Medicina intensiva
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Neuromuscular blockade monitoring aims should be based on effectiveness criteria, that is, to administer the lowest effective dose, and on security criteria, avoiding overdosage and detecting possible residual blockade before patient extubation. A neuromuscular blockade monitoring and usage protocol should be available with predefined objectives for each patient to achieve the minimum effective doses. Maintenance of a light blockade level probably influences the decrease in complications associated with these drugs' use. ⋯ Ensuring adequate sedation and analgesia in a paralysed patient is essential. An inadequately sedated but paralysed patient may subsequently suffer serious psychological and emotional stress. Bispectral index monitoring with sedative doses adjusted to 40-60 values assures, in most situations, correct sedation.
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The airway management is one of the principal skills that a physician needs to ensure optimal ventilation and oxygenation. In this guideline, Sedation and Analgesia Working Group of SEMICYUC describes rapid sequence intubation (RSI) and induction drugs and neuromuscular blocking agents. RSI is the best procedure to ensure optimal airway management in the majority of critically ill patients. ⋯ A proper position of the patient is essential to establish an adequate airway management. Direct visualization of glottis and endotracheal tube pass through vocal cords is the best way to confirm the correct position of it. There are different devices to confirm correct position of the endotracheal tube.
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The use of neuromuscular blockers (NMB) is a frequent practice in Intensive Care Units. However most of the experience with the use of these agents come from the operating room used to deal with patients with different characteristics from those admitted in the ICU. ⋯ Those NMB with organ-independent metabolism as well as those with rapid onset of action are the preferred ones for the use in the critically ill patient substituting older depolarizing agents and those whose metabolism is dependent on the liver and/or kidney, organs frequently impaired in the critically ill patients. Neuromuscular blocking in the critically ill patient should be done according to protocols and monitor its effects in order to avoid complications related to its prolonged use.
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There is a wide intra- and inter-individual variability in sedative dose requirements in mechanically ICU patients. Patient's heterogeneity, the frequent and variable organic dysfunctions, the drug interactions and the possibility of metabolite accumulation could explain this variability. However, this fact must not justify the use of excessive doses to achieve the goals of sedation. ⋯ This SEMICYUC Analgesia and Sedation Work Group recommends not administering more than 4.5 mg/kg/h of propofol or 0.25 mg/kg/h of midazolam. The need to use more than these doses should force a change in the sedative or the combined administration of both. Depending on the clinical situation or the clinical patient's evolution, the use of clonidine, haloperidol or remifentanil could be better options.
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The basic concepts of sedation and analgesia and the tools to asses the level of sedation and analgesia are review. The different methods of sedation and the non pharmacological interventions are described. ⋯ The etiology of patient-ventilator asynchrony in ventilated children and how to treat it are analyzed, giving guides of how to adapt sedation to the level of mechanical ventilation therapy. Finally, general recommendations are given for the analgesia and sedation in mechanically ventilated children.