Management of sedation in mechanically ventilated patients

Current Opinion in Critical Care

Volumn 10, Issue 1, 2004, Pages 40-46

  Hogarth, D Kyle ^a   Hall, Jesse ^a  

^a UNIVERSITY OF CHICAGO MEDICAL CENTER   (United States)

Author keywords

Analgesia; BIS; Dexmedetomidine; Mechanical ventilation; RASS; Sedation

Indexed keywords

BENZODIAZEPINE DERIVATIVE; DEXMEDETOMIDINE; DIAZEPAM; FENTANYL; HALOPERIDOL; HYDROMORPHONE; LORAZEPAM; METHADONE; MIDAZOLAM; MORPHINE; OPIATE DERIVATIVE; PETHIDINE; PROPOFOL;

ADDICTION; AGITATION; ANALGESIA; ARTIFICIAL VENTILATION; BIOLOGICAL MONITORING; BIOSAFETY; BIOTECHNOLOGY; CARDIOVASCULAR DISEASE; CLINICAL PROTOCOL; CLINICAL TRIAL; DELIRIUM; DOSE RESPONSE; DRUG DISTRIBUTION; DRUG EFFECT; DRUG HALF LIFE; DRUG METABOLISM; EXTRAPYRAMIDAL SYMPTOM; HOSPITAL BED; HUMAN; HYPOTENSION; INTENSIVE CARE UNIT; MENTAL HEALTH; MYOCLONUS; NEUROTOXICITY; PAIN; PATIENT CARE; PATIENT MONITORING; PSYCHOLOGICAL ASPECT; QT INTERVAL; REVIEW; SCORING SYSTEM; SEDATION; SEIZURE; TIME; VENTILATOR;

ALGORITHMS; ANXIETY; BENZODIAZEPINES; HUMANS; HYPNOTICS AND SEDATIVES; INTENSIVE CARE UNITS; MONITORING, PHYSIOLOGIC; NARCOTICS; PAIN; PROPOFOL; TIME FACTORS; VENTILATORS, MECHANICAL;

EID: 0842312953     PISSN: 10705295     EISSN: None     Source Type: Journal    
DOI: 10.1097/00075198-200402000-00007     Document Type: Review

References (84)

