Critical care clinics
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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 understood. ⋯ 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.
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Critical care clinics · Jul 2009
ReviewCurrent sedation practices: lessons learned from international surveys.
Patient outcomes are significantly influenced by the choice of sedative and analgesic agents, the presence of over- or undersedation, poor pain control, and delirium. Individualized sedation management using sedation assessment tools, sedation protocols, and daily sedative interruption can improve clinical outcomes. ⋯ 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.
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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 commonly used critical care sedatives: propofol, the benzodiazepines, opioids, and alpha(2)-adrenoceptor agonists. Benzodiazepines, opioids, and possibly even propofol worsen outcome in animal models of infection, whereas preliminary evidence suggests that the alpha(2)-adrenoceptor agonist, dexmedetomidine, may improve outcomes in the setting of infection. Given the burden of sepsis and secondary infections in critical care, choice of sedation may need to be carefully considered to preserve immune responses in critically ill patients.
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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". ⋯ 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. Considering the importance and the consequences of delirium in the critical care setting, addiction studies are urgently needed.
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Critical care clinics · Jul 2009
ReviewPharmacology of commonly used analgesics and sedatives in the ICU: benzodiazepines, propofol, and opioids.
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.