New horizons (Baltimore, Md.)
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Critically ill patients experience many unpleasant and frightening events while in an ICU. Appropriate concern for pain, discomfort, and anxiety is required from caregivers. The use of reassuring mannerisms, honest communication, and analgesics and sedatives, especially during therapeutic paralysis, improves patient comfort and reduces the morbidity rate. This article reviews the therapeutic options for sedation and experience with these agents in the critically ill.
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Aggressive methods of decreasing oxygen consumption, such as therapeutic musculoskeletal paralysis, are used in patients with marginal oxygen delivery associated with cardiac and respiratory insufficiency. This is especially true of new mechanical ventilation methods designed to decrease tidal volume and peak airway pressures. ⋯ Escalated doses of sedatives, followed by oppressive hemodynamic and ventilatory side-effects, sometimes indicate the need for therapeutic musculoskeletal paralysis to quickly control life-threatening agitation syndromes. Cerebral-function monitoring with portable, noninvasive, computer-processed monitors allows quick recognition of brain functions under titrated, suspended animation in real time, facilitating modulation of therapy when the visual clues of neuronal function disappear.
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Pain is a major problem and primary concern of patients in the ICU. While nonintubated patients can verbalize their discomfort to healthcare providers, intubated patients cannot effectively communicate and are more at risk for inadequate analgesia. Mechanically ventilated, paralyzed patients are at even greater risk for inadequate control of pain. ⋯ A number of techniques are available, ranging from nonsteroidal anti-inflammatory drugs to other techniques and medications. However, analgesia usually requires the use of exogenous opioids. The most critically ill, mechanically ventilated patient receiving controlled alveolar minute ventilation is a candidate for continuous infusion of intravenous narcotics.(ABSTRACT TRUNCATED AT 250 WORDS)
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Neuromuscular blocking agents (NMBAs) are used in critical illness to reduce metabolic demands and prevent ventilator asynchrony in patients refractory to sedation and anxiolysis. Concurrent interventions for patients receiving neuromuscular blockade include many factors related to prevention, maintenance, and monitoring during immobilization. Prevention interventions include skin care, turning regimes, physical therapy, eye care, and pulmonary toilet to prevent atelectasis, pneumonia, skin breakdown, and corneal ulceration. ⋯ Cost of therapy is influenced by preventing the side-effects of immobility, the choice of NMBA, and concurrent drug therapies, as well as by titration of the NMBA to the lowest drug dose possible to obtain clinical end-points. Clinical end-points are individualized by the prescribing physician and may range from "no movement" to "movement acceptable but no evidence of spontaneous respirations" to "movement acceptable but no ventilator asynchrony." Whenever "no movement"c is identified as the goal, a nerve stimulator is used to identify the depth of paralysis and prevent accidental surplus drug administration, which may result in prolonged paralysis. Methods for using the nerve stimulator and troubleshooting techniques are discussed.
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The practice of critical care medicine has progressed dramatically over the past several decades. With the advent of new pharmacological therapies and technological interventions, our ability to manage a multitude of pathophysiologic conditions has grown. ⋯ Associated with new therapeutic and diagnostic interventions are secondary side effects and complications. It is often the undesired sequela of all interventions that forces clinicians to periodically reevaluate to whom, why, how, and when we employ new drugs or procedures.