1. Hansen-Flaschen JH, Brazinsky S, Basile C, Lanken PN: Use of sedating drugs and neuromuscular blocking agents in patients requiring mechanical ventilation for respiratory failure. A national survey. JAMA 1991, 266:2870-2875.
2. Christensen BV, Thunedborg LP: Use of sedatives, analgesics and neuromuscular blocking agents in Danish ICUs 1996/97. A national survey. Intensive Care Med 1999, 25:186-191.
3. Westcott C: The sedation of patients in intensive care units: a nursing review. Intensive Crit Care Nurs 1995, 11:26-31.
4. Novaes MA, Knobel E, Bork AM, et al.: Stressors in ICU: perception of the patient, relatives and health care team. Intensive Care Med 1999, 25:1421-1426.
5. Carroll KC, Atkins PJ, Herold GR, et al.: Pain assessment and management in critically ill postoperative and trauma patients: a multisite study. Am J Crit Care 1999, 8:105-117.
6. Ferguson J, Gilroy D, Puntillo K: Dimensions of pain and analgesic administration associated with coronary artery bypass grafting in an Australian intensive care unit. J Adv Nurs 1997, 26:1065-1072.
7. Joint Commission for Accreditation of Health Care Organizations. Pain Assessment and Management Standards-Hospitals. Available at: http://www. jcaho.org. Accessed December 8, 2003.
8. Kissin I, Vinik HR, Castillo R, Bradley EL Jr: Alfentanil potentiates midazolam-induced unconsciousness in subanalgesic doses. Anesth Analg 1990, 71:65-69.
9. Ben-Shlomo I, abd-el-Khalim H, Ezry J, et al.: Midazolam acts synergistically with fentanyl for induction of anaesthesia. Br J Anaesth 1990, 64:45-47.
10. Rotondi AJ, Chelluri L, Sirio C, et al.: Patients' recollections of stressful experiences while receiving prolonged mechanical ventilation in an intensive care unit. Crit Care Med 2002, 30:746-752. This study highlights an important reason to achieve adequate sedation in the ICU.
11. Bidani A, Tzouanakis AE, Cardenas VJ Jr, Zwischenberger JB: Permissive hypercapnia in acute respiratory failure. JAMA 1994, 272:957-962.
12. Vinayak A, Kress J, Gehlbach B, et al.: The relationship between sedative infusion requirements and permissive hypercapnia in critically ill, mechanically ventilated patients. American Thoracic Society International Conference. Seattle, WA. May 16-21, 2003. Abstract Poster #904, 2003.
13. Jones C, Griffiths RD, Humphris G: Disturbed memory and amnesia related to intensive care. Memory 2000, 8:79-94.
14. Jones C, Griffiths RD, Humphris G, Skirrow PM: Memory, delusions, and the development of acute posttraumatic stress disorder-related symptoms after intensive care. Crit Care Med 2001, 29:573-580. Discusses factors that contribute to the development of post-traumatic stress disorder in ICU survivors.
15. Kanski GW, Janelli LM, Jones HM, Kennedy MC: Family reactions to restraints in an acute care setting. J Gerontol Nurs 1996, 22:17-22.
16. Mendelsohn AB, Chelluri L: Interviews with intensive care unit survivors: assessing post-intensive care quality of life and patients' preferences regarding intensive care and mechanical ventilation. Crit Care Med 2003, 31(5 Suppl):S400-406. Interesting collection of data indicates that many patients would still be treated in the ICU despite painful/stressful experiences.
17. Rundshagen I, Schnabel K, Wegner C, am Esch S: Incidence of recall, nightmares, and hallucinations during analgosedation in intensive care. Intensive Care Med 2002, 28:38-43. This study should increase the reader's awareness of the high incidence of psychological trauma associated with ICU care.
18. Scragg P, Jones A, Fauvel N: Psychological problems following ICU treatment. Anaesthesia 2001, 56:9-14.
19. Jones C: 'Take me away from all this', can reminiscence be therapeutic in an intensive care unit? Intensive Crit Care Nurs 1995, 11:341-343.
20. Jones C, O'Donnell C: After intensive care-what then? Intensive Crit Care Nurs 1994, 10:89-92.
21. Jones C, Macmillan RR, Griffiths RD: Providing psychological support for patients after critical illness. Clin Intensive Care 1994, 5:176-179.
