Sedation or Analgo-sedation in the ICU:A Multimodality Approach

F. Meurant, A. Bodart, and J.P. Koch

Yearbook of Intensive Care Unit and Emergency Medicine, 2008, Volume 2008, Section XXI

Vital signs have been used until now to assess sedation in critical care patients. However, this simplistic approach does not seem to be adequate to achieve optimal patent care. Sedation is an essential component of caring critically ill patients, necessitating both appropriate selection and adequate monitoring of drug therapy. Everyone working in an intensive care unit (ICU) understands the challenge of achieving an adequate level of sedation in an anxious and agitated patient with difficult airway management requiring optimalization of mechanical ventilation. In addition, we know that these patients can rapidly develop hypotension and decreased cardiac output leading to multiple organ dysfunction. This complicates the choice of sedative regimen. The ideal regimen should control pain, anxiety, agitation and delirium while avoiding withdrawal symptoms and minimizing respiratory and cardiac depression. Moreover, pain is a common and unpleasant experience for most medical, surgical, and trauma ICU patients. Failure to recognize pain that frequently leads to agitation may result in excessive daily administration of sedatives, delaying ICU discharge. According to a current consensus regarding sedation in the ICU, pain must be recognized in order to permit a treatment adapted to patient needs. Mechanical ventilation with endotracheal suctioning, surgical incisions, indwelling intravascular or urinary catheters, decubitus muscular and articular compression, as well as mechanical ventilation itself, are all potential sources of pain for long-term treatment patients. This could promote secondary hyperalgesia. Successful pain management improves patient outcomes. Although pain is certainly a cause for anxiety in most ICU patients, many patients suffer from anxiety even after successful analgesia. It is evident that being critically ill and dependent on others for care can invoke anxiety by itself. Accordingly, sedation strategies must recognize and address this problem. Although it may seem self-evident that amnesia for a period of critical illness is desirable, data supporting this notion are lacking. On the contrary, in our experience, the absence of recall for a period in a person’s life may be unsettling for some, even if that period is the negative experience of a critical illness. Pain, anxiety and agitation also trigger a stress response. Sedatives should never be given as a substitute for adequate analgesia. A strategy focusing initially on adequate analgesia will often reduce the need for other sedatives in many critically ill patients. Accordingly, the adequacy of pain management should be frequently reassessed. Whereas some analgesics have sedative properties, the reverse is not true and adequate analgesia should be achieved before any sedation is considered or infused. There is now strong evidence to show that if ICU patients requiring mechanical ventilation have good analgesia, they can be conscious, aware and cooperative all of which lead to a more positive patient experience. In order to perform this, we have to control stress and pain. Delirium is characterized by an acutely changing or fluctuating mental status, inattention, disorientation and an altered level of consciousness that may or may not be accompanied by agitation. Although agitation could be part of delirium, it frequently follows drug withdrawal after a long-term weaning period. This must be anticipated and recognized early to avoid the inherent complications of this extreme comportment, which is, unfortunately, frequent in ICUs.

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