Sedation and analgesia in the ICU: pharmacology, protocolization, and clinical consequences
Saved in:
| Main Author: | |
|---|---|
| Format: | Book |
| Language: | English |
| Published: |
Philadelphia [u.a.]
Saunders
2009
|
| Series: | Critical care clinics
25,3 |
| Subjects: | |
| Online Access: | Inhaltsverzeichnis |
| Physical Description: | XVI, S.[431]-635 graph. Darst. |
| ISBN: | 9781437712032 1437712037 |
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| adam_text | Titel: Sedation and analgesia in the ICU
Autor: Pandharipande, Pratik
Jahr: 2009
Sedation and Analgesia in the ICU: Pharmacology, Protocolization, and Clinical Consequences
Contents
Erratum xiii
Preface xv
Pratik Pandharipande and E. Wesley Ely
Pharmacology of Commonly Used Analgesics and Sedatives in the ICU:
Benzodiazepines, Propofol, and Opioids 431
John W. Devlin and Russel J. Roberts
Opioids, benzodiazepines, and propofol remain the mainstay by which to
optimize patient comfort and facilitate mechanical ventilation in patients
who are critically ill. Unfortunately none of these agents share all of the
characteristics of the ideal sedative or analgesic agent: rapid onset, rapid
recovery, a predictable dose response, a lack of drug accumulation, and
no toxicity. To optimize care, critical care clinicians should be familiar with
the many pharmacokinetic, pharmacodynamic, and pharmacogenetic
variables that can affect the safety and efficacy of these sedatives and
analgesics.
Pharmacology of Sedative-Analgesic Agents: Dexmedetomidine, Remitentanil,
Ketamine, Volatile Anesthetics, and the Role of Peripheral Mu Antagonists 451
Oliver Panzer, Vivek Moitra, and Robert N. Sladen
In this article, the authors discuss the pharmacology of sedative-analgesic
agents like dexmedetomidine, remifentanil, ketamine, and volatile anes¬
thetics. Dexmedetomidine is a highly selective alpha-2 agonist that pro¬
vides anxiolysis and cooperative sedation without respiratory depression.
It has organ protective effects against ischemic and hypoxic injury, includ¬
ing cardioprotection, neuroprotection, and renoprotection. Remrfentanil is
an ultra-short-acting opioid that acts as a mu-receptor agonist. Ketamine
is a nonbarbiturate phencyclidine derivative and provides analgesia and
apparent anesthesia with relative hemodynamic stability. Volatile anes¬
thetics such as isoflurane, sevoflurane, and desflurane are in daily use in
the operating room in the delivery of general anesthesia. A major advantage
of these halogenated ethers is their quick onset, quick offset, and ease of
titration in rendering the patient unconscious, immobile, and amnestic.
Current Sedation Practices: Lessons Learned from International Surveys 471
Sangeeta Mehta, lain McCullagh, and Lisa Burry
Patient outcomes are significantly influenced by the choice of sedative and
analgesic agents, the presence of over- or undersedation, poor pain con¬
trol, and delirium. Individualized sedation management using sedation
assessment tools, sedation protocols, and daily sedative interruption
can improve clinical outcomes. Despite the publication of randomized
trials and numerous guidelines, Hie uptake of proven strategies into routine
Contents
practice can be slow. Surveys of clinicians self-reported practice and
prospective practice audits characterize sedation and analgesia practices
and provide directions for education and future research. The objective of
this review is to present the findings of surveys and practice audits,
evaluating the management of sedation and analgesia in mechanically
ventilated adults in the intensive care unit, and to summarize international
critical care sedation practices.
Protocolized and Target-based Sedation and Analgesia in the ICU 489
Curtis N. Sessler and Sammy Pedram
Administering sedative and analgesic medications is a cornerstone of opti¬
mizing patient comfort and minimizing distress, yet may lead to unintended
consequences including delayed recovery from critical illness and slower
liberation from mechanical ventilation. The use of structured approaches to
sedation management, including guidelines, protocols, and algorithms can
promote evidence-based care, reduce variation in clinical practice, and
systematically reduce the likelihood of excessive and/or prolonged sedation.
Patient-focused sedation algorithms are multidisciplinary, including physi¬
cian, nurse, and pharmacist development and implementation. Key compo¬
nents of sedation algorithms include identification of goals and specific
targets, use of valid and reliable tools to assess analgesia, agitation, and
sedation, and incorporation of logical medication selection. Sedation proto¬
cols generally focus on a) algorithms that incorporate treating sedation and
analgesia based upon escalation, de-escalation, or changing medications
according to specific targets, or b) daily interruption of sedative and opioid
analgesic infusions. Many published sedation protocols have been tested
in controlled clinical trials, often demonstrating benefit such as shorter dura¬
tion of mechanical ventilation, reduced ICU length of stay, and/or superior
sedation management compared to usual care. Implementation of sedation
algorithms in ICUs is a challenging process for which sufficient resources
must be allocated.
