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Analgesia and Sedation

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Surgical Intensive Care Medicine

Abstract

Adequate and appropriate analgesia and sedation is a crucial component in the care of critically ill patients. Implementation of a protocol for the assessment for adequate provision of sedation and analgesia is of paramount importance in the management of the critically ill patient. Both pharmacological and not pharmacological interventions play a role and influence outcomes. The assessment and prevention of delirium also influences outcomes and should be also routinely assessed and treated.

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References

  1. Society of Critical Care Medicine. Post-intensive care syndrome. 2013 [Internet] available from: http://www.myicucare.org/Adult-Support/Pages/Post-intensive-Care-Syndrome.aspx. Accessed 25 Mar 2014.

  2. Samuelson KA, Lundberg D, Fridlund B. Stressful memories and psychological distress in adult mechanically ventilated intensive care patients—a 2-month follow-up study. Acta Anaesthesiol Scand. 2007;51:671–8.

    Article  CAS  PubMed  Google Scholar 

  3. Jones C, Bäckman C, Capuzzo M, Flaatten H, Rylander C, Griffiths RD. Precipitants of posttraumatic stress disorder following intensive care: a hypothesis generating study of diversity in care. Intensive Care Med. 2007;33:978–85.

    Article  CAS  PubMed  Google Scholar 

  4. Jones C, Griffiths RD, Humphris G, Skirrow PM. Memory, delusions, and the development of acute posttraumatic stress disorder-related symptoms after intensive care. Crit Care Med. 2001;29:573–80.

    Article  CAS  PubMed  Google Scholar 

  5. Wade DM, Howell DC, Weinman JA, Hardy RJ, Mythen MG, Brewin CR, et al. Investigating risk factors for psychological morbidity three months after intensive care: a prospective cohort study. Crit Care. 2012;16:R192.

    Article  PubMed  PubMed Central  Google Scholar 

  6. Khitab A, Reid J, Bennett V, Adams GC, Balbuena L. Late onset and persistence of post-traumatic stress disorder symptoms in survivors of critical care. Can Respir J. 2013;20:429–33.

    Article  PubMed  PubMed Central  Google Scholar 

  7. Sukantarat K, Greer S, Brett S, Williamson R. Physical and psychological sequelae of critical illness. Br J Health Psychol. 2007;12(Pt 1):65–74.

    Article  PubMed  Google Scholar 

  8. Lat I, McMillian W, Azocar R, In H, Agarwal S, Burke P, et al. The incidence of delirium is associated with longer ICU stay and fewer ventilator free days in surgical ICU patients. Crit Care Med. 2006;34:S483.

    Article  Google Scholar 

  9. Ely EW, Shintani A, Truman B, Speroff T, Gordon SM, Harrell Jr FE, et al. Delirium as a predictor of mortality in mechanically ventilated patients in the intensive care unit. JAMA. 2004;291:1753–62.

    Article  CAS  PubMed  Google Scholar 

  10. Engel HJ, Needham DM, Morris PE, Gropper MA. ICU early mobilization: from recommendation to implementation at three medical centers. Crit Care Med. 2013;41(9 Suppl 1):S69–80.

    Article  PubMed  Google Scholar 

  11. Puthucheary Z, Rawal J, Ratnayake G, Harridge S, Montgomery H, Hart N. Neuromuscular blockade and skeletal muscle weakness in critically ill patients time to rethink the evidence? Am J Respir Crit Care Med. 2012;185:911–7.

    Article  CAS  PubMed  Google Scholar 

  12. Lipshutz AK, Gropper MA. Acquired neuromuscular weakness and early mobilization in the intensive care unit. Anesthesiology. 2013;118:202–15.

    Article  PubMed  Google Scholar 

  13. Balas MC, Vasilevskis EE, Olsen KM, Schmid KK, Shostrom V, Cohen MZ, et al. Effectiveness and safety of the awakening and breathing coordination, delirium monitoring/management, and early exercise/mobility bundle. Crit Care Med. 2014;42:1024–36.

    Article  PubMed  PubMed Central  Google Scholar 

  14. Dale CR, Kannas DA, Fan VS, Daniel SL, Deem S, Yanez 3rd ND, et al. Improved analgesia, sedation and delirium protocol associated with decreased duration of delirium and mechanical ventilation. Ann Am Thorac Soc. 2014;11:367–74.

    Article  PubMed  PubMed Central  Google Scholar 

  15. Reade MC, Finfer S. Sedation and delirium in the intensive care unit. N Engl J Med. 2014;370:444–54.

    Article  CAS  PubMed  Google Scholar 

  16. Barr J, Fraser GL, Puntillo K, Ely EW, Gélinas C, Dasta JF, et al. Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit. Crit Care Med. 2013;41:263–306.

