Sedation and analgesia in the ICU: pharmacology, protocolization, and clinical consequences
Saved in:
| Format: | Book |
|---|---|
| Language: | English |
| Published: |
Philadelphia, PA
Saunders
2011
|
| Series: | Anesthesiology clinics
29,4 |
| Subjects: | |
| Online Access: | Inhaltsverzeichnis |
| Physical Description: | XVI S., S. 567 - 773 Ill., graph. Darst. |
| ISBN: | 9781455733606 |
Staff View
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| adam_text | Sedation and Analgesia in the ICU: Pharmacology, Protocolization, and Clinical Consequences
Contents
Foreword
xiii
Lee A. Fleisher
Preface
xv
Pratik P. Pandharipande and E. Wesley Ely
Pharmacology of Commonly Used Analgesics and Sedatives in the ICU:
Benzodiazepines, Propof ol, and Opioids
567
John W. Deviin 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 pharmacoge-
netic variables that can affect the safety and efficacy of these sedatives
and analgesics.
Pharmacology of Sedative-Analgesic Agents: Dexmedetomidine, Remifentanil,
Ketamine, Volatile Anesthetics, and the Role of Peripheral Mu Antagonists
587
Oliver Panzer, Vivek Moitra, and Robert
N.
Sfaden
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. Remifentanil 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
titratkxi in rendering the patient unconscious, immobile, and amnestic.
Current Sedation Practices: Lessons Learned from International Surveys
607
Sangeeta
Menta,
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 as¬
sessment tools, sedation protocols, and daily sedative interruption can
improve clinical outcomes. Despite the publication of randomized trials
and numerous guidelines, the uptake of proven strategies into routine
practice can be slow. Surveys of clinicians self-reported practice and
Contents
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, eval¬
uating the management of sedation and analgesia in mechanically venti¬
lated adults in the intensive care unit, and to summarize international
critical care sedation practices.
Protocolized and Target-based Sedation and Analgesia in the ICU
625
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 se¬
dation. Patient-focused sedation algorithms are muitidiscipiinary, including
physician, nurse, and pharmacist development and implementation. Key
components of sedation algorithms include identification of goals and spe¬
cific targets, use of valid and reliable tools to assess analgesia, agitation,
and sedation, and incorporation of logical medication selection. Sedation
protocols generally focus on a) algorithms that incorporate treating seda¬
tion and analgesia based upon escalation, de-escalation, or changing med¬
ications 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 benefits such as
shorter duration of mechanical ventilation, reduced ICU length of stay,
and/or superior sedation management compared to usual care. Implemen¬
tation of sedation algorithms in ICUs is a challenging process for which suf¬
ficient resources must be allocated.
Sedation and Weaning from Mechanical Ventilation: Linking Spontaneous
Awakening Trials and Spontaneous Breathing Trials to Improve Patient Outcomes
651
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
affected by strategies for ventilator weaning and sedation. The authors re¬
view literature on weaning from mechanical ventilation and delivery of se¬
dation in critically ill patients, including current guidelines recommending
the use of spontaneous breathing trials and spontaneous awakening trials.
Implementation of these strategies in a wake-up-and-breathe protocol has
demonstrated benefit over the use of spontaneous breathing trials alone.
Altering Intensive Care Sedation Paradigms to Improve Patient Outcomes
663
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 unit (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 dexmede-
tomidine. 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
675
Gerald
L
Weinhouse and Paula
L
Watson
The need for compassionate care of the critically ill often compels clinicians
to treat these patients with
pharmacologie
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
because 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 and
Immunomodulation 687
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
immunologie
effects of the com¬
monly used critical care sedatives: propofol, the benzodiazepines, opioids,
and o^-adrenoceptor agonists. Benzodiazepines, opioids, and possibly
even propofol worsen outcomes in animal models of infection, whereas
preliminary evidence suggests that the 02-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.