Sedation and Weaning from Mechanical Ventilation: Linking Spontaneous
Awakening Trials and Spontaneous Breathing Trials to Improve Patient Outcomes 515
Michael H. Hooper and Timothy D. Girard
Liberation from mechanical ventilation is a vital treatment goal in the man¬
agement of critically ill patients. The duration of mechanical ventilation is af¬
fected by strategies for ventilator weaning and sedation. The authors review
literature on weaning from mechanical ventilation and delivery of sedation in
critically ill patients, including current guidelines recommending the use of
spontaneous breathing trials and spontaneous awakening trials, implemen¬
tation of these strategies in a wake-up-and-breathe protocol has demon¬
strated benefit over the use of spontaneous breathing trials alone.
Altering Intensive Care Sedation Paradigms to Improve Patient Outcomes 527
Richard R. Riker and Gilles L Fraser
Providing sedation and comfort for intensive care patients has evolved in
the last few years. New approaches to improving outcomes for intensive
care unrt (ICU) patients include providing analgesia before adding sedation
and recognizing dangerous adverse effects associated with sedative
Contents
medications, such as prolonged effects of midazolam, propylene glycol
toxicity with lorazepam, propofol infusion syndrome, the deliriogenic
effects of benzodiazepines and propofol, and bradycardia with dexmedeto-
midine. There are now reliable and valid ways to monitor pain and delirium in
ICU patients. Dexmedetomidine reduces the incidence of delirium, reduces
the duration of mechanical ventilation, and appears to be cost effective.
Sedation and Sleep Disturbances in the ICU 539
Gerald L. Weinhouse and Paula L Watson
The need for compassionate care of the critically ill often compels clinicians
to treat these patients with pharmacologic sedation. Although patients may
appear to be asleep under the influence of these sedating medications, the
relationship between sleep and sedation is complex and not fully under¬
stood. These medications exert their effects at different points along the
central nervous system s natural sleep pathway, leading to similarities
and differences between the two states. This relationship is important be¬
cause critically ill patients sleep poorly and this phenomenon has been
linked to poor intensive care unit outcomes. Therefore, greater awareness
of the effects of these medications on sleep may lead to sedation protocols
that further improve outcomes. This article reviews the relationship between
sedation and sleep from physiologic and clinical perspectives.
Sedation Immunomodulation 551
Robert D. Sanders, Tracy Hussell, and Mervyn Maze
The management of critically ill patients necessitates the use of sedatives
and analgesics to provide patient comfort and cooperation. These drugs
exert profound effects on all organ systems, not only the central nervous
system, and this article describes the immunologic effects of the com¬
monly used critical care sedatives: propofol, the benzodiazepines, opioids,
and c^-adrenoceptor agonists. Benzodiazepines, opioids, and possibly
even propofol worsen outcome in animal models of infection, whereas
preliminary evidence suggests that the a2-adrenoceptor agonist, dexme¬
detomidine, may improve outcomes in the setting of infection. Given the
burden of sepsis and secondary infections in critical care, choice of seda¬
tion may need to be carefully considered to preserve immune responses in
critically ill patients.
Pharmacoeconomia of Sedation in the ICU 571
Joseph F. Dasta and Sandra Kane-Gill
Despite considerable information on the pharmacotherapy of sedation in
the ICU, there is little published on the pharmacoeconomics of sedation
in patients who are critically ill. The purpose of this article is to discuss
the various components that contribute to the cost of treating the agftated
ICU patient and to critically review the articles published since 2000 that
evaluated costs and cost-effectiveness in ICU patients receiving drugs
for agitation and/or pain. Clinicians should look beyond the acquisition
cost of a sedative and include the effect of sedatives on the cost of care
when selecting the most appropriate sedative.
i
Contents
Delirium Prevention and Treatment 585
Yoanna Skrobik
Delirium occurs in 35% to 80% of critically ill hospitalized patients. Little is
known of delirium prevention and treatment in the critical care setting.
Trials emphasizing early mobilization suggest that this nonpharmacologic
approach is associated with improved outcome as well as delirium days .
Titration and reduction of opiate analgesics and sedatives may improve
subsyndromal delirium rates. All critical care caregivers should rigorously
screen for alcohol abuse, apply alcohol withdrawal scales in alcoholic
patients, and titrate sedative drugs. No nonpharmacologic approach or
drug has been shown to be beneficial once delirium is established. Consi¬
dering the importance and the consequences of delirium in the critical care
setting, addiction studies are urgently needed.