22. Kress JP LM, Pliskin N, Pohlman A, Hall J: The Long Term Psychological Effects Of Daily Sedative Interruption In Critically III Patients. American Thoracic Society International Conference. San Francisco, CA. May 18-23, 2001. ATS Abstract, 2001.
23. Shapiro BA, Warren J, Egol AB, et al.: Practice parameters for sustained neuromuscular blockade in the adult critically ill patient: an executive summary. Society of Critical Care Medicine. Crit Care Med 1995, 23:1601-1605.
24. Nasraway SA Jr, Jacobi J, Murray MJ, Lumb PD: Sedation, analgesia, and neuromuscular blockade of the critically ill adult: revised clinical practice guidelines for 2002. Crit Care Med 2002, 30:117-118. One of the only available guidelines to assist the clinician in managing patient's pain and sedation in the ICU.
25. Murray MJ, Cowen J, DeBlock H, et al.: Clinical practice guidelines for sustained neuromuscular blockade in the adult critically ill patient. Crit Care Med 2002, 30:142-156. Excellent guidelines to be used for any patient receiving neuromuscular blockade.
26. Kollef MH, Levy NT, Ahrens TS, et al.: The use of continuous i.v. sedation is associated with prolongation of mechanical ventilation. Chest 1998, 114:541-548.
27. Kress JP, Pohlman AS, O'Connor MF, Hall JB: Daily interruption of sedative infusions in critically ill patients undergoing mechanical ventilation. N Engl J Med 2000, 342:1471-1477.
28. Fonsmark L, Rasmussen YH, Carl P: Occurrence of withdrawal in critically ill sedated children. Crit Care Med 1999, 27:196-199.
29. French JP, Nocera M: Drug withdrawal symptoms in children after continuous infusions of fentanyl. J Pediatr Nurs 1994, 9:107-113.
30. Brown C, Albrecht R, Pettit H, et al.: Opioid and benzodiazepine withdrawal syndrome in adult burn patients. Am Surg 2000, 66:367-370; discussion 370-371.
31. Tobias JD: Tolerance, withdrawal, and physical dependency after long-term sedation and analgesia of children in the pediatric intensive care unit. Crit Care Med 2000, 28:2122-2132.
32. Katz R, Kelly HW, Hsi A: Prospective study on the occurrence of withdrawal in critically ill children who receive fentanyl by continuous infusion. Crit Care Med 1994, 22:763-767.
33. Cammarano WB, Pittet JF, Weitz S, et al.: Acute withdrawal syndrome related to the administration of analgesic and sedative medications in adult intensive care unit patients. Crit Care Med 1998, 26:676-684.
34. Mohta M, Sethi AK, Tyagi A, Mohta A: Psychological care in trauma patients. Injury 2003, 34:17-25.
35. Gehlbach BK, Kress JP: Sedation in the intensive care unit. Curr Opin Crit Care 2002, 8:290-298.
36. Liu LL, Gropper MA: Postoperative analgesia and sedation in the adult intensive care unit: a guide to drug selection. Drugs 2003, 63:755-767. An exceptional review of the medications commonly used in the ICU for sedation and pain control.
37. Meiser A, Sirtl C, Bellgardt M, et al.: Desflurane compared with propofol for postoperative sedation in the intensive care unit. Br J Anaesth 2003, 90:273-280. In patients on short-term mechanical ventilation, gas anesthesia is useful but has technical limitations making it difficult to implement in most ICUs.
38. McCaffery M: The patient's report of pain. Am J Nurs 2001, 101:73-74.
39. Phillips DM: JCAHO pain management standards are unveiled. Joint Commission on Accreditation of Healthcare Organizations. JAMA 2000, 284:428-429.
40. Payen JF, Bru O, Bosson JL, et al.: Assessing pain in critically ill sedated patients by using a behavioral pain scale. Crit Care Med 2001, 29:2258-2263.
41. Acello B: Meeting JCAHO standards for pain control. Nursing 2000, 30:52-54.
42. Harden N, Cohen M: Unmet needs in the management of neuropathic pain. J Pain Symptom Manage 2003, 25(5 Suppl):S12-17.
43. Reyes-Gibby CC, McCrory LL, Cleeland CS: Variations in patients' self-report of pain by treatment setting. J Pain Symptom Manage 2003, 25:444-448.
