Sedation and analgesia in ICU

Objectives: Mechanically ventilated patients account for about one-third of all admissions to the intensive care unit (ICU). Ketamine has been conditionally recommended to aid with analgesia in such patients, with low quality of evidence available to support this recommendation. We aimed to perform a narrative scoping review of the current knowledge of the use of ketamine, with a specific focus on mechanically ventilated ICU patients. Methods: We searched MEDLINE and EMBASE for relevant articles. Bibliographies of retrieved articles were examined for references of potential relevance...

Sedation/analgesia in patients with acute brain damage, either traumatic or non-traumatic, is paramount to prevent alterations in brain perfusion secondary to the injury. Despite reviews on sedative and analgesic drugs, adequate sedation is an overlooked therapy in the prevention and treatment of intracranial hypertension. When to indicate continued sedation? How to guide the level of sedation? How to terminate sedation? This narrative review provides a practical approach to the individualized use of sedative/analgesic drugs in patients with acute brain damage...

PURPOSE OF REVIEW: Patients with acute neurologic injury require a specialized approach to critical care, particularly with regard to sedation and analgesia. This article reviews the most recent advances in methodology, pharmacology, and best practices of sedation and analgesia for the neurocritical care population. RECENT FINDINGS: In addition to established agents such as propofol and midazolam, dexmedetomidine and ketamine are two sedative agents that play an increasingly central role, as they have a favorable side effect profile on cerebral hemodynamics and rapid offset can facilitate repeated neurologic exams...

METHODS: We reviewed the electronic medical record of critically ill adults who received a continuous infusion of ketamine for ≥24 hours during invasive mechanical ventilation in three hospitals over a two-year period. We captured data including ketamine indication, dose, unintended effects, and adjustments to coadministered sedatives or opioids. We analyzed these data to determine the incidence of reported unintended effects of ketamine infusion (primary outcome) and changes in exposure to coadministered sedatives or opioids during ketamine use (secondary outcome)...

Rationale: The SPICE III (Sedation Practice in Intensive Care Evaluation) trial reported significant heterogeneity in mortality with dexmedetomidine treatment. Supplemental propofol was commonly used to achieve desirable sedation. Objectives: To quantify the association of different infusion rates of dexmedetomidine and propofol, given in combination, with mortality and to determine if this is modified by age. Methods: We included 1,177 patients randomized in SPICE III to receive dexmedetomidine and given supplemental propofol, stratified by age (>65 or ⩽65 yr)...

Delirium, often underdiagnosed in the intensive care unit, is a common complication of critical illness that contributes to significant morbidity and mortality. Clinicians should be aware of common risk factors and triggers and should work to mitigate these as much as possible to reduce the occurrence of delirium. This review first provides an overview of the epidemiology, pathophysiology, evaluation, and consequences of delirium in critically ill patients. Presented next is the current evidence for the pharmacologic management of delirium, focusing on prevention and treatment of delirium in the intensive care unit...

BACKGROUND: Dexmedetomidine is widely used in patients with sepsis. However, its effect on septic patients remains controversial. The objective of this study was to summarize all randomized controlled trials (RCTs) examining dexmedetomidine use in sepsis patients. METHODS: This systematic review and meta-analysis included RCTs comparing dexmedetomidine with other sedatives in adult sepsis patients. We generated pooled relative risks (RRs) and standardized mean differences and performed trial sequential analysis and a cumulative meta-analysis...

BACKGROUND AND OBJECTIVE: In hospitalized patients, opiates are essential analgesics and sedatives used in intensive care unit (ICU) patients. However, the iatrogenic opioid withdrawal syndrome (IOWS) in ICU patients has been poorly characterized, and there are no well accepted, standardized diagnostic tools for hospitalized adults. This review analyzed recent clinical studies to determine the frequency, characteristics, and treatment of IOWS in critically ill adults. METHODS: The initial literature search used the PubMed MeSH terms "Analgesics", "Opioids", "Iatrogenic Disease", and "Neurobiology"...

BACKGROUND: Opioid induced chest wall rigidity was first described in the early 1950s during surgical anesthesia and has often been referred to as fentanyl induced rigid chest syndrome (FIRCS). It has most commonly been described in the setting of procedural sedation and bronchoscopy, characterized by pronounced abdominal and thoracic rigidity, asynchronous ventilation, and respiratory failure. FIRCS has been infrequently described in the setting of continuous analgesia in critically ill adult patients...