Delirium: An Emerging Frontier in the Management of Critically III Children 593
Heidi A.B. Smith, D. Catherine Fuchs, Pratik P. Pandharipande,
Frederick E. Barr, and E. Wesley Ely
The objectives of this article are (1) to introduce pediatric delirium and
provide understanding of acute brain dysfunction with its classification
and clinical presentations (2) to understand how delirium is diagnosed
and discuss current modes of delirium diagnosis in the critically ill adult pop¬
ulation and translation to pediatrics (3) to understand the prevalence and
prognostic significance of delirium in the adult and pediatric critically ill pop¬
ulation (4) to discuss the pathophysiology of delirium as currently
understood, and (5) to provide general management guidelines for delirium.
Cognitive Functioning, Mental Health, and Quality of Life in the ICU Survivors:
An Overview 615
James C. Jackson, Nathaniel Mitchell, and Ramona O. Hopkins
Critical illness can and often does lead to significant cognitive impairment and
to the development of psychological disorders. These conditions are persis¬
tent and, although they improve with time, often fail to completely abate.
Although the functional correlates of cognitive and psychological morbidity
(depression, anxiety, and posttraumatic stress disorder) have been studied,
they may include poor quality of life, inability to return to work or to work at
previously established levels, and inability to function effectively in emotional
and interpersonal domains. The potential etiologies of cognitive impairment
and psychological morbidity in ICU survivors are particularly poorly under¬
stood and may vary widely across patients. Potential contributors may in¬
clude the potentially toxic effects of sedatives and narcotics, delirium,
hypoxia, glucose dysregulation, metabolic derangements, and inflammation.
Patients with preexisting vulnerabilities, including predisposing genetic fac¬
tors, and frail elderly populations may be at particular risk for emergence of
acceleration of conditions such as mild cognitive impairment.
Index 629
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| spelling | Pandharipande, Pratik Verfasser (DE-588)139010505 aut Sedation and analgesia in the ICU pharmacology, protocolization, and clinical consequences guest ed. Pratik Pandharipande Philadelphia [u.a.] Saunders 2009 XVI, S.[431]-635 graph. Darst. txt rdacontent n rdamedia nc rdacarrier Critical care clinics 25,3 Anesthesia Anesthesia and Analgesia Critical Care Critical care medicine Sedatives Intensivstation (DE-588)4161965-1 gnd rswk-swf Analgesie (DE-588)4001847-7 gnd rswk-swf Sedierung (DE-588)4180607-4 gnd rswk-swf 1\p (DE-588)4143413-4 Aufsatzsammlung gnd-content Intensivstation (DE-588)4161965-1 s Analgesie (DE-588)4001847-7 s Sedierung (DE-588)4180607-4 s b DE-604 Critical care clinics 25,3 (DE-604)BV000019838 25,3 HBZ Datenaustausch application/pdf http://bvbr.bib-bvb.de:8991/F?func=service&doc_library=BVB01&local_base=BVB01&doc_number=017759512&sequence=000002&line_number=0001&func_code=DB_RECORDS&service_type=MEDIA Inhaltsverzeichnis 1\p cgwrk 20201028 DE-101 https://d-nb.info/provenance/plan#cgwrk |
| spellingShingle | Pandharipande, Pratik Sedation and analgesia in the ICU pharmacology, protocolization, and clinical consequences Critical care clinics Anesthesia Anesthesia and Analgesia Critical Care Critical care medicine Sedatives Intensivstation (DE-588)4161965-1 gnd Analgesie (DE-588)4001847-7 gnd Sedierung (DE-588)4180607-4 gnd |
| subject_GND | (DE-588)4161965-1 (DE-588)4001847-7 (DE-588)4180607-4 (DE-588)4143413-4 |
| title | Sedation and analgesia in the ICU pharmacology, protocolization, and clinical consequences |
| title_auth | Sedation and analgesia in the ICU pharmacology, protocolization, and clinical consequences |
| title_exact_search | Sedation and analgesia in the ICU pharmacology, protocolization, and clinical consequences |
| title_full | Sedation and analgesia in the ICU pharmacology, protocolization, and clinical consequences guest ed. Pratik Pandharipande |
| title_fullStr | Sedation and analgesia in the ICU pharmacology, protocolization, and clinical consequences guest ed. Pratik Pandharipande |
| title_full_unstemmed | Sedation and analgesia in the ICU pharmacology, protocolization, and clinical consequences guest ed. Pratik Pandharipande |
| title_short | Sedation and analgesia in the ICU |
| title_sort | sedation and analgesia in the icu pharmacology protocolization and clinical consequences |
| title_sub | pharmacology, protocolization, and clinical consequences |
| topic | Anesthesia Anesthesia and Analgesia Critical Care Critical care medicine Sedatives Intensivstation (DE-588)4161965-1 gnd Analgesie (DE-588)4001847-7 gnd Sedierung (DE-588)4180607-4 gnd |
| topic_facet | Anesthesia Anesthesia and Analgesia Critical Care Critical care medicine Sedatives Intensivstation Analgesie Sedierung Aufsatzsammlung |
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