    Article  PubMed  Google Scholar 

  17. Chanques G, Sebbane M, Barbotte E, Viel E, Eledjam JJ, Jaber S. A prospective study of pain at rest: incidence and characteristics of an unrecognized symptom in surgical and trauma versus medical intensive care unit patients. Anesthesiology. 2007;107:858–60.

    Article  PubMed  Google Scholar 

  18. Turner JS, Briggs SJ, Springhorn HE, Potgieter PD. Patients’ recollection of intensive care unit experiences. Crit Care Med. 1990;18:966–8.

    Article  CAS  PubMed  Google Scholar 

  19. Puntillo KA, White C, Morris AB, Perdue ST, Stanik-Hutt J, Thompson CL, et al. Patients’ perceptions and responses to procedural pain: results from Thunder Project II. Am J Crit Care. 2001;10:238–51.

    CAS  PubMed  Google Scholar 

  20. Puntillo KA. Pain experiences of intensive care unit patients. Heart Lung. 1990;19:526–33.

    CAS  PubMed  Google Scholar 

  21. Schelling G, Stoll C, Haller M, Briegel J, Manert W, Hummel T, et al. Health-related quality of life and posttraumatic stress disorder in survivors of the acute respiratory distress syndrome. Crit Care Med. 1998;26:651–9.

    Article  CAS  PubMed  Google Scholar 

  22. Ahlers SJ, van der Veen AM, van Dijk M, Tibboel D, Knibbe CA. The use of the Behavioral Pain Scale to assess pain in conscious sedated patients. Anesth Analg. 2010;110:127–33.

    Article  PubMed  Google Scholar 

  23. Gélinas C, Johnston C. Pain assessment in the critically ill ventilated adult: validation of the Critical-Care Pain Observation Tool and physiologic indicators. Clin J Pain. 2007;23:497–505.

    Article  PubMed  Google Scholar 

  24. Payen JF, Bosson JL, Chanques G, Mantz J, Labarere J, DOLOREA Investigators. Pain assessment is associated with decreased duration of mechanical ventilation in the intensive care unit: a post hoc analysis of the DOLOREA study. Anesthesiology. 2009;111:1308–16.

    Article  PubMed  Google Scholar 

  25. Chanques G, Viel E, Constantin JM, Jung B, de Lattre S, Carr J, et al. The measurement of pain in intensive care unit: comparison of 5 self-report intensity scales. Pain. 2010;151:711–21.

    Article  PubMed  Google Scholar 

  26. Memis D, Inal MT, Kavalci G, Sezer A, Sut N. Intravenous paracetamol reduced the use of opioids, extubation time, and opioid-related adverse effects after major surgery in intensive care unit. J Crit Care. 2010;25:458–62.

    Article  CAS  PubMed  Google Scholar 

  27. Liu LL, Gropper MA. Postoperative analgesia and sedation in the adult intensive care unit. A guide to drug selection. Drugs. 2003;63:755–67.

    Article  CAS  PubMed  Google Scholar 

  28. Strøm T, Martinussen T, Toft P. A protocol of no sedation for critically ill patients receiving mechanical ventilation: a randomised trial. Lancet. 2010;375:475–80.

    Article  PubMed  Google Scholar 

  29. Murdoch S, Cohen A. Intensive care sedation: a review of current British practice. Intensive Care Med. 2000;26:922–8.

    Article  CAS  PubMed  Google Scholar 

  30. Battershill AJ, Keating GM. Remifentanil: a review of its analgesic and sedative use in the intensive care unit. Drugs. 2006;66:365–85.

    Article  CAS  PubMed  Google Scholar 

  31. Dahaba AA, Grabner T, Rehak PH, List WF, Metzler H. Remifentanil versus morphine analgesia and sedation for mechanically ventilated critically ill patients: a randomized double blind study. Anesthesiology. 2004;101:640–6.

    Article  CAS  PubMed  Google Scholar 

  32. Martin J, Franck M, Fischer M, Spies C. Sedation and analgesia in German intensive care units: how is it done in reality? Results of a patient-based survey of analgesia and sedation. Intensive Care Med. 2006;32:1137–42.

    Article  PubMed  Google Scholar 

  33. Pickering G, Loriot MA, Libert F, Eschalier A, Beaune P, Dubray C. Analgesic effect of acetaminophen in humans: first evidence of a central serotonergic mechanism. Clin Pharmacol Ther. 2006;79:371–8.