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Inhaled sedation with halogenated agents, such as isoflurane or sevoflurane, is now feasible in intensive care unit (ICU) patients through dedicated vaporisers and scavenging systems. Such a sedation strategy requires specific equipment and adequate training of ICU teams. Isoflurane and sevoflurane have ideal pharmacological properties that allow efficient, well-tolerated, and titratable light-to-deep sedation. In addition to their function as sedative agents, these molecules may have clinical benefits that could be especially relevant to ICU patients...

BACKGROUND: The use of processed electroencephalography (pEEG) for depth of sedation (DOS) monitoring is increasing in anesthesia; however, how to use of this type of monitoring for critical care adult patients within the intensive care unit (ICU) remains unclear. METHODS: A multidisciplinary panel of international experts consisting of 21 clinicians involved in monitoring DOS in ICU patients was carefully selected on the basis of their expertise in neurocritical care and neuroanesthesiology...

PURPOSE: PRIS is a potentially fatal syndrome characterized by various clinical symptoms and abnormalities. Experts suggest that propofol treatment duration ≥48 h or dose ≥83 μg/kg/min is associated with developing PRIS. We hypothesized PRIS might be underdiagnosed due to the overlap of PRIS clinical manifestations with critical illnesses. MATERIALS AND METHODS: Multihospital, retrospective study of adult patients who received continuous propofol infusion ≥48 h or dose ≥60μg/kg/min for >24 h since admission were assessed for the development of PRIS...

Delirium is a serious and complex problem facing critically ill patients, their families, and the health care system. When delirium develops, it is associated with prolonged hospital stays, increased costs, and long-term cognitive impairment in many patients. This article uses a clinical case to discuss our approach to delirium prevention and treatment in the ICU. We believe that an effective strategy to combat delirium requires implementation and adherence to a pain and sedation protocol as part of bundled care, use of a validated tool to detect delirium when present, and a focus on nonpharmacologic care strategies, including reorientation, early mobility, and incorporating family into care when possible...

Delirium, a form of acute brain dysfunction, is very common in the critically ill adult patient population. Although its pathophysiology is poorly understood, multiple factors associated with delirium have been identified, many of which are coincident with critical illness. To date, no drug or non-drug treatments have been shown to improve outcomes in patients with delirium. Clinical trials have provided a limited understanding of the contributions of multiple triggers and processes of intensive care unit (ICU) acquired delirium, making identification of therapies difficult...

BACKGROUND: Pain assessment in brain-injured patients in the intensive care unit (ICU) is challenging and existing scales may not be representative of behavioral reactions expressed by this specific group. This study aimed to validate the French-Canadian and English revised versions of the Critical-Care Pain Observation Tool (CPOT-Neuro) for brain-injured ICU patients. METHODS: A prospective cohort study was conducted in three Canadian and one American sites. Patients with a traumatic or a non-traumatic brain injury were assessed with the CPOT-Neuro by trained raters (i...

PURPOSE: Compare outcomes of adult patients admitted to ICU- length of ICU stay, length of mechanical ventilation (MV), and time until extubation- according to the use of propofol versus midazolam. METHODS: We searched MEDLINE, EMBASE, LILACS, and Cochrane databases to retrieve RCTs that compared propofol and midazolam used as sedatives in adult ICU patients. We applied a random-effects, meta-analytic model in all calculations. We applied the Cochrane collaboration tool and GRADE...

BACKGROUND: The short-term and long-term consequences of the most frequent painful procedures performed in the ICU are unclear. This study aimed to identify the risk factors associated with pain-related discomfort perceived by critically ill patients during the whole ICU stay as self-reported by patients at the end of their ICU stay. METHODS: The study involved 34 ICUs. Adult patients who survived an ICU stay of 3 calendar days or more were eligible for inclusion...

Delirium, a syndrome characterized by an acute change in attention, awareness and cognition, is caused by a medical condition that cannot be better explained by a pre-existing neurocognitive disorder. Multiple predisposing factors (for example, pre-existing cognitive impairment) and precipitating factors (for example, urinary tract infection) for delirium have been described, with most patients having both types. Because multiple factors are implicated in the aetiology of delirium, there are likely several neurobiological processes that contribute to delirium pathogenesis, including neuroinflammation, brain vascular dysfunction, altered brain metabolism, neurotransmitter imbalance and impaired neuronal network connectivity...

Acute Respiratory Distress Syndrome (ARDS) is one of the most demanding conditions in an Intensive Care Unit (ICU). Management of analgesia and sedation in ARDS is particularly challenging. An expert panel was convened to produce a "state-of-the-art" article to support clinicians in the optimal management of analgesia/sedation in mechanically ventilated adults with ARDS, including those with COVID-19. Current ICU analgesia/sedation guidelines promote analgesia first and minimization of sedation, wakefulness, delirium prevention and early rehabilitation to facilitate ventilator and ICU liberation...