Critical care clinics
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Recent advances in the pharmacology of sedative drugs have expanded their use in the intensive care unit. Indications and endpoints for sedation, however, often are defined poorly and are difficult to assess. ⋯ New indications for sedation have been proposed in recent years, including enforcing sleep/wake cycles, manipulating cellular metabolism, and preventing myocardial ischemia. The evidence supporting the efficacy of these new indications is not yet complete.
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This article discusses the potential benefits of sedation for the mechanically ventilated patient. These benefits include the alleviation of anxiety and pain, which may result in a reduction of oxygen consumption. Other advantages include improved synchronization of a patient's breathing pattern with ventilator settings and better patient care, comfort, and safety. The patient's clinical situation, such as respiratory failure caused by right-to-left shunt, cardiovascular problems, elevated intracranial pressure, hepatic disease, and renal failure, needs to be considered when selecting a sedative agent.
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Intravenous (IV) sedation is convenient, and many different IV agents are used. They are not always effective, however, and there are disadvantages to every intravenous agent used in clinical practice. Inhalational anesthetics are a useful alternative and have specific advantages. Further technologic refinements in the technique of inhalational sedation of mechanically ventilated patients may lead to wider clinical applications.
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In a modern, hectic, and stressful intensive care unit, sedation is an important aspect of care, and every nurse and physician in a critical care setting must be familiar with it. This article describes older modalities of sedation, including barbiturates and neuroleptics, and compares them to a more recently developed drug, propofol.
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Critical care clinics · Oct 1995
ReviewOptimal intravenous dosing strategies for sedatives and analgesics in the intensive care unit.
Achieving and maintaining adequate levels of analgesia and sedation in critically ill patients is a fundamental part of ICU care. Understanding the clinical pharmacology of commonly used sedative agents (e.g., midazolam, lorazepam, and propofol) and opioids (e.g., fentanyl and morphine) enables clinicians to best dose these drugs to the desired clinical effect while minimizing the risk of excessive sedation and cardiopulmonary depression. This has significant safety and cost implications for patient care in the ICU. ⋯ Given the uncertainty of resulting plasma concentrations with long-term administration of these medications, the best ways to achieve and maintain optimal levels of sedation and analgesia while minimizing the risk of oversedation and side effects are to (1) initiate sedation in an incremental fashion until the desired level of sedation is achieved, then periodically (i.e., once a day) titrate the infusion rate of sedative-hypnotics and opioids downward until the patient begins to emerge from the sedative effects of these drugs; and finally gradually increase the infusion rate until the desired level of sedation is once again achieved; and (2) consider the use of a sedation scale to standardize the level of sedation to be maintained (see Table 3). The use of such a scale enables physicians to communicate to nursing staff the specific level of sedation to be achieved and maintained in an individual patient (i.e., titrate the midazolam infusion between 0 to 5 mg/hr to maintain a sedation score of 2-3; call MD for inadequate sedation, respiratory depression, or hypotension). Achieving optimal sedation and analgesia of patients in the ICU requires not only that the choice of medication(s) be appropriate for the clinical setting but also that there are specific clinical endpoints for the agents used (i.e., light versus deep sedation, continuous versus intermittent sedation, sedation with