Critical care clinics
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Critical care clinics · Jul 2009
Pharmacology of sedative-analgesic agents: dexmedetomidine, remifentanil, ketamine, volatile anesthetics, and the role of peripheral mu antagonists.
In this article, the authors discuss the pharmacology of sedative-analgesic agents like dexmedetomidine, remifentanil, ketamine, and volatile anesthetics. Dexmedetomidine is a highly selective alpha-2 agonist that provides anxiolysis and cooperative sedation without respiratory depression. It has organ protective effects against ischemic and hypoxic injury, including cardioprotection, neuroprotection, and renoprotection. ⋯ Ketamine is a nonbarbiturate phencyclidine derivative and provides analgesia and apparent anesthesia with relative hemodynamic stability. Volatile anesthetics such as isoflurane, sevoflurane, and desflurane are in daily use in the operating room in the delivery of general anesthesia. A major advantage of these halogenated ethers is their quick onset, quick offset, and ease of titration in rendering the patient unconscious, immobile, and amnestic.
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Critical care clinics · Jul 2009
ReviewDelirium: an emerging frontier in the management of critically ill children.
The objectives of this article are (1) to introduce pediatric delirium and provide understanding of acute brain dysfunction with its classification and clinical presentations (2) to understand how delirium is diagnosed and discuss current modes of delirium diagnosis in the critically ill adult population and translation to pediatrics (3) to understand the prevalence and prognostic significance of delirium in the adult and pediatric critically ill population (4) to discuss the pathophysiology of delirium as currently understood, and (5) to provide general management guidelines for delirium.
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Critical care clinics · Jul 2009
ReviewAltering intensive care sedation paradigms to improve patient outcomes.
Providing sedation and comfort for intensive care patients has evolved in the last few years. New approaches to improving outcomes for intensive care unit (ICU) patients include providing analgesia before adding sedation and recognizing dangerous adverse effects associated with sedative medications, such as prolonged effects of midazolam, propylene glycol toxicity with lorazepam, propofol infusion syndrome, the deliriogenic effects of benzodiazepines and propofol, and bradycardia with dexmedetomidine. There are now reliable and valid ways to monitor pain and delirium in ICU patients. Dexmedetomidine reduces the incidence of delirium, reduces the duration of mechanical ventilation, and appears to be cost effective.
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Critical care clinics · Jul 2009
ReviewProtocolized and target-based sedation and analgesia in the ICU.
Administering sedative and analgesic medications is a cornerstone of optimizing patient comfort and minimizing distress, yet may lead to unintended consequences including delayed recovery from critical illness and slower liberation from mechanical ventilation. The use of structured approaches to sedation management, including guidelines, protocols, and algorithms can promote evidence-based care, reduce variation in clinical practice, and systematically reduce the likelihood of excessive and/or prolonged sedation. Patient-focused sedation algorithms are multidisciplinary, including physician, nurse, and pharmacist development and implementation. ⋯ Sedation protocols generally focus on a) algorithms that incorporate treating sedation and analgesia based upon escalation, de-escalation, or changing medications according to specific targets, or b) daily interruption of sedative and opioid analgesic infusions. Many published sedation protocols have been tested in controlled clinical trials, often demonstrating benefit such as shorter duration of mechanical ventilation, reduced ICU length of stay, and/or superior sedation management compared to usual care. Implementation of sedation algorithms in ICUs is a challenging process for which sufficient resources must be allocated.
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Delirium occurs in 35% to 80% of critically ill hospitalized patients. Little is known of delirium prevention and treatment in the critical care setting. Trials emphasizing early mobilization suggest that this nonpharmacologic approach is associated with improved outcome as well as "delirium days". ⋯ All critical care caregivers should rigorously screen for alcohol abuse, apply alcohol withdrawal scales in alcoholic patients, and titrate sedative drugs. No nonpharmacologic approach or drug has been shown to be beneficial once delirium is established. Considering the importance and the consequences of delirium in the critical care setting, addiction studies are urgently needed.