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Évaluation et monitorage de la sédation (échelles de sédation et monitorage de la profondeur de sédation)

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Analgésie et sédation en réanimation

Part of the book series: Le point sur ... ((POINT))

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Plusieurs scores cliniques ont été proposés pour surveiller le degré de sédation des patients de réanimation. Il n’existe pas de méthode de référence et la décision du compromis entre simplicité et exhaustivité se prend au sein de chaque service. Il convient de souligner l’importance de l’évaluation clinique de la sédation. De nombreuses études ont en effet démontré des bénéfices significatifs grâce à un protocole de sédation guidée et titrée par la clinique. Les techniques instrumentales viennent élargir les possibilités offertes aux réanimateurs pour évaluer le niveau de sédation de leurs patients. Mais nous sommes loin d’avoir démontré, avec les index dérivés de l’EEG, un bénéfice cliniquement perceptible dans la gestion de la sédation et en termes de devenir du patient.

Le BIS est un outil facile à utiliser, tant dans sa mise en place que dans l’interprétation des données, mais il est peut-être temps de cibler plus précisément les objectifs attendus de ce moniteur. La sédation en réanimation est en effet particulièrement complexe et fait intervenir de nombreux paramètres: hypnose, anxiolyse, analgésie, adaptation au ventilateur, confort du patient, réactivité adrénergique, adaptation à l’environnement de réanimation, immobilité... Cela explique très probablement le fait qu’un seul chiffre issu de l’activité électrique corticale ne puisse intégrer tant de paramètres complexes, contrairement à un score plus complet comme l’échelle ATICE ou l’association de plusieurs scores (RASS et BPS par exemple). Le BIS a été créé pour monitorer une profondeur d’anesthésie et non les nombreux facteurs constituant la sédation du patient de réanimation. L’écueil de son utilisation en réanimation réside possiblement dans une interprétation trop simpliste de la sédation comme une simple « anesthésie légère ». Il ne faut probablement pas chercher à retrouver en réanimation les bénéfices démontrés de l’utilisation du BIS en anesthésie (réduction de coût liée à une moindre consommation en hypnotique, délai de réveil, sevrage ventilatoire plus précoce). En revanche, l’utilisation de ce moniteur dans la prise en charge globale de la sédation en réanimation en complément de la clinique, ou dans le cadre de la recherche, reste possible. Le BIS a vraisemblablement une place dans le monitorage de la sédation chez les patients curarisés au long cours et chez les patients en HTIC réfractaire nécessitant une sédation par des barbituriques. La conférence de consensus sur la sédation en réanimation de 2007 recommande d’ailleurs l’utilisation du BIS chez les patients curarisés. En revanche, il existe des études intéressantes et encourageantes sur l’utilisation des index dérivés de l’EEG dans le monitorage cérébral. Ces nouveaux outils pourraient apporter une aide dans l’évaluation du pronostic neurologique.

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  1. S. Hamada
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  3. J. Mantz
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Hamada, S., Trouiller, P., Mantz, J. (2010). Évaluation et monitorage de la sédation (échelles de sédation et monitorage de la profondeur de sédation). In: Analgésie et sédation en réanimation. Le point sur .... Springer, Paris. https://doi.org/10.1007/978-2-287-99029-8_4

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