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Analgosedation of adult patients with elevated intracranial pressure

Survey of current clinical practice in Austria

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Summary

Background

Analgesia and sedation are key items in intensive care. Recently published S3 guidelines specifically address treatment of patients with elevated intracranial pressure.

Methods

The Austrian Society of Anesthesiology, Resuscitation and Intensive Care Medicine carried out an online survey of neurointensive care units in Austria in order to evaluate the current state of practice in the areas of analgosedation and delirium management in this high-risk patient group.

Results

The response rate was 88%. Induction of anesthesia in patients with elevated intracranial pressure is carried out with propofol/fentanyl/rocuronium in >80% of the intensive care units (ICU), 60% use midazolam, 33.3% use esketamine, 13.3% use barbiturates and 6.7% use etomidate. For maintenance of analgosedation up to 72 h, propofol is used by 80% of the ICUs, followed by remifentanil (46.7%), sufentanil (40%) and fentanyl (6.7%). For long-term sedation, 86.7% of ICUs use midazolam, 73.3% sufentanil and 73.3% esketamine. For sedation periods longer than 7 days, 21.4% of ICUs use propofol. Reasons for discontinuing propofol are signs of rhabdomyolysis (92.9%), green urine, elevated liver enzymes (71.4% each) and elevated triglycerides (57.1%). Muscle relaxants are only used during invasive procedures. Inducing a barbiturate coma is rated as a last resort by 53.3% of respondents. The monitoring methods used are bispectral index (BIS™, 61.5% of ICUs), somatosensory-evoked potentials (SSEP, 53.8%), processed electroencephalography (EEG, 38.5%), intraparenchymal partial pressure of oxygen (pO2, 38.5%) and microdialysis (23.1%). Sedation and analgesia are scored using the Richmond agitation and sedation score (RASS, 86.7%), sedation agitation scale (SAS, 6.7%) or numeric rating scale (NRS, 50%) and behavioral pain scale (BPS, 42.9%), visual analogue scale (VAS), critical care pain observation tool (CCPOT, each 14.3%) and verbal rating scale (VRS, 7.1%). Delirium monitoring is done using the confusion assessment method for intensive care units (CAM-ICU, 46.2%) and intensive care delirium screening checklist (ICDSC, 7.7%). Of the ICUs 46.2% do not carry out delirium monitoring.

Conclusion

We found good general compliance with the recommendations of the current S3 guidelines. Room for improvement exists in monitoring and the use of scores to detect delirium.

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Author information

Authors and Affiliations

  1. Department of Anesthesia, Emergency Medicine and Intensive Care; Karl Landsteiner Institute for Emergency Medicine, Medical Simulation and Patient Safety, General Hospital Wiener Neustadt, Corvinusring 3–5, 2700, Wiener Neustadt, Austria

    Guenther Herzer MSc &  Helmut Trimmel MSc

  2. Clinical Department of Anesthesia and Intensive Care, University Hospital, St. Pölten, Austria

    Claudia Mirth

  3. Department of Neuroanesthesia and Intensive Care, Kepler University Hospital, Linz, Austria

    Udo M. Illievich

  4. Department of Anesthesia and Intensive Care, AUVA Trauma Hospital, Salzburg, Austria

    Wolfgang G. Voelckel MSc

Authors
  1. Guenther Herzer MSc
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  2. Claudia Mirth
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  3. Udo M. Illievich
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  4. Wolfgang G. Voelckel MSc
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  5. Helmut Trimmel MSc
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Corresponding author

Correspondence to Helmut Trimmel MSc.

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Conflict of interest

G. Herzer, C. Mirth, U.M. Illievich, W.G. Voelckel, and H. Trimmel declare that they have no competing interests.

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Appendix

Appendix

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Herzer, G., Mirth, C., Illievich, U.M. et al. Analgosedation of adult patients with elevated intracranial pressure. Wien Klin Wochenschr 130, 45–53 (2018). https://doi.org/10.1007/s00508-017-1228-5

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