    Article  CAS  PubMed  Google Scholar 

  34. Peduto VA, Ballabio M, Stefanini S. Efficacy of propacetamol in the treatment of postoperative pain. Morphine sparing effect in orthopedic surgery. Italian Collaborative Group on Propacetamol. Acta Anaesthesiol Scand. 1998;42:293–8.

    Article  CAS  PubMed  Google Scholar 

  35. Tuman KJ, McCarthy RJ, March RJ, DeLaria GA, Patel RV, Ivankovich AD. Effects of epidural anesthesia and analgesia on coagulation and outcome after major vascular surgery. Anesth Analg. 1991;73:696–704.

    Article  CAS  PubMed  Google Scholar 

  36. Ryan P, Schweitzer SA, Woods RJ. Effect of epidural and general anaesthesia compared with general anaesthesia alone in large bowel anastomoses. A prospective study. Eur J Surg. 1992;158:45–9.

    CAS  PubMed  Google Scholar 

  37. Stevens RA, Mikat-Stevens M, Flanigan R, Waters WB, Furry P, Sheikh T, et al. Does the choice of anesthetic technique affect the recovery of bowel function after radical prostatectomy? Urology. 1998;52:213–8.

    Article  CAS  PubMed  Google Scholar 

  38. Bauer C, Hentz JG, Ducrocq X, Meyer N, Oswald-Mammosser M, Steib A, et al. Lung function after lobectomy: a randomized, double-blinded trial comparing thoracic epidural ropivacaine/sufentanil and intravenous morphine for patient-controlled analgesia. Anesth Analg. 2007;105:238–44.

    Article  CAS  PubMed  Google Scholar 

  39. Flisberg P, Törnebrandt K, Walther B, Lundberg J. Pain relief after esophagectomy: thoracic epidural analgesia is better than parenteral opioids. J Cardiothorac Vasc Anesth. 2001;15:282–7.

    Article  CAS  PubMed  Google Scholar 

  40. Grass JA. The role of epidural anesthesia and analgesia in postoperative outcome. Anesthesiol Clin North America. 2000;18:407–28.

    Article  CAS  PubMed  Google Scholar 

  41. Schweinger JW. The pathophysiology, diagnosis and management for flail chest injury and pulmonary contusion: a review. Review course lectures. Anesth Analg. 2001;92:S86–93.

    Article  Google Scholar 

  42. Simon BJ, Cushman J, Barraco R, Lane V, Luchette FA, Miglietta M, et al. Pain management guidelines for blunt thoracic trauma. Trauma. 2005;59:1256–67.

    Article  Google Scholar 

  43. Hall RI, MacLaren C, Smith MS, McIntyre AJ, Allen CT, Murphy JT, et al. Light versus heavy sedation after cardiac surgery: myocardial ischemia and the stress response. Maritime Heart Centre and Dalhousie University. Anesth Analg. 1997;85:971–8.

    CAS  PubMed  Google Scholar 

  44. Kress JP, Pohlman AS, O’Connor MF, Hall JB. Daily interruption of sedative infusions in critically ill patients undergoing mechanical ventilation. N Engl J Med. 2000;342:1471–7.

    Article  CAS  PubMed  Google Scholar 

  45. Ramsay MA, Savege TM, Simpson BR, Goodwin R. Controlled sedation with alphaxalone-alphadolone. Br Med J. 1974;2:656–9.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  46. Riker RR, Picard JT, Fraser GL. Prospective evaluation of the Sedation-Agitation Scale for adult critically ill patients. Crit Care Med. 1999;27:1325–9.

    Article  CAS  PubMed  Google Scholar 

  47. Sessler CN, Gosnell MS, Grap MJ, Brophy GM, O’Neal PV, Keane KA, et al. The Richmond Agitation-Sedation Scale: validity and reliability in adult intensive care unit patients. Am J Respir Crit Care Med. 2002;166:1338–44.

    Article  PubMed  Google Scholar 

  48. Ely EW, Truman B, Shintani A, Thomason JW, Wheeler AP, Gordon S, et al. Monitoring sedation status over time in ICU patients: reliability and validity of the Richmond Agitation-Sedation Scale (RASS). JAMA. 2003;289:2983–91.

    Article  PubMed  Google Scholar 

  49. Riker RR, Fraser GL, Simmons LE, Wilkins ML. Validating the Sedation-Agitation Scale with the Bispectral Index and Visual Analog Scale in adult ICU patients after cardiac surgery. Intensive Care Med. 2001;27:853–8.