Pharmacoeconomics of Sedation in the ICU
707
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 agitated
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.
Contents
Delirium
Prevention and Treatment
721
Yoanna Skrobik
Deiirium occurs in
35%
to
80%
of critically ill hospitalized patients. Little is
known of delirium prevention and treatment in the critical care setting. Tri¬
als emphasizing early mobilization suggest that this nonpharmacologic ap¬
proach 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 pa¬
tients, and titrate sedative drugs. No nonpharmacologic approach or drug
has been shown to be beneficial once delirium is established. Considering
the importance and the consequences of delirium in the critical care set¬
ting, addiction studies are urgently needed.
Deiirium: An Emerging Frontier in the Management of Critically III Children
729
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 pro¬
vide understanding of acute brain dysfunction with its classification and
clinical presentations
(2)
to understand how delirium is diagnosed and dis¬
cuss current modes of delirium diagnosis in the critically ill adult population
and translation to pediatrics
(3)
to understand the prevalence and prognos¬
tic significance of delirium in the adult and
pediatric
critically ill population
(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
751
James
С
Jackson, Nathaniel Mitchell, and
Ramona
О.
Hopkins
Critical illness can and often does lead to significant cognitive impairment
and to the development of psychological disorders. These conditions are
persistent 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 ef¬
fectively in emotional and interpersonal domains. The potential etiologies of
cognitive impairment and psychological morbidity in ICU survivors are par¬
ticularly poorly understood and may vary widely across patients. Potential
contributors may include the potentially toxic effects of sedatives and nar¬
cotics, delirium, hypoxia, glucose dysregulation, metabolic derangements,
and inflammation. Patients with preexisting vulnerabilities, including pre¬
disposing genetic factors, and frail elderly populations may be at particular
risk for emergence of acceleration of conditions such as mild cognitive
impairment
index
765
Sedation and Analgesia in the ICU: Pharmacology, Protocoiization, and Clinical Consequences
xi
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| spelling | Sedation and analgesia in the ICU pharmacology, protocolization, and clinical consequences guest ed. Pratik P. Pandharipande ; E. Wesley Ely Philadelphia, PA Saunders 2011 XVI S., S. 567 - 773 Ill., graph. Darst. txt rdacontent n rdamedia nc rdacarrier Anesthesiology clinics 29,4 Analgesie (DE-588)4001847-7 gnd rswk-swf Sedierung (DE-588)4180607-4 gnd rswk-swf Intensivstation (DE-588)4161965-1 gnd rswk-swf (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 1\p DE-604 b DE-604 Pandharipande, Pratik Sonstige (DE-588)139010505 oth Ely, Eugene Wesley Sonstige (DE-588)1018471383 oth Anesthesiology clinics 29,4 (DE-604)BV021538977 29,4 Digitalisierung UB Regensburg application/pdf http://bvbr.bib-bvb.de:8991/F?func=service&doc_library=BVB01&local_base=BVB01&doc_number=024648795&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 | Sedation and analgesia in the ICU pharmacology, protocolization, and clinical consequences Anesthesiology clinics Analgesie (DE-588)4001847-7 gnd Sedierung (DE-588)4180607-4 gnd Intensivstation (DE-588)4161965-1 gnd |
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| 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 P. Pandharipande ; E. Wesley Ely |
| title_fullStr | Sedation and analgesia in the ICU pharmacology, protocolization, and clinical consequences guest ed. Pratik P. Pandharipande ; E. Wesley Ely |
| title_full_unstemmed | Sedation and analgesia in the ICU pharmacology, protocolization, and clinical consequences guest ed. Pratik P. Pandharipande ; E. Wesley Ely |
| 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 | Analgesie (DE-588)4001847-7 gnd Sedierung (DE-588)4180607-4 gnd Intensivstation (DE-588)4161965-1 gnd |
| topic_facet | Analgesie Sedierung Intensivstation Aufsatzsammlung |
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