44. Blengini C, Joranson DE, Ryan KM: Italy reforms national policy for cancer pain relief and opioids. Eur J Cancer Care (Engl) 2003, 12:28-34.
45. Potter VT, Wiseman CE, Dunn SM, Boyle FM: Patient barriers to optimal cancer pain control. Psychooncology 2003, 12:153-160.
46. Cascinu S, Giordani P, Agostinelli R, et al.: Pain and its treatment in hospitalized patients with metastatic cancer. Support Care Cancer 2003.
47. Pederson C, Matthies D, McDonald S: A survey of pediatric critical care nurses' knowledge of pain management. Am J Crit Care 1997, 6:289-295.
48. Szokol JW, Vender JS: Anxiety, delirium, and pain in the intensive care unit. Crit Care Clin 2001, 17:821-842.
49. Shelly MP, Mendel L, Park GR: Failure of critically ill patients to metabolise midazolam. Anaesthesia 1987, 42:619-626.
50. Vree TB, Shimoda M, Driessen JJ, et al.: Decreased plasma albumin concentration results in increased volume of distribution and decreased elimination of midazolam in intensive care patients. Clin Pharmacol Ther 1989, 46:537-544.
51. Driessen JJ, Vree TB, Guelen PJ: The effects of acute changes in renal function on the pharmacokinetics of midazolam during long-term infusion in ICU patients. Acta Anaesthesiol Belg 1991, 42:149-155.
52. Byatt CM, Lewis LD, Dawling S, Cochrane GM: Accumulation of midazolam after repeated dosage in patients receiving mechanical ventilation in an intensive care unit. Br Med J (Clin Res Ed) 1984, 289:799-800.
53. Malacrida R, Fritz ME, Suter PM, Crevoisier C: Pharmacokinetics of midazolam administered by continuous intravenous infusion to intensive care patients. Crit Care Med 1992, 20:1123-1126.
54. McKeage K, Perry CM: Propofol: a review of its use in intensive care sedation of adults. CNS Drugs 2003, 17:235-272. A must-read article for anyone who uses propofol.
55. Kress JP, O'Connor MF, Pohlman AS, et al.: Sedation of critically ill patients during mechanical ventilation: a comparison of propofol and midazolam. Am J Respir Crit Care Med 1996, 153:1012-1018.
56. Hall RI, Sandham D, Cardinal P, et al.: Propofol vs midazolam for ICU sedations Canadian multicenter randomized trial. Chest 2001, 119:1151-1159.
57. Weinbroum AA, Halpern P, Rudick V, et al.: Midazolam versus propofol for long-term sedation in the ICU: a randomized prospective comparison. Intensive Care Med 1997, 23:1258-1263.
58. Walder B, Elia N, Henzi I, et al.: A lack of evidence of superiority of propofol versus midazolam for sedation in mechanically ventilated critically ill patients: a qualitative and quantitative systematic review. Anesth Analg 2001, 92:975-983.
59. Sanchez-Izquierdo-Riera JA, Caballero-Cubedo RE, Perez-Vela JL, et al.: Propofol versus midazolam: safety and efficacy for sedating the severe trauma patient. Anesth Analg 1998, 86:1219-1224.
60. Theilen HJ, Adam S, Albrecht MD, Ragaller M: Propofol in a medium-and long-chain triglyceride emulsion: pharmacological characteristics and potential beneficial effects. Anesth Analg 2002, 95:923-929.
61. Cremer OL, Moons KG, Bouman EA, et al.: Long-term propofol infusion and cardiac failure in adult head-injured patients. Lancet 2001, 357:117-118.
62. Jacobi J, Fraser GL, Coursin DB, et al.: Clinical practice guidelines for the sustained use of sedatives and analgesics in the critically ill adult. Crit Care Med 2002, 30:119-141. Clinical guidelines from the American College of Critical Care Medicine.
63. Riker RR, Fraser GL, Cox PM: Continuous infusion of haloperidol controls agitation in critically ill patients. Crit Care Med 1994, 22:433-440.
64. Sharma ND, Rosman HS, Padhi ID, Tisdale JE: Torsades de pointes associated with intravenous haloperidol in critically ill patients. Am J Cardiol 1998, 81:238-240.
65. Scheinin H, Virtanen R, MacDonald E, et al.: Medetomidine-a novel alpha 2-adrenoceptor agonist: a review of its pharmacodynamic effects. Prog Neuropsychopharmacol Biol Psychiatry 1989, 13:635-651.
