Annales françaises d'anesthèsie et de rèanimation
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Analgesia and hypnosis are two separate entities and should result in distinct assessment and management for patients admitted to an intensive care unit (ICU). Those patients are exposed to moderate-severe pain and they are likely to remember pain as one bothersome experience. Any cause of patient discomfort is sought with the priority given to pain and adequate analgesia. ⋯ The concept of multimodal analgesia should be extended to the ICU since it may reduce the opioids requirements. In order to facilitate systematic pain and sedation assessment and to adjust daily drug dosages accordingly, it appears crucial to promote educational programs and elaboration of protocols/guidelines in ICU. Protocols/guidelines may help caregivers to rationally use sedatives and opioids and possibly reduce mechanical ventilation and ICU length of stay.
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Sedation and analgesia are a constant challenging issue in paediatric intensive care units, for ethical reasons among others. Basically, goals and available treatments in that context do not differ from those in adults. For instance, while we propose midazolam as the first choice benzodiazepine, there is no evidence for encouraging the use of one morphinomimetic rather than others in children. ⋯ However, some practices can be highlighted such as the use of written protocol on pain/sedation evaluation and therapeutics adapted to children, literature data and local habits, the training of medical/nursing staff and the constitution of local referring team. A particular attention should be paid to propofol: its use longer than several hours should be strongly discouraged in infants and children due to the risk of Propofol Infusion Syndrome. Further clinical studies should be conducted in an attempt to provide answers to routine, daily issues and questions, for example, how to tailor the level of sedation to the needs of the patient, how to stop it, which drug must be preferred or what place for non-pharmacological approaches.
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Sedation-analgesia occupies an essential place in the specific therapeutic arsenal of the brain-injured patients. The maintenance of the perfusion of the brain, its relaxation and its protection are the fundamental objectives whose finality is to avoid the extension of the lesions and to preserve the neuronal capital. Sedation is instituted when patients are severely agitated or present a deterioration of their state of consciousness (GCS< or =8). ⋯ Etomidate does not have its place apart from induction in fast sequence. The neuro-protective effects of ketamine require to be demonstrated in man before being recommended routinely. Withdrawal of sedation can be responsible for a state of agitation which can be controlled by neuroleptics.
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Only few studies have focused on the issues raised by discontinuing sedation in ICU patients. Several lines of evidence allow defining the risk factors for the occurrence of a weaning syndrome due to discontinuation of sedatives and analgesics in ICU patients. These primarily include a prolonged (more than seven days) period of continuous intravenous administration of high doses of hypnotics and opioids. Weaning from sedation is tightly linked to weaning from the ventilator and this area should be the target of research work in the near future.
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To assess the role of sedation and myorelaxant agents in acute respiratory distress syndrome (ARDS) and to propose an updated management according to recent literature. EXTRACTION OF DATA: From Medline and Cochrane database of English and French language articles. Keywords were: acute respiratory distress syndrome, acute lung injury, general anaesthetics, inhalation, intravenous anaesthetics and intensive care. Selection of original articles, reviews and expert reports. Case reports have been included. ⋯ With regard to benefits and inconvenient, sedation is considered as a treatment of ARDS. Its goals are the well being of patient and his/her adaptation to ventilator, but also the prevention on mechanical ventilation associated injuries. Hence, most authors suggest using a deep sedation at the early phase of ARDS. In this contact, use of myorelaxant agent is an intersecting adjuvant if sedation is not enough. The benefit is terms of survival and outcome remains to show.