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© The Board of Management and Trustees of the British Journal of Anaesthesia [2008]. All rights reserved. For Permissions, please email: journals.permissions@oxfordjournals.org
Sedation in the intensive care unit
Specialist Registrar in Anaesthesia
Norfolk and Norwich University Hospital
Norwich
UK
Consultant Anaesthetist
Deputy Regional Advisor and Clinical
Lead Doctor
Norfolk and Norwich University Hospital
Colney Lane
Norwich NR4 7UY
UK
Tel: + 44 1603 287074 Fax: + 44 1603 287886 E-mail: simon.fletcher@nnuh.nhs.uk
Key Words: Over-sedation can increase time on ventilatory support, prolong ICU stay, and may precipitate unnecessary neurological investigations. • Sedation should be tailored to the individual needs of the patient. A combination of drugs is often required. • A continuous infusion of a benzodiazepine has been identified as an independent predictor of a longer duration of mechanical ventilation, stay in the intensive care unit and stay in hospital. • Sedation scores should be used to allow titration of drug administration. • The sedation ‘holiday’ strategy has been shown to decrease the duration of mechanical ventilation and length of stay in ICU.
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Principles of sedation |
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Sedation allows the depression of patients' awareness of the environment and reduction of their response to external stimulation. It plays a pivotal role in the care of the critically ill patient, and encompasses a wide spectrum of symptom control that will vary between patients, and among individuals throughout the course of their illnesses. Heavy sedation in critical care to facilitate endotracheal tube tolerance and ventilator synchronization, often with neuromuscular blocking agents, was routine until relatively recently. The modern ICU ventilator is equipped with a wide range of ventilatory modes and, with the addition of electronic flow triggering, synchronization problems have largely disappeared. The replacement of an endotracheal tube by a tracheostomy reduces the discomfort associated with an artificial airway and may often remove the need for sedation entirely. Thus, modern day sedation involves more than tube tolerance and is now focused on the multifactorial individual needs of the patient.
Critical
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Monitoring sedation |
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Why is it important?
Scoring systems
Clinical scoring systems
Instrumental measures of sedation
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Non-pharmacological methods of aiding sedation |
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Pharmacological management |
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I.V. anaesthetic agents
Propofol
Thiopental
Etomidate
Ketamine
Neuroleptic agents
Haloperidol
Chlorpromazine
Benzodiazepines
Opioids
Remifentanil
Clonidine and dexmedetomidine
Neuromuscular blocking agents
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Delivery of sedation |
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Sedation holidays |
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Sleep on the ICU |
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Methods of aiding sleep
Non-pharmacological methods
Pharmacological methods
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Delirium |
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Accumulation of sedatives |
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Sedation protocols |
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