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The prevention or treatment of pain, anxiety, and delirium in the ICU is an important goal. But achieving a balance between sedation and analgesia, especially in critically ill patients on mechanical ventilation, can be challenging. Both under- and oversedation carry serious risks. In 2002 the Society of Critical Care Medicine, along with the American Society of Health-System Pharmacists, updated recommendations in its clinical practice guidelines for the sustained use of sedatives and analgesics in adults. This two-part series examines those recommendations that relate to sedation assessment and management, as well as the current literature. This month Part 1 also reviews pertinent recommendations concerning pain and delirium and discusses tools for assessing pain, delirium, and sedation. In August Part 2 will explore pharmacologic and nonpharmacologic management of anxiety and agitation in critically ill patients. The prevention or treatment of pain, anxiety, and delirium in the ICU is an important goal. But achieving a balance between sedation and analgesia, especially in critically ill patients on mechanical ventilation, can be challenging. Both under- and oversedation carry serious risks. In 2002 the Society of Critical Care Medicine, along with the American Society of Health-System Pharmacists, updated recommendations in its clinical practice guidelines for the sustained use of sedatives and analgesics in adults. This two-part series examines those recommendations that relate to sedation assessment and management, as well as the current literature. This month Part 1 also reviews pertinent recommendations concerning pain and delirium and discusses tools for assessing pain, delirium, and sedation. In August Part 2 will explore pharmacologic and nonpharmacologic management of anxiety and agitation in critically ill patients.
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PMID:The sedation of critically ill adults: Part 1: Assessment. The first in a two-part series focuses on assessing sedated patients in the ICU. 1758 28

In 2000, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) introduced the mandate for the implementation of standards for both pain assessment and need for therapy in hospitalized patients. The need for the appropriate titration of sedation and analgesia is particularly poignant in an intensive care unit (ICU) setting where iatrogenic discomfort often complicates patient management. Neurologically ill patients in ICUs present particularly complex sedation issues, owing to the need to monitor these patients with serial neurological exams. Hence, maximal comfort without diminishing neurological responsiveness is desirable. Here, we review the frequently applied methods of evaluating levels of pain and agitation in critically ill patients as well as discuss the appropriate classes of pharmaceutical agents common to this population, with particular emphasis on the potential neurophysiological impact of such therapy.
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PMID:Critical care sedation for neuroscience patients. 1763 15

The purpose of this study was to ascertain whether total intravenous anesthesia (TIVA) with propofol and remifentanil differs from inhalational anesthesia with desflurane and nitrous oxide in terms of hemodynamics, recovery profile, and postoperative analgesic demand in patients undergoing elective microsurgical vertebral disk resection. A total of 60 patients were randomly assigned to receive TIVA with propofol and remifentanil or inhalational anesthesia with desflurane and nitrous oxide. The TIVA group (n=30) then received 50%/50% N(2)O/O(2). A constant infusion of remifentanil was provided at 0.125 microg/kg/min accompanied by propofol at 10 mg/kg/h in the first 10 min, 6 mg/kg/h in the second 10 min, then 4 mg/kg/h. The desflurane group (n=30) received 50%/50% N(2)O/O(2), with 5% desflurane after intubation and 6% before incision; desflurane was administered in a minimum alveolar concentration 1 fashion during the operation. Hemodynamic, O(2) saturation, and end-tidal CO(2) data were recorded before induction, after intubation, after prone positioning, 5, 10, 15, 20, and 30 min into the operation, and at 15-min intervals thereafter until the end of the operation. Details on perioperative bradycardia, hypotension or hypertension, spontaneous breathing, extubation, eye opening, recovery time of ability to give name and date of birth, postoperative nausea and vomiting, shivering, agitation, and hypoxia were recorded. Patients anesthetized with desflurane responded to skin incision with increasing blood pressure and tachycardia; however, no other hemodynamic differences were noted between the 2 groups. In the TIVA group, recovery times were shorter for spontaneous ventilation (2.33-3.53 min), extubation (3.13-3.88 min), eye opening (4.06-6.23 min), and being able to give name and date of birth (5.4-7.9 min) compared with times in the desflurane group (P<.05). In the TIVA group, more postoperative shivering (16.7% of patients) and greater analgesic demand were seen than in the desflurane group. Although nausea and vomiting were more common in the desflurane group, no difference in bronchospasm was reported. In the TIVA group, a shorter recovery period and a greater demand for postoperative analgesia were seen. Because of the lack of residual analgesic effects, postoperative analgesic treatment should be initiated immediately in patients undergoing TIVA.
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PMID:Remifentanil-propofol in vertebral disk operations: hemodynamics and recovery versus desflurane-n(2)o inhalation anesthesia. 1766 Jan 73

