Sedation and analgesia

in
critical care
Dr.Muthukumar
 Need for sedation and analgesia
• Anxiolysis and lessening of fear due to disease

• Prerequisites for NMB administration

• Strange and noisy surroundings

• Inability to communicate

• Pain and discomfort from catheters, ICD, ETT, tracheostomy …

• Inability to move and restraints can cause agitation

• Decreases the complication of metabolic and humoral response to

injury
 Routes of administration

• Intermittent IV as bolus ( midaz, lorazep)

• Continuous infusion (propofol)

• Transdermal application (fentanyl)

• Intramuscular or subcutaneous (morphine)

• Regional blocks and epidural (local anesthetics)

• Oral and rectal

 Ramsay Sedation Score
Level 1 Awake, anxious, agitated, restlessness

Level 2 Awake, cooperative, tranquil.

Level 3 Respond to commands.

Level 4 Asleep, brisk response to stimuli.

Level 5 Asleep, sluggish response to stimuli.

Level 6 Asleep, no response

 Ramsay Sedation Score
Pros
• – 3 levels of awake states
• – 3 levels of asleep states
• – Acceptable interrater reliability
• – Used in many comparative sedation trials
• – Widely used clinically
…and Cons
• – (does not assess “anxiety”)
• – Lack of discrimination and differentiation
• – Does not account for agitation or over sedation
 Richmond Agitation Sédation Scale
Target RASS Description
RASS
+4 Combative, violent, danger to staff
+3 Pulls or removes tube(s) or catheters; aggressive
+2 Frequent nonpurposeful movement, fights ventilator
+1 Anxious, apprehensive , but not aggressive
0 Alert and calm
-1 awakens to voice (eye opening/contact) >10 sec
-2 light sedation, briefly awakens to voice (eye
opening/contact) <10 sec
-3 moderate sedation, movement or eye opening. No eye contact
-4 deep sedation, no response to voice, but movement or
eye opening to physical stimulation
Visual analog scale
 Sleep in critical care patients
• Disruption in sleep-wake cycle and sleep quality

• Nocturnal sleep replaced by fragmented microsleep

• Loss of time sense,inotrops, external stimuli, inadequate light

exposure and sedatives – cause of sleep fragmentation
• BDZ promote sleep continuity but decreases REM and SWS
( stage 3 NREM)
• Leads to thermodysregulation , immune suppression, increased
stress harmone and delirium
 Drugs used for sedation and analgesia
• Benzodiazepines (midazolam, lorazepam)

• Hypnotics (propofol , ketamine, thiopentone)

• Opoids (fentanyl, remifentanyl, morphine)

• Alpha 2 agonists ( dexmeditomedine, clonidine)

• Inhalational anesthetics ( sevoflurane)

• Antipsychotics ( haloperidol, )

• Local anesthetics ( lignocaine, bupivacaine)

• Muscle relaxants ( atracurium, vecuronium, rocuronium, scoline)

 Choice of sedatives

• Short term or long term

• Painful or painless procedure

• Organ dysfunction in patients

• Treating withdrawal syndrome

• Disease pattern
 Concerns

• Daily interruption of sedative infusions

• Continuous infusion vs. intermittent bolus

• Use of neuromuscular blocking agents

• De-escalation of sedation based on protocol

• Monitoring of sedation scale and level (BIS)

Guidelines for sedation in ventilator
patients
Early head injury sedation protocol
ACCM guidelines for NMB in critically ill
 Propofol vs. midazolam infusion
midazolam propofol
Long acting > 48 hrs of ventilation Short acting < 48 hrs of ventilation

Causes delirium by altering sleep pattern Does not interfere with sleep .causes PIS if
when infused for long duration infused > 48 hrs @ > 5mg/kg/hr

More stable hemodynamics Hypotension

Caution in hepatic and renal dysfunction due Safe in hepatic and renal dysfunction
to its metabolites

Addictive if used for > 1 week Not addictive

Increase the ventilator time ( Hall et al) Less when compared to propofol
 Morphine vs. fentanyl
fentanyl morphine
100 times more potent Less potent
Rapid onset short acting ( fat soluble) Long acting and slow onset (water soluble)

High accumulation and Vd cleared by liver Low Vd . Cleared by liver and kidneys

Long time to get eliminated if infused for Eliminated within 6 hours

long duration

Suitable for hepatic and renal dysfunction Caution in renal and hepatic dysfunction

No histamine release Histamine release

Greater hemodynamic stability Hypotension
 Alpha 2 agonists

• Clonidine and dexmedetomidine

• Analgesic, anxiolytic, sedative but not amnestic

• Causes hypotension and bradycardia

• Used with caution in hepatic and renal dysfunction

• Discouraged in patients with LVEF < 30% and heart block

 ketamine

• NMDA antagonist

• Status asthamaticus as infusion

• Dissociative anesthesia , hallucinations, cataleptic state

• Stable hemodynamic & no respiratory depression

• Contraindicated in raised ICP, glaucoma, MI

• Abuse potential is high