Current trends in long-term pharmacological sedation of the critically ill


Authors: Stibor Bronislav ;  Schwameis Franz
Authors‘ workplace: ICU, Landesklinikum Baden bei Wien, Austria
Published in: Anest. intenziv. Med., 25, 2014, č. 4, s. 307-314
Category: Intensive Care Medicine - Review Article

Overview

Pain and stress are very common in critically ill patients. Provision of adequate analgesia and elimination of psychological discomfort are essential components of treatment goals on the ICU care. In the past few years there has been a focus on the side-effects of long-term sedation such as the presence of delirium, cognitive dysfunction, prolongation of the time on mechanical ventilation, and ICU and hospital length of stay. The new 2013 guidelines by the American College of Critical Care Medicine and Society of Critical Care Medicine have redefined the management of sedation, analgesia and prevention and treatment of the delirium.

The traditional approach represents giving sedatives to all mechanically ventilated patients. The principle of deep level sedation in all patients has become obsolete. There is a focus on pain management firstly with intravenous analgesics, and sedation is used only if needed. Sedation with modern nonbenzodiazepine drugs (such as dexmedetomidine) is preferred while benzodiazepine-based sedation should be used only in specific situations.

Implementation of scoring systems for effective monitoring of pain, depth of sedation and delirium is also essential.

Keywords:
sedation – analgesia – RASS – CAM-ICU – guidelines – delirium – benzodiazepines – dexmedetomidine


Sources

1. Braun, J. P., Mende, H., Bause, H., Bloos, F., Geldner, G., Kastrup, M., Kuhlen, R., Markewitz, A., Martin, J., Quintel, M., Steinmeier-Bauer, K., Waydhas, C., Spies, C. Quality indicators in intensive care medicine: why? Use or burden for the intensivist. Ger. Med. Sci., 2010, 8, 22.

2. Braun, J. P., Kumpf, O., Deja, M., Brinkmann, A., Marx, G., Bloos, F., Kaltwasser, A., Dubb, R., Muhl, E., Greim, C., Bause, H., Weiler, N., Chop, I., Waydhas, C., Spies, C. The German quality indicators in intensive care medicine 2013 – second edition. Ger. Med. Sci., 2013,11, Doc09.

3. Barr, J., Fraser, G. L., Puntillo, K., et al. American College of Critical Care Medicine: Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit. Crit. Care Med., 2013, 41, p. 263–306.

4. Sessler, C. N., Gosnell, M. S., Grap, M. J., Brophy, G. M., O‘Neal, P. V., Keane, K. A., Tesoro, E. P., Elswick, R. K. The Richmond Agitation-Sedation Scale: validity and reliability in adult intensive care unit patients. Am. J. Respir. Crit. Care Med., 2002, 166, 10, p. 1338–1344.

5. Ely, E. W., Truman, B., Shintani, A., Thomason, J. W. W., Wheeler, A. P., Gordon, S. et al. Monitoring sedation status over time in ICU patients: the reliability and validity of the Richmond Agitation Sedation Scale (RASS). JAMA, 2003, 289, p. 2983–2991.

6. Sessler, C. N., Grap, M. J., Brophy, G. M. Multidisciplinary management of sedation and analgesia in critical care. Semin. Respir. Crit. Care Med., 2001, 22, 2, p. 211–2126.

7. Ely, E. W., Inouye, S. K., Bernard, G. R., Gordon, S., Francis, J., May, L., Truman, B., Speroff, T., Gautam, S., Margolin, R., Hart, R. P., Dittus, R. Delirium in mechanically ventilated patients: validity and reliability of the confusion assessment method for the intensive care unit (CAM-ICU). JAMA, 2001, 286, 21, p. 2703–2710.

8. Hopkins, R. O., Brett, S. Chronic neurocognitive effects of critical illness. Curr. Opin. Crit. Care, 2005, 11, 4, p. 369–375.

9. Newman, M. F., Kirchner, J. L., Phillips-Bute, B., Gaver, V.,Grocott, H., Jones, R. H., Mark, D. B., Reves, J. G., Blumen-thal, J. A., Neurological Outcome Research Group and the Cardiothoracic Anesthesiology Research Endeavors Investigators Longitudinal assessment of neurocognitive function after coronary-artery bypass surgery. N. Engl. J. Med., 2001, 344, 6, p. 395–402.

10. Hopkins, R. O., Weaver, L. K., Pope, D., Orme, J. F., Big-ler, E. D., Larson-Lohr, V. Neuropsychological sequelae and impaired health status in survivors of severe acute respiratory distress syndrome. Am. J. Respir. Crit. Care Med., 1999,160, 1, p. 50–56.

11. Spronk, P. E., Riekerk, B., Hofhuis, J., Rommes, J. H. Occurrence of delirium is severely underestimated in the ICU during daily care. Intensive Care Med., 2009, 35, 7, p. 1276–1280.