66. Arain SR, Ebert TJ: The efficacy, side effects, and recovery characteristics of dexmedetomidine versus propofol when used for intraoperative sedation. Anesth Analg 2002, 95:461-466. There is increasing literature on dexmedetomidine, but limited clinical trials. This article gives some good background about the drug. More study is still needed to determine the role this drug will play in the ICU.
67. Ben-Abraham R, Ogorek D, Weinbroum AA: Dexmedetomidine: a promising agent for anesthesia and perioperative care. Isr Med Assoc J 2000, 2:793-796.
68. Venn RM, Bradshaw CJ, Spencer R, et al.: Preliminary UK experience of dexmedetomidine, a novel agent for postoperative sedation in the intensive care unit. Anaesthesia 1999, 54:1136-1142.
69. Triltsch AE, Weite M, von Homeyer P, et al.: Bispectral index-guided sedation with dexmedetomidine in intensive care: a prospective, randomized, double blind, placebo-controlled phase II study. Crit Care Med 2002, 30:1007-1014. A nice small trial that shows the potential usefulness of both BIS and dexmedetomidine.
70. Venn RM, Karol MD, Grounds RM: Pharmacokinetics of dexmedetomidine infusions for sedation of postoperative patients requiring intensive caret. Br J Anaesth 2002, 88:669-675. An excellent article to read to increase one's understanding of dexmedetomidine.
71. Venn RM, Grounds RM: Comparison between dexmedetomidine and propofol for sedation in the intensive care unit: patient and clinician perceptions. Br J Anaesth 2001, 87:684-690.
72. Ely EW, Baker AM, Evans GW, Haponik EF: The prognostic significance of passing a daily screen of weaning parameters. Intensive Care Med 1999, 25:581-587.
73. Ramsay MA, Savege TM, Simpson BR, Goodwin R: Controlled sedation with alphaxalone-alphadolone. Br Med J 1974, 2:656-659.
74. Sessler CN, Gosnell MS, Grap MJ, et al.: The Richmond Agitation-Sedation Scale: validity and reliability in adult intensive care unit patients. Am J Respir Crit Care Med 2002, 166:1338-1344. One of the most significant advances in management of sedation during this review period. RASS is an important new tool for the ICU team to utilize.
75. Ely EW, Truman B, Shintani A, et al.: Monitoring sedation status over time in ICU patients: reliability and validity of the Richmond Agitation-Sedation Scale (RASS). JAMA 2003, 289:2983-2991. Increasing the evidence that the RASS is a useful tool for the ICU.
76. Mondello E, Siliotti R, Noto G, et al.: Bispectral Index in ICU: correlation with Ramsay Score on assessment of sedation level. J Clin Monit Comput 2002, 17:271-277. A good article to read to increase one's understanding of BIS and the possible role it may play in managing sedation.
77. Crain N, Slonim A, Pollack MM: Assessing sedation in the pediatric intensive care unit by using BIS and the COMFORT scale. Pediatr Crit Care Med 2002, 3:11-14.
78. Frenzel D, Greim CA, Sommer C, et al.: Is the bispectral index appropriate for monitoring the sedation level of mechanically ventilated surgical ICU patients? Intensive Care Med 2002, 28:178-183.
79. Crocker C: Nurse led weaning from ventilatory and respiratory support. Intensive Crit Care Nurs 2002, 18:272-279.
80. Ely EW, Bennett PA, Bowton DL, et al.: Large scale implementation of a respiratory therapist-driven protocol for ventilator weaning. Am J Respir Crit Care Med 1999, 159:439-446.
81. Ely EW: The utility of weaning protocols to expedite liberation from mechanical ventilation. Respir Care Clin North Am 2000, 6:303-319.
82. Ely EW, Meade MO, Haponik EF, et al.: Mechanical ventilator weaning protocols driven by nonphysician health-care professionals: evidence-based clinical practice guidelines. Chest 2001, 120(6 Suppl):454S-63S.
83. Shapiro BA, Warren J, Egol AB, et al.: Practice parameters for intravenous analgesia and sedation for adult patients in the intensive care unit: an executive summary. Society of Critical Care Medicine. Crit Care Med 1995, 23:1596-1600.
84. Egerod I: Uncertain terms of sedation in ICU: how nurses and physicians manage and describe sedation for mechanically ventilated patients. J Clin Nurs 2002, 11:831-840.