    Article  CAS  PubMed  Google Scholar 

  50. De Deyne C, Struys M, Decruyenaere J, Creupelandt J, Hoste E, Colardyn F. Use of continuous bispectral EEG monitoring to assess depth of sedation in ICU patients. Intensive Care Med. 1998;24:1294–8.

    Article  PubMed  Google Scholar 

  51. Nasraway Jr SASA, Wu EC, Kelleher RM, Yasuda CM, Donnelly AM. How reliable is the Bispectral Index in critically ill patients? A prospective, comparative, single blinded observer study. Crit Care Med. 2002;30:1483–7.

    Article  Google Scholar 

  52. Weatherburn C, Endacott R, Tynan P, Bailey M. The impact of bispectral index monitoring on sedation administration in mechanically ventilated patients. Anaesth Intensive Care. 2007;35:204–8.

    CAS  PubMed  Google Scholar 

  53. Ely EW, Truman B, Manzi DJ, Sigl JC, Shintani A, Bernard GR. Consciousness monitoring in ventilated patients: bispectral EEG monitors arousal not delirium. Intensive Care Med. 2004;30:1537–43.

    Article  PubMed  Google Scholar 

  54. Deogaonkar A, Gupta R, DeGeorgia M, Sabharwal V, Gopakumaran B, Schubert A. Bispectral Index monitoring correlates with sedation scales in brain-injured patients. Crit Care Med. 2004;32:2403–6.

    Article  PubMed  Google Scholar 

  55. Jacobs JR, Reves JG, Glass PS. A rationale and technique for continuous infusions in anesthesia. Int Anesthesiol Clin. 1991;29:23–38.

    Article  CAS  PubMed  Google Scholar 

  56. Kress JP, Hall JB. Sedation in the mechanically ventilated patient. Crit Care Med. 2006;34:2541–6.

    Article  PubMed  Google Scholar 

  57. Pandharipande P, Shintani A, Peterson J, Pun BT, Wilkinson GR, Dittus RS. Lorazepam is an independent risk factor for transitioning to delirium in intensive care unit patients. Anesthesiology. 2006;104:21–6.

    Article  CAS  PubMed  Google Scholar 

  58. Wilson KC, Reardon C, Theodore AC, Farber HW. Propylene glycol toxicity: a severe iatrogenic illness in ICU patients receiving IV benzodiazepines: a case series and prospective, observational pilot study. Chest. 2005;128:1674–81.

    Article  CAS  PubMed  Google Scholar 

  59. Devlin JW, Lau AK, Tanios MA. Propofol-associated hypertriglyceridemia and pancreatitis in the intensive care unit: an analysis of frequency and risk factors. Pharmacotherapy. 2005;25:348–52.

    Article  Google Scholar 

  60. Kam PC, Cardone D. Propofol infusion syndrome. Anaesthesia. 2007;62:690–701.

    Article  CAS  PubMed  Google Scholar 

  61. Corbett SM, Moore J, Rebuck JA, Rogers FB, Greene CM. Survival of propofol infusion syndrome in a head-injured patient. Crit Care Med. 2006;34:2479–83.

    Article  CAS  PubMed  Google Scholar 

  62. Vasile B, Rasulo F, Candiani A, Latronico N. The pathophysiology of propofol infusion syndrome. A simple name for a complex syndrome. Intensive Care Med. 2003;29:1417–25.

    Article  PubMed  Google Scholar 

  63. Lang BC, Yang J, Wang Y, Luo Y, Kang Y, Liu J, Zhang WS. An improved design of water-soluble propofol prodrugs characterized by rapid onset of action. Anesth Analg. 2014;118:745–54.

    Article  CAS  PubMed  Google Scholar 

  64. Wong C, Burry L, Molino-Carmona S, Leo M, Tessler J, Hynes P, et al. Analgesic and sedative pharmacology in the intensive care unit. Dynamics. 2004;15:23–6.

    PubMed  Google Scholar 

  65. Ip Yam PC, Forbes A, Kox WJ. Clonidine in the treatment of alcohol withdrawal in the intensive care unit. Br J Anaesth. 1992;68:106–8.

    Article  CAS  PubMed  Google Scholar 

  66. Maccioli GA. Dexmedetomidine to facilitate drug withdrawal. Anesthesiology. 2003;98:575–7.

    Article  PubMed  Google Scholar 

  67. Jakob SM, Ruokonen E, Grounds RM, Sarapohja T, Garratt C, Pocock SJ, et al. Dexmedetomidine vs midazolam or propofol for sedation during prolonged mechanical ventilation. JAMA. 2012;307:1151–60.

