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Sedation and analgesia are important treatments for critically ill patients who often receive painful interventions in the intensive care unit (ICU) and for whom an ICU stay can be a traumatic experience. As sedation became more commonly used for comfort, we increasingly recognized that too much sedation causes adverse outcomes such as delirium, which is associated with increased morbidity and mortality. In this section, we cover the key principles of:
There are many reasons for sedation in the ICU, such as to prevent dyssynchrony between a patient and the ventilator and to prevent the patient from removing his or her endotracheal tubes or intravenous catheters. However, increasing evidence indicates that minimizing the use of sedation is beneficial.
No conclusive trials have demonstrated a benefit of one sedative medication over another. An open-label trial showed that dexmedetomidine was associated with significantly more adverse effects when used as a single agent for early sedation, as compared with the standard care (propofol, midazolam), while another trial showed no differences.
Common regimens for mechanically ventilated patients include propofol infusion or combination fentanyl and midazolam infusions (pairing analgesic and amnesic effects). The table below lists the common sedatives and analgesics used in the ICU along with their doses and adverse effects.
To balance the right amount of sedation, titrate dose to a target on a validated scale, such as the Riker Sedation–Agitation Scale (SAS) or the Richmond Agitation–Sedation Scale (RASS). Typical goals for a mechanically ventilated patient are 3 to 4 for the SAS and -2 to 0 for the RASS.
Delirium is an acute-onset, fluctuating change in cognition, attention, and/or awareness that is not directly caused by an acute medical condition. It can be classified as:
It’s important to recognize delirium, which is associated with increased mortality and long-term cognitive dysfunction. In the BRAIN-ICU study, patients who experienced longer duration of delirium in the ICU had more profound cognitive decline at 12 months after discharge.
Delirium is very common in the ICU, and it’s more likely to occur in older patients who have received sedatives (especially benzodiazepines) and in patients with more severe illness. A complex interplay of factors contributes to delirium (see figure below).
Delirium is a clinical diagnosis that is made after ruling out other causes of altered mental status (e.g., hypercarbia, drug intoxication, hepatic encephalopathy, uremia, primary central nervous system pathology). Validated scoring systems (see examples in the table below) can aid diagnosis and help with screening for delirium, but they don’t distinguish between hypoactive and hyperactive subtypes.
Confusion Assessment Method for the ICU (CAM-ICU)† Scoring is positive or negative according to the presence or absence of criteria listed Patient must be sufficiently awake (RASS* score, −3 or more) for assessment according to the following criteria:
A score of ≥4 is positive for delirium (with scores of 1 to 3 termed “subsyndromal delirium”) Patient must show at least a response to mild or moderate stimulation. Then score 1 point for each of the following features, as assessed in the manner thought appropriate by the clinician:
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Procedures explained and demonstrated
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Geurin C et al. for the PROSEVA Study Group. N Engl J Med 2013.
In the multicenter PROSEVA trial, 466 patients with moderate-to-severe ARDS (P/F ratio <150) were randomized within 36 hours of intubation and mechanical ventilation to the prone or supine position. Prone positioning reduced 28-day (16% vs. 33%, P<0.001) and 90-day mortality (24% vs. 41%, P<0.001). All centers had used prone positioning in daily practice for more than 5 years and complication rates were similar in the two groups.
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