Sedation in Critically ill

On the issue of sedation of critically ill patients, in recent years is taking place internationally significant cultural revolution.
The use of sedative drugs, or a sedative analgesic drugs, lead to safe benefits for patients admitted to intensive care (comfort, decrease anxiety and agitation, ability to perform life-saving therapies), but show non-negligible side effects: cardio-respiratory depression, delayed weaning from mechanical ventilation, delirium, increased sepsis, worsening of neurological outcome after intensive care, increased mortality. For these reasons, the most important publications of recent years have stressed the importance of reducing the amount of sedatives used, offering a variety of hypotheses:

- Interruption of daily continuous administration of sedatives;
- Use of guide-lines aimed to reducing drug use;
- Sedation based on analgesia, with substantial reduction in the use of sedatives;
- Continuous monitoring of chance to wake-up patients and make them breathe spontaneously;
- Start early physical rehabilitation, to avoid the weakness induced immobility

All these strategies are aimed essentially to accept that patients hospitalized in intensive care unit are more 'awake than was necessary in the past. In particular, with the exception of the first 24 / 48 hours of admission, which may be necessary to maintain deep sedation to perform invasive procedures and for clinical stabilization, the aim to be pursued even in critically ill patients at high risk, which show prolonged critical conditions, it’s RASS = -1 / 0.
The maintenance of critically ill patients in a "quiet and awake" state, well adapted to the environment of the ICU and to the necessary invasive-care does not mean that you must stop the use of sedatives! The critically ill patients comfort is an essential goal that still has to be pursued, but that has proved compatible with the "conscious sedation".
The use of enteral sedation is an effective strategy to maintain an adequate sedation at least as intravenous sedation. However It has fewer cardio-respiratory side effects, presenting a slower pharmacokinetics to discontinuation of therapy may lead to a reduction of delirium induced by drugs. Finally it determines a marked reduction about hospital spending, for sedative drugs.

 

A&A 2009 Haenggi - Auditory potentials, BIS, and entropy for levels of sedation in ICU

 

AJRCCM 2002 Kress - Sedation and analgesia in Intensive Care Unit

 

ANESTH 2007 Payen - Current practices in sedation and analgesia for ventilated ICU patients

 

CC 2008 Sessler - Analgesia and sedation in ICU

 

CC 2010 Jackson - A systemtic review of theimpact of sedation practice in ICU

 

CC 2010 Ogundele - Commentary on reducing sedation in critically ill patients

 

CCM 2002 Jacobi - Clinical practice guidelines for analgesics and sedatives in ICU

 

CHEST 2008 Sessler - Patient focused sedation

 

German guidelines on analgesia-sedation 2010

 

ICM 2005 Cigada - Enteral sedation in ICU patients

 

ICM 2011 Mesnil - Sedation with Sevoflurane vs Propofol vs Midazolam  

 

JAMA 2007 Pandharipande - MENDS Dexmedetomidine vs Lorazepam

 

JAMA 2009 Riker - SEDCOM Dexmedetomidine vs Midazolam

 

JCC 2008 Cigada - Conscious sedation for critically ill patients

 

JCC 2009 Mistraletti - Actigraphic monitoring for observation guided sedation

 

LANCET 2008 Girard - ABC trial in ICU patients

 

LANCET 2010 Strøm - A protocol of no sedation for ventilated ICU patients

 

MA 2010 Strøm - Time to wake up ICU patients

 

Pharmacotherapy 2005 Riker - Adverse events associated with sedatives and analgesics

 

Review 2008 Meurant - Sedation or analgo-sedation in the ICU a multimodality approach