    Article  CAS  PubMed  Google Scholar 

  68. Patil N, Weinhouse GL. Randomized controlled trial of dexmedetomidine to treat intensive care unit delirium. Crit Care Med. 2006;34:A1.

    Article  Google Scholar 

  69. Szumita PM, Baroletti SA, Anger KE, Wechsler ME. Sedation and analgesia in the intensive care unit: evaluating the role of dexmedetomidine. Am J Health Syst Pharm. 2007;64:37–44.

    Article  CAS  PubMed  Google Scholar 

  70. Riker RR, Shehabi Y, Bokesch PM, Ceraso D, Wisemandle W, Koura F, et al. Dexmedetomidine vs midazolam for sedation of critically ill patients: a randomized trial. JAMA. 2009;301:489–99.

    Article  CAS  PubMed  Google Scholar 

  71. Pandharipande PP, Pun BT, Herr DL, Maze M, Girard TD, Miller RR, et al. Effect of sedation with dexmedetomidine vs lorazepam on acute brain dysfunction in mechanically ventilated patients: the MENDS randomized controlled trial. JAMA. 2007;298:2644–53.

    Article  CAS  PubMed  Google Scholar 

  72. Inouye SK, Bogardus Jr ST, Charpentier PA, Leo-Summers L, Acampora D, Holford TR, et al. A multicomponent intervention to prevent delirium in hospitalized older patients. N Engl J Med. 1999;340:669–76.

    Article  CAS  PubMed  Google Scholar 

  73. Marcantonio ER, Flacker JM, Wright RJ, Resnick NM. Reducing delirium after hip fracture: a randomized trial. J Am Geriatr Soc. 2001;49:516–22.

    Article  CAS  PubMed  Google Scholar 

  74. Hopkins RO, Weaver LK, Pope D, Orme JF, Bigler ED, Larson-Lohr V. Neuropsychological sequelae and impaired health status in survivors of acute respiratory distress syndrome. Am J Respir Crit Care Med. 1999;160:50–6.

    Article  CAS  PubMed  Google Scholar 

  75. Pandharipande P, Cotton BA, Shintani A, Thompson J, Costabile S, Truman Pun B, et al. Motoric subtypes of delirium in mechanically ventilated surgical and trauma intensive care patients. Intensive Care Med. 2007;33:1726–31.

    Article  PubMed  Google Scholar 

  76. Ely EW, Inouye SK, Bernard GR, Gordon S, Francis J, May L, et al. Delirium in mechanically ventilated patients: validity and reliability of the confusion assessment method for the intensive care unit (CAM-ICU). JAMA. 2001;286:2703–10.

    Article  CAS  PubMed  Google Scholar 

  77. Bergeron N, Dubois MJ, Dumont M, Dial S, Skrobik Y. Intensive care delirium screening checklist: evaluation of a new screening tool. Intensive Care Med. 2001;27:859–64.

    Article  CAS  PubMed  Google Scholar 

  78. Inouye SK, Rushing JT, Foreman MD, Palmer RM, Pompei P. Does delirium contributes to poor hospital outcomes? A three site epidemiological study. J Gen Intern Med. 1998;13:234–42.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  79. Milbrandt EB, Deppen S, Harrison PL, Shintani AK, Speroff T, Stiles RA, et al. Costs associated with delirium. Crit Care Med. 2004;32:955–62.

    Article  PubMed  Google Scholar 

  80. Pun BT, Gordon SM, Peterson JF, Shintani AK, Jackson JC, Foss J, et al. Large scale implementation of sedation and delirium monitoring in the intensive care unit: a report from two medical centers. Crit Care Med. 2005;33:1199–205.

    Article  PubMed  Google Scholar 

  81. Tesar GE, Murray GB, Cassem NH. Use of high-dose intravenous haloperidol in the treatment of agitated cardiac patients. J Clin Psychopharmacol. 1985;5:344–7.

    Article  CAS  PubMed  Google Scholar 

  82. Devlin JW, Roberts RJ, Fong JJ, Skrobik Y, Riker RR, Hill NS. Efficacy and safety of quetiapine in critically ill patients with delirium: a prospective, multicenter, randomized, double-blind, placebo-controlled pilot study. Crit Care Med. 2010;38:419–27.

    Article  CAS  PubMed  Google Scholar 

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Correspondence to Ruben J. Azocar MD, FCCM .

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Alli, S., Azocar, R.J. (2016). Analgesia and Sedation. In: O'Donnell, J., Nácul, F. (eds) Surgical Intensive Care Medicine. Springer, Cham. https://doi.org/10.1007/978-3-319-19668-8_11

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