The prevention and treatment of pain, anxiety, and delirium in the ICU are important goals. But achieving a balance between sedation and analgesia, especially in critically ill patients on mechanical ventilation, can be challenging. Both under- and oversedation carry grave risks. Without having an agreed-upon end point for sedation, different providers will likely have disparate treatment goals, increasing the risk of iatrogenic complications and possibly impeding recovery. In 2002 the Society of Critical Care Medicine, along with the American Society of Health-System Pharmacists, updated recommendations in its clinical practice guidelines for the sustained use of sedatives and analgesics in adults. This two-part series examines those recommendations concerning sedation assessment and management, as well as the current literature. Last month, Part 1 reviewed pertinent recommendations concerning pain and delirium and discussed tools for assessing pain, delirium, and sedation. This month, Part 2 explores pharmacologic and nonpharmacologic management of anxiety and agitation in the ICU. The second in a two-part series focuses on the pharmacologic and nonpharmacologic management of anxiety and agitation in the ICU.
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PMID:The sedation of critically ill adults: part 2: management. 1766 89

Psychological status of patients during epidural and intravenous (i.v.) morphine administration are not known enough. It's known that after administration of morphine epidurally and intravenously plasma concentrations are similar but the concentrations in cerebrospinal fluide are different. The effects of two postoperative analgesia treatment regimens on the psychological and mental functions of the elderly after major orthopedic surgery were investigated in this randomized, blinded study. Morphine was used epidurally in Group E and intravenously in Group IV with patient controlled analgesia method for postoperative analgesia treatment. All patients were assessed for psychological status the day before surgery and 2 days after surgery using the Brief Symptom Inventory (BSI). The results of the BSI were assessed with the Global Severity Index (GSI). Nine subscales were also derived: depression, somatization, obsessive-compulsive, anxiety, interpersonal sensitivity, hostility, phobic anxiety, paranoid ideation, and psychoticism. There was not significant difference between the groups for preoperative and postoperative GSI results (p>0.05). Only interpersonal sensitivity subscale results in Group i.v. were decreased compared to the baseline (p<0.001). Preoperative BSI and submeasurement test scores revealed no correlation with total morphine consumption in both groups (p>0.05). Mental changes like agitation, time and place disorientation were seen equally in both groups. This study showed that after epidural and intravenouse morphine administration, no psychologycal changes were observed in the postoperative period compared with baseline. Patients who received morphine intravenously were showed less interpersonal sensitivity in the postoperative period.
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PMID:The effect of opioid administration by different routes on the psychological functions of elderly patients. 1815 77

Patient-focused sedation and analgesia in the ICU encompasses a strategy of comprehensive structured management that matches initial evaluation, monitoring, medication selection, and the use of protocols with patient characteristics and needs. This is best accomplished through interdisciplinary management by physicians, nurses, and pharmacists. An early consideration is that of the potential predisposing and precipitating factors, as well as prior sedative or analgesic use, factors that may influence pharmacologic and supportive therapy. Frequent monitoring with validated tools improves communication among clinicians and plays an important role in detecting and treating pain and agitation while avoiding excessive or prolonged sedation. Patient-focused management encompasses selecting medications best suited to patient characteristics, including the presence of organ dysfunction that may influence drug metabolism or excessive risk for side effects. The use of protocols to optimize drug therapy has emerged as a key component of management, resulting in reductions in the duration of sedation, mechanical ventilation, and ICU length of stay demonstrated with strategies to titrate medications to specific targets, daily interruption of sedation, intermittent rather than continuous therapy, and analgesia-based therapy. While much attention is paid to the initiation and maintenance of therapy, greater emphasis must be placed on careful de-escalation of therapy in order to avoid analgesic or sedative withdrawal. Finally, more work is needed to explore the relationship of critical illness and sedation management with long-term psychological outcomes.
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PMID:Patient-focused sedation and analgesia in the ICU. 1868 73

