Seminars in respiratory and critical care medicine
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Semin Respir Crit Care Med · Jan 2001
Multidisciplinary management of sedation and analgesia in critical care.
Management of sedation and analgesia in critical care medicine is a multidisciplinary process that involves physicians, nurses, pharmacists, and other healthcare providers. Optimal management of these common issues includes recognition of the importance of predisposing and causative conditions that contribute to the sensations of pain and discomfort, anxiety, and delirium. ⋯ Optimal use of sedative and analgesic medications involves matching unique properties of specific medications with individual patient characteristics. Guidelines that minimize unnecessary variability in practice, prevent excessive medication, and emphasize management based on individual patient characteristics improve the effective utilization of these medications.
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Current choices for sustained sedation in the critically ill include the benzodiazepines, the opiates, and propofol. Each of these groups of medications has their particular benefits: benzodiazepines provide the greatest amnesia, opiates are the only agents to provide analgesia, and propofol is the most easily titratable and the least likely to excessively accrue. ⋯ Further research is needed to determine the role of dexmedetomidine in the ICU. The emerging standard of care for sustained sedation is the use of standardized protocols, formulated with the help of clinical practice guidelines, and titrated with the guidance of sedation monitoring.
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The sleep of intensive care unit (ICU) patients is remarkably disrupted. Several studies, employing both subjective and objective measures of sleep quality, have demonstrated that critically ill patients exhibit severe sleep fragmentation and reduced restorative sleep, particularly a suppression of rapid eye movement (REM) sleep. ⋯ Noise has been a significant focus of investigation, and the effects of medications, light, and patient-care activities have also been examined. Several questions remain to be answered so that caregivers can improve sleep in ICU patients, including the relative contribution of different sleep-disrupting factors and possible changes in patient susceptibility to these factors over time.
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Semin Respir Crit Care Med · Jan 2001
Monitoring sedation, agitation, analgesia, neuromuscular blockade, and delirium in adult ICU patients.
Preliminary evidence suggests that closely monitoring sedation may have a positive effect on patient outcomes, including reductions in intensive care unit (ICU) stay, duration of mechanical ventilatory support, and number of diagnostic tests requested to assess central nervous system function. In the last few years, subjective instruments to assess agitation and sedation have been developed and tested for reliability and validity, including the Sedation-Agitation Scale and the Motor Activity Assessment Scale. ⋯ Promising techniques for objective assessment of sedation (such as the bispectral index) and strategies to guide neuromuscular blockade with train-of-four (TOF) or clinical exam monitoring have emerged. Future efforts should focus on evaluating the impact of these monitoring techniques on specific outcomes in an effort to improve patient comfort, minimize adverse events, and reduce resource consumption.
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Neuromuscular blocking agents (NMBA) are frequently utilized in the ICU, primarily to facilitate mechanical ventilation. An ideal NMBA is nondepolarizing, has no propensity to accumulate, is easily titrated, has a rapid onset and offset, does not rely on organ function for metabolism, and has no toxic or active metabolites. Current NMBAs are classified as aminosteroids or benzylisoquinoliniums and have different features, but none are ideal. ⋯ There are well-recognized complications of NMBA, including prolonged drug effect and acute quadriplegic myopathy. The latter condition can result in prolonged rehabilitation. The use of an NMBA can be essential for the successful outcome from critical illness; however, cautious use of these agents with a structured approach to minimize complications is urged.