Anesthesiology clinics
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Anesthesiology clinics · Dec 2011
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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Despite considerable information on the pharmacotherapy of sedation in the ICU, there is little published on the pharmacoeconomics of sedation in patients who are critically ill. The purpose of this article is to discuss the various components that contribute to the cost of treating the agitated ICU patient and to critically review the articles published since 2000 that evaluated costs and cost-effectiveness in ICU patients receiving drugs for agitation and/or pain. Clinicians should look beyond the acquisition cost of a sedative and include the effect of sedatives on the cost of care when selecting the most appropriate sedative.
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Protocolized target-based sedation and analgesia is central to effective management of sedation. Important components include identifying goals and specific targets,using valid and reliable tools to measure pain, agitation, and sedation, and titrating a logically selected combination of sedatives and analgesics to defined end-points. A variety of approaches to structured management have been tested in controlled trials with major categories of (1) sedation algorithms and protocols and (2) daily interruption of sedation. ⋯ The somewhat discrepant results illustrate, however, that various approaches,such as DIS, may not be optimal for all patients. Further research will be necessary to define these patients and examine alternative strategies. Finally, implementation of structured approaches to sedation management is a challenging, time-consuming process for clinicians that must be supported with sufficient resources to be successful.
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Little is known of nonpharmacologic and pharmacologic delirium prevention and treatment in the critical care setting. Trials emphasizing early mobilization suggest that this nonpharmacologic approach is associated with an improvement in delirium incidence. ⋯ 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, studies to further address prevention and rigorous trials addressing pharmacologic intervention are urgently needed.
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Anesthesiology clinics · Dec 2011
Altering intensive care sedation paradigms to improve patient outcomes.
Providing sedation and comfort for intensive care patients has evolved in the last 30 years but remains difficult for clinicians. As research has focused on this challenging area, the authors have identified ways to improve practice, including providing analgesia before sedation, strategies to help recognize dangerous adverse effects associated with the medications that are used, and better ways to monitor pain and delirium in patients. Dexmedetomidine and propofol have become the preferred sedatives for many ICU situations, and creative ways to administer them, such as linking awakening and breathing trials, are emerging. Finally, screening survivors for cognitive impairments may allow clinicians to refer them for the focused rehabilitation they require.