Cestrum nocturnum is a garden shrub from the family Solanaceae and is used as a remedy for different health disorders. The aim of the present work was to investigate the potential neuropharmacological action profile of decoctions obtained from dry leaves of the plant. Decoctions were tested in different neuropharmacological models-Irwin test, exploratory behavior, tests for analgesia, isoniazid- and picrotoxin-induced convulsions, and maximal electroshock seizures-in mice, as well as in amphetamine-induced stereotypies and penicillin epileptic foci in rats. Decoctions of 1 and 5% (D1 and D5) induced restlessness, and the 30% decoction (D30) induced passivity. D5 and D30 reduced significantly exploratory behavior and amphetamine-induced stereotypies within a 3-hour observation period. The latter effect was apparent during the second 60 minutes. Decoctions reduced the amount of writhes induced by acetic acid in a dose-dependent manner, but were not effective in the hot plate model. The decoctions were not effective against pharmacologically induced convulsions. However, repeated administration of five doses of D5, at 1-hour intervals, reduced the amplitude of penicillin-induced epileptic spikes in both primary and secondary foci, in curarized rats. Taken together, the results suggest that C. nocturnum possesses active substances with analgesic activity provided through a peripheral action mechanism, in parallel with some psychoactive activity that does not fit well the neuropharmacological action profile of known reference neurotropic drugs.
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PMID:Behavioral and antiepileptic effects of acute administration of the extract of the plant Cestrum nocturnum Lin (lady of the night). 1827 93

Once analgesia is assured, sedation has special relevance in the critically ill ventilated patient's global treatment. Sedatives should be adjusted to individual needs, by administering minimal effective doses to achieve the AIM. This aim must be clearly identified, defined at the beginning of the treatment and revised on a regular basis, ideally at least once per shift. Sedation strategies should foresee the different needs throughout the day within dynamic sedation concept framework. Required sedation depth depends on the patient's psychological characteristics, foreseen evolution and patient tolerance to the support techniques used in treatment. Sedation monitoring permits identification and correction of under- or over-sedation, either of which could negatively influence critically ill patient evolution. The over-sedation concept must be applied to all situations where patients receive more sedation than required. This Spanish Society of Critical Care Medicine's Analgesia and Sedation Work Group recommends the Richmond Agitation Sedation Scale, due to its interrelationship with the Confusion Assessment Method Scale (CAM-ICU), for sedation monitoring in patients under light sedation while it recommends bispectral index sedation monitoring in patients under deep sedation. In the latter case, maintaining values under 40 on the bispectral index doesn't produce any benefits except in patients who require a maximum decrease in neuronal metabolism. To avoid recall phenomena, bispectral monitoring is highly advisable in patients treated with neuromuscular blockers.
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PMID:[Monitoring of sedation]. 1840 38

Management of analgesia and sedation in the intensive care unit requires evaluation and monitoring of key parameters in order to detect and quantify pain and agitation, and to quantify sedation. The routine use of subjective scales for pain, agitation, and sedation promotes more effective management, including patient-focused titration of medications to specific end-points. The need for frequent measurement reflects the dynamic nature of pain, agitation, and sedation, which change constantly in critically ill patients. Further, close monitoring promotes repeated evaluation of response to therapy, thus helping to avoid over-sedation and to eliminate pain and agitation. Pain assessment tools include self-report (often using a numeric pain scale) for communicative patients and pain scales that incorporate observed behaviors and physiologic measures for noncommunicative patients. Some of these tools have undergone validity testing but more work is needed. Sedation-agitation scales can be used to identify and quantify agitation, and to grade the depth of sedation. Some scales incorporate a step-wise assessment of response to increasingly noxious stimuli and a brief assessment of cognition to define levels of consciousness; these tools can often be quickly performed and easily recalled. Many of the sedation-agitation scales have been extensively tested for inter-rater reliability and validated against a variety of parameters. Objective measurement of indicators of consciousness and brain function, such as with processed electroencephalography signals, holds considerable promise, but has not achieved widespread implementation. Further clarification of the roles of these tools, particularly within the context of patient safety, is needed, as is further technology development to eliminate artifacts and investigation to demonstrate added value.
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PMID:Evaluating and monitoring analgesia and sedation in the intensive care unit. 1849 53

Sedation-analgesia occupies an essential place in the specific therapeutic arsenal of the brain-injured patients. The maintenance of the perfusion of the brain, its relaxation and its protection are the fundamental objectives whose finality is to avoid the extension of the lesions and to preserve the neuronal capital. Sedation is instituted when patients are severely agitated or present a deterioration of their state of consciousness (GCS< or =8). Under cover of mechanical ventilation, sedation is the first line treatment of intracranial hypertension, a common pathway of various acute brain diseases of traumatic, vascular or other origin. The use of the combination of hypnotic and opioids is the rule. The combined action of these two classes reinforces and improves their sedative effects. Midazolam is the 2 benzodiazepine of reference. Propofol is more and more frequently added to the combination of hypnotic and opioids. The "propofol infusion syndrome" is a severe limitation to its long term administration in particular among patients presenting a severe septic or inflammatory state. Propofol will be imperatively stopped