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Abstract
Optimal level of sedation and analgesia is important for the comfort and safety of critically ill patients. However, suboptimal sedation is relatively common in the intensive care unit (ICU) and it could cause prolonged mechanical ventilation and ICU stay, also increase delirium and ICU acquired weakness and resultant decreased survival. Therefore, accurate assessment of the level of sedation and analgesia, maintaining adequate level of sedation, and daily evaluation of each patient and following adjustment could be important treatment strategy in critically ill patients. Recently, the strategy for sedation in the ICU is changing toward the direction of lowering sedation level or even "no sedation" with concurrent use of analgesics and the use of ultra short acting analgesics could be helpful in some patients. Clinicians should be aware of the importance of algorithmic approach including daily interruption of sedative and assessment of sedation level and especially in the patients under mechanical ventilation, organizational approaches such as the 'ABCDE' bundle could improve the management of critically ill patients.
Figures and Tables
Figure 1
The 'ABCDE' of critical care. This figure is reprinted from the article by Morandi A, Brummel NE, Ely EW. Sedation, delirium and mechanical ventilation: the 'ABCDE' approach. Curr Opin Crit Care 2011;17:43-9.
Figure 2
Algorithm for the sedation and analgesia of mechanically ventilated patients. Doses are approximate for a 70-kg adult. IVP: intravenous push. aNumeric rating scale or other pain scale. bRiker sedation-agitation scale or other sedation scale. cConfusion assessment method for the ICU. dSee table 2 for intermittent dosing for specific agents. This figure is reprinted from the article Jacobi J, Fraser GL, Coursin DB, Riker RR, Fontaine D, Wittbrodt ET, et al. Clinical practice guidelines for the sustained use of sedatives and analgesics in the critically ill adult. Crit Care Med 2002;30:119-41.
Figure 3
Diagnosis of delirium by CAM-ICU. CAM-ICU: confusion assessment method for the intensive care unit. This figure is reprinted from the article Jacobi J, Fraser GL, Coursin DB, Riker RR, Fontaine D, Wittbrodt ET, et al. Clinical practice guidelines for the sustained use of sedatives and analgesics in the critically ill adult. Crit Care Med 2002;30:119-41.
Table 1
Scales used to measure sedation and agitation
α: Noxious stimulus=suctioning or 5 seconds of vigorous orbital, sterna, or nail bed pressure. This table is reprinted from the book chapter by Jung SW, Kwon YS, Choi JC. Clinical practice guidelines for the use of sedatives and analgesics. In: Koh YS, editor. Clinical practice guideline of the Korean Society of Critical Care Medicine. Seoul: Medlang; 2009. p. 6-19.
Table 2
Pharmacology of selected sedatives
*More frequent doses may be needed for management of acute agitation in mechanically ventilated patients. This table is reprinted from the article Jacobi J, Fraser GL, Coursin DB, Riker RR, Fontaine D, Wittbrodt ET, et al. Clinical practice guidelines for the sustained use of sedatives and analgesics in the critically ill adult. Crit Care Med 2002;30:119-41.
Table 3
Pharmacology of selected analgesics
*More frequent doses may be needed for acute pain management in mechanically ventilated patients; †MAOIs: monoamine oxidase inhibitors; ‡SSRIs: selective serotonin-reuptake inhibitors. This table is reprinted from the article Jacobi J, Fraser GL, Coursin DB, Riker RR, Fontaine D, Wittbrodt ET, et al. Clinical practice guidelines for the sustained use of sedatives and analgesics in the critically ill adult. Crit Care Med 2002;30:119-41.
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