofol as required, for a maximum of 10 days, or to conventional regimens (n = 109) of propofol, midazolam or lorazepam combined with fentanyl or morphine . CONCLUSIONS: In patients with an expected short-term duration of MV, remifentanil significantly improves sedation and agitation levels and reduces weaning time. This contributes to a shorter duration of MV and ICU-LOS .

Rozendaal FW Intensive Care Med 2009 .Feb;35(2):291-8

The current practice of sedation and analgesia in intensive care units in Malaysian public
hospitals.
A questionnaire survey sent by mail to 40 ICUs. 92.5% response rate. 35% routinely assess the degree of sedation (Ramsay scale). A written protocol for sedation was available in only 14 centers (38%). 36 centers (95%) routinely adjust the degree of sedation according to patient's clinical progress,

only 10 centers (14%) interrupt sedation on a daily basis.

Ahmad N ,Tan CC , Med J Malaysia 2007 .Jun;62(2):122-6

the selection of agents for sedation depends on familiarity (97%), pharmacology (97%), the expected duration for sedation (92%), patient's clinical diagnosis (89%) and cost (73%). Midazolam (89%) and morphine (86%)

14% frequently use NMB, mostly in head injury patients.

CONCLUSION the standard of practice could still be improved by implementing the practice of sedation score assessment and daily interruption of sedative infusion as well as having a written protocol for sedation and analgesia.

Ahmad N ,Tan CC ,Balan S Med J Malaysia 2007 .Jun;62(2):122-6

Sedation and analgesia assessment tools in ICU

patients
The usefulness of the BIS in ICU for patients lightly sedated is limited, mainly because of EMG artifact, when subjective scales are more appropriated in this situation. On the other hand, subjective scales are insensitive to detect oversedation in patients requiring deep sedation. The contribution of the BIS in deeply sedation patients, patients under neuromuscular blockade or barbiturates has to be proved
Thuong M .Ann Fr Anesth Reanim. 2008 Jul-Aug;27(7-8):581-95

Sedation in the intensive care unit with remifentanil/propofol versus midazolam/fentanyl

CONCLUSION: Compared with midazolam/fentanyl, a

remifentanil - based regimen for analgesia and sedation supplemented with propofol significantly reduced the time on

mechanical ventilation and allowed earlier discharge from the

ICU, at equal overall costs .
Muellejans B Germany .Crit Care 2006 :)3(10 R91.

Dexmedetomidine vs midazolam for sedation of critically ill patients

Prospective, double-BRT conducted in 68 centers in 5 countries between March 2005 and August 2007 among 375 medical/ surgical ICU patients with expected mechanical ventilation for more than 24 hours CONCLUSIONS: At comparable sedation levels, dex-treated patients spent less time on the ventilator, experienced less delirium, and developed less tachycardia and hypertension. The most notable adverse effect of dex was bradycardia.

Riker RR USA JAMA 2009 .Feb 4;301(5):489-99

Sedation in the neurologic intensive care unit .

Providing adequate sedation in NICU depends on determination of proper goals for sedation, adequate assessment of the level of sedation, and appropriate choice of drug based on the patient's physiology. The management of sedation in the ICU will influence long-term outcome. Delirium, anxiety, and pain must be identified and treated separately. The use of protocols can improve compliance with published evidence - based recommendations.
Keegan MT. Curr Treat Options Neurol 2008 .Mar;10(2):111-25

Propofol and dexmedetomidine may be used for rapidly titratable sedation, benzodiazepines for anxiolysis, neuroleptics for treatment of delirium, and opiates for analgesia. Unique aspects of patients with acute brain disease, such as elevated intracranial pressure or status epilepticus, require adaptation of sedative regimens. Processed EEG monitoring and volatile anesthetic agents have not yet proven beneficial or practical for use in the ICU.

Keegan MT. Curr Treat Options Neurol 2008 .Mar;10(2):111-25

Observational study of patient-ventilator asynchrony

and relationship to sedation level
METHODS: Airway pressure and airflow were recorded for 15 minutes. Patient-ventilator asynchrony was assessed by determining the number of breaths demonstrating ineffective triggering, double triggering, short cycling, and prolonged cycling. Ineffective triggering index (ITI) was calculated by dividing the number of ineffectively triggered breaths by the total number of breaths (triggered and ineffectively triggered). Sedation level was assessed by RASS, awake (yes or no), and CAM-ICU. Diagnosis of COPD, sedative type or dose, MV mode, and trigger method had no effect on ITI. CONCLUSIONS: Asynchrony is common, and deeper sedation level is a predictor of ineffective triggering
de Wit M USA, J Crit Care 2009 .Mar;24(1):74-80

A randomized trial of intermittent lorazepam versus propofol with daily interruption in mechanically ventilated patients.
Median ventilator days 5.8 vs. 8.4, p = .04. hospital survivors 4.4 vs. 9.0, p = .006. ventilator-free survival 18.5 days vs. 10.2 p = .06. Hospital mortality was not different

CONCLUSIONS: For medical patients requiring >48 hrs of mechanical ventilation, sedation with propofol results insignificantly fewer ventilator days compared with intermittent lorazepam when sedatives are interrupted daily

Carson SS ; Crit Care Med. 2006 May;34(5):1326-1332.

Daily interruption of sedative infusions and complications of critical illness in mechanically ventilated patients
VAP; upper GIT hge; bacteremia; barotrauma; DVT; and cholestasis or sinusitis requiring surgical intervention. daily interruption of sedatives(2.8%) vs. 26 (6.2%) in those subjected to conventional sedation techniques (p =.04). CONCLUSIONS: Daily interruption of sedative infusions in MV reduces ICU-LOS and, in turn, decreases the incidence of complications of critical illness associated with prolonged intubation and mechanical ventilation.

Crit Care Med 2004 Jun;32(6):1272-6. University-based hospital Chicago

Daily sedative interruption in mechanically ventilated patients at risk for coronary artery disease .

CONCLUSIONS: Myocardial ischemia is common in critically ill mechanically ventilated patients with coronary artery disease risk factors. Daily sedative interruption is not associated with an increased occurrence of myocardial ischemia in these patients .

Kress JP ,Crit Care Med. 2007 Feb;35(2):365-71.

Administration of Sedatives and Level of Sedation: Comparative Evaluation via the Sedation-Agitation Scale and the Bispectral Index

Conclusion Objective and subjective assessments of sedation

are highly correlated. Use of continuous infusions is associated with deeper levels of sedation, and patients receiving continuous infusions are more likely to be oversedated. Sedation therapy should be guided by subjective or objective assessment.

American Journal of Critical Care. 2003;12: 343-348

Before I forget...

any question..

Thank you
A H M A D F. M A D y