Critical care clinics
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Critical care clinics · Oct 2001
ReviewAnalgesic agents. Pharmacology and application in critical care.
Evaluation of analgesic agents is multifactorial. The authors know of no direct comparisons among the choices in analgesic agents that suggest one therapy over another in global outcomes such as mortality or morbidity. Therefore, until further outcome differentiation between agents is proved, understanding the primary difference of delivery routes, mechanisms of action, pharmacokinetics, and adverse effects serves as the best guide for selecting the appropriate agent for each patient.
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Anxiety, agitation, delirium, and pain are common findings in the ICU. These unhealthy states may lead to increased irritability, discomfort, hypertension, tachycardia, cardiac ischemia, harmful motor activity, and psychologic disquiet for the patient. The appropriate treatment of these conditions may lead to decreased morbidity and mortality in the critically ill patient. ⋯ Furthermore, many caregivers lack sufficient understanding of the appropriate or indicated uses of drugs to allay patients' fears and pain. The use of suitable protocols for the proper titration of sedation of mechanically ventilated patients and monitoring of the level of sedation in ventilated patients may decrease the amount of time that patients are ventilated and may alleviate some of the emotional stresses of recall of painful procedures or uncomfortable mechanical ventilation. Future research into protocols for the care of the critically ill patient can enhance the overall well-being of these patients.
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Several advances are likely to benefit the ICU patient requiring sedation, analgesia, and anxiolysis. The cooperative sedation induced by dexmedetomidine is a unique and valuable state that allows patients to be aroused easily and interferes little with ventilation. Remifentanil is the prototype of short-acting drugs, providing fast onset and offset; its relatively high cost may be balanced by limiting the risk for long-lasting respiratory depression. Lorazepam seems to be finding more proponents, especially in long-term ICU sedation where the costs of the newer agents may be prohibitive.
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Critical care clinics · Oct 2001
ReviewUse of propofol and other nonbenzodiazepine sedatives in the intensive care unit.
Sedatives continue to be used on a routine basis in critically ill patients. Although many agents are available and some approach an ideal, none are perfect. Patients require continuous reassessment of their pain and need for sedation. ⋯ Benzodiazepines and narcotics often are used in concert with propofol to provide reliable amnesia and to relieve pain, respectively. Propofol frequently causes hypotension when administered as a bolus or infusion, particularly in patients with limited cardiac reserve or hypovolemia. More data must be obtained to identify potential deleterious effects of hypertriglyceridemia, and further evaluation of the potential benefits in certain patient populations, such as neurosurgical patients, is needed.
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Although patients with cancer may derive much benefit from treatment, they are at risk for developing life-threatening complications. Hypersensitivity reactions can be severe, as in the case of anaphylaxis with L-asparaginase. Cardiac toxicities consist of arrhythmias with various drugs, hemorrhagic myocarditis with cyclophosphamide and ifosfamide, cardiomyopathy with anthracyclines, and pericardial disease. ⋯ Hemorrhagic cystitis caused by cyclophosphamide and ifosfamide can be severe and result in exsanguination if unresponsive to treatment. Disseminated intravascular coagulation and thrombotic microangiopathy can produce thrombotic or hemorrhagic complications. Gastrointestinal toxicities include significant hepatotoxicity with a variety of drugs and development of acute surgical abdomen.