12. Ely, E. W., Shintani, A., Truman, B., Speroff, T., Gordon, S. M.,Harrell, F. E. Jr., Inouye, S. K., Bernard, G. R., Dittus, R. S. Delirium as a predictor of mortality in mechanically ventilated patients in the intensive care unit. JAMA, 2004, 291, 14, p. 1753–1762.

13. Luetz, A., Heymann, A., Radtke, F. M., Chenitir, C., Neuhaus, U.,Nachtigall, I., von Dossow, V., Marz, S., Eggers, V., Heinz, A., Wernecke, K. D., Spies, C. D. Different assessment tools for intensive care unit delirium: which score to use? Crit. Care Med., 2010, 38, 2, p. 409–418.

14. http://www.icudelirium.org/docs/CAM_ICU_worksheet_Czech.pdf

15. Martin, J., Parsch, A., Franck, M., Wernecke, K. D., Fischer, M.,Spies, C. Practice of sedation and analgesia in German intensive care units: results of a national survey. Crit. Care, 2005, 9, 2, p. R117–R123.

16. Pisani, M. A., Murphy, T. E., Araujo, K. L., Slattum, P., Van Ness, P. H., Inouye, S. K. Benzodiazepine and opioid use and the duration of intensive care unit delirium in an older population. Crit. Care Med., 2009, 37, 1, p. 177–183.

17. Barr, J., Zomorodi, K., Bertaccini, E. J., et al. A double-blind, random­ized comparison of i.v. lorazepam versus midazolam for sedation of ICU patients via a pharmacologic model. Anesthesiology, 2001, 95, p. 286–298.

18. Barr, J., Egan, T. D., Sandoval, N. F., et al. Propofol dosing regimens for ICU sedation based upon an integrated pharmacokinetic-pharmaco­dynamic model. Anesthesiology, 2001, 95, p. 324–333.

19. Roberts, R. J., Barletta, J. F., Fong, J. J., et al. Incidence of propofol-related infusion syndrome in critically ill adults: A prospective, multicenter study. Crit. Care, 2009, 13, p. R169.

20. Rubino, A. S., Onorati, F., Caroleo, S., Galato, E., Nucera, S., Amantea, B., Santini, F., Renzulli, A. Impact of clonidine administration on delirium and related respiratory weaning after surgical correction of acute type-A aortic dissection: results of a pilot study. Interact. Cardiovasc. Thorac. Surg., 2010, 10, 1, p. 58–62.

21. Venn, R. M., Karol, M. D., Grounds, R. M. Pharmacokinetics of dexme­detomidine infusions for sedation of postoperative patients requiring intensive caret. Br. J. Anaesth., 2002, 88, p. 669–675.

22. Shehabi, Y., Ruettimann, U., Adamson, H., et al. Dexme-detomidine infu­sion for more than 24 hours in critically ill patients: Sedative and cardiovascular effects. Intensive Care Med., 2004, 30, p. 2188–2196.

23. Adams, R., Brown, G. T., Davidson, M., Fisher, E., Mathisen, J.,Thomson, G., Webster, N. R. Efficacy of dexmedetomidine compared with midazolam for sedation in adult intensive care pa-tients: a systematic review. Br. J. Anaesth., 2013, 111, 5, p. 703–710.

24. Pandharipande, P. P., Pun, B. T., Herr, D. L., Maze, M., Gi-rard, T. D., Miller, R. R., Shintani, A. K., Thompson, J. L., Jackson, J. C., Deppen, S. A., Stiles, R. A., Dittus, R. S., Bernard, G. R., Ely, E. W. Effect of sedation with dexmedetomidine vs lorazepam on acute brain dysfunction in mechanically ventilated patients: the MENDS randomized controlled trial. JAMA, 2007, 298, 22, p. 2644–2653.

25. Riker, R. R., Shehabi, Y., Bokesch, P. M., Ceraso, D., Wisemandle, W., Koura, F., Whitten, P., Margolis, B. D., Byr-ne, D. W., Ely, E. W., Rocha, M. G., SEDCOM (Safety and Efficacy of Dexmedetomidine Compared With Midazolam) Study Group Dexmedetomidine vs midazolam for sedation of critically ill pa-tients: a randomized trial. JAMA, 2009, 301, 5, p. 489–499.

26. Gerlach, A. T., Murphy, C. V., Dasta, J. F. An updated focused review of dexmedetomidine in adults. Ann. Pharmacother., 2009, 43, p. 2064–2074.

27. Panzer, O., Moitra, V., Sladen, R. N. Pharmacology of sedative-analgesic agents: Dexmedetomidine, remifentanil, ketamine, volatile anesthet­ics, and the role of peripheral Mu antagonists. Anesthesiol. Clin., 2011, 29, p. 587–605.

28. Payen, J. F., Changues, G., Mantz, J., et al. Current Practices in Sedation and Analgesia for Mechanically Ventilated Critically Ill Patients: A Prospective Multicenter Patient-Based Study. Anesthesiology, 2007, 106, p. 687–695.

29. Martin, J., Franck, M., Sigel, S., Weiss, M., Spies, C. Changes in sedation management in German intensive care units between 2002 and 2006: a national follow-up survey. Crit. Care, 2007, 11, 6, p. R124.

30. Jackson, D. L., Proudfoot, C. W., Cann, K. F., Walsh, T. S. The incidence of sub-optimal sedation in the ICU: a systematic review. Crit. Care, 2009, 13, 6, p. R204.

31. Barr, J., Pandharipande, P. P. The pain, agitation, and delirium care bundle: synergistic benefits of implementing the 2013 Pain, Agitation, and Delirium Guidelines in an integrated and interdisciplinary fashion. Crit. Care Med., 2013, 41, 9 Suppl 1, p. 99–115.

32. Fraser, G. L., Devlin, J. W., Worby, C. P., Alhazzani, W., Barr, J., Dasta, J. F., Kress, J. P., Davidson, J. E., Spencer, F. A.Benzodiazepine versus nonbenzodiazepine-based sedation for mechanically ventilated, critically ill adults: a systematic review and meta-analysis of randomized trials. Crit. Care Med., 2013, 41, 9 Suppl 1, p. 30–38.

33. Jakob, S. M., Ruokonen, E., Grounds, R. M., Sarapohja, T., Garratt, C., Pocock, S. J., Bratty, J. R., Takala, J. Dexmedetomidine for Long-Term Sedation Investigators. Dexmedetomidine vs midazolam or propofol for sedation during prolonged mechanical ventilation: two randomized controlled trials. JAMA, 2012, 307, 11, p. 1151–1160.

34. Li, S. Y., Wang, T. J., Vivienne Wu, S. F., et al. Efficacy of controlling night-time noise and activities to improve patients’ sleep quality in a surgi­cal intensive care unit. J. Clin. Nurs., 2011, 20, p. 396–407.

35. Dennis, C. M., Lee, R., Woodard, E. K., et al. Benefits of quiet time for neuro-intensive care patients. J. Neurosci. Nurs., 2010, 42, p. 217–224.

36. Schweickert, W. D., Pohlman, M. C., Pohlman, A. S., et al. Early physical and occupational therapy in mechanically ventilated, critically ill patients: A randomised controlled trial. Lancet, 2009, 373, p. 1874–1882.

37. Needham, D. M., Korupolu, R., Zanni, J. M., Pradhan, P., Colantuoni, E., Palmer, J. B., Brower, R. G., Fan, E. Early physical medicine and rehabili­tation for patients with acute respiratory failure: A quality improve­ment project. Arch. Phys. Med. Rehabil., 2010, 91, 53.

38. Erstad, B. L., Puntillo, K., Gilbert, H. C., et al. Pain management principles in the critically ill. Chest, 2009, 135, p. 1075–1086.

39. Cepeda, M. S., Carr, D. B., Lau, J., et al. Music for pain relief. Cochrane Database Syst. Rev., 2006, CD004843.

40. Strøm, T., Martinussen, T., Toft, P. A protocol of no sedation for criti­cally ill patients receiving mechanical ventilation: A randomised trial. Lancet, 2010, 375, p. 475–480.

41. Girard, T. D., Kress, J. P., Fuchs, B. D., Thomason, J. W., Schweickert, W. D., Pun, B. T., Taichman, D. B., Dunn, J. G., Pohlman, A. S., Kinniry, P. A., Jackson, J. C., Canonico, A. E., Light, R. W., Shintani, A. K., Thompson, J. L., Gordon, S. M., Hall, J. B.,Dittus, R. S., Bernard, G. R., Ely, E. W. Efficacy and safety of a paired sedation and ventilator weaning protocol for mechanically ventilated patients in intensive care (Awakening and Breathing Controlled trial): a randomised controlled trial. Lancet, 2008, 371, 9607, p. 126–134.

42. Morandi, A., Brummel, N. E., Ely, E. W. Sedation, delirium and mechanical ventilation: the ‚ABCDE‘ approach. Curr. Opin Crit. Care, 2011, 17, 1, p. 43–49.

43. Riker, R. R., Fraser, G. L., Cox, P. M. Continuous infusion of haloperidol controls agitation in critically ill patients. Crit. Care Med., 1994, 22, 3, p. 433–440.

44. Reade, M. C., Finfer, S. Sedation and Delirium in the Intensive Care Unit. N. Engl. J. Med., 2014, 370, p. 444–454.

Autoři v minulosti obdrželi honoráře za přednáškovou činnost od Orion Pharma.

Labels
Anaesthesiology, Resuscitation and Inten Intensive Care Medicine

Article was published in

Anaesthesiology and Intensive Care Medicine

Issue 4

2014 Issue 4

Most read in this issue

This topic is also in:


Login
Forgotten password

Don‘t have an account?  Create new account

Forgotten password

Enter the email address that you registered with. We will send you instructions on how to set a new password.

Login

Don‘t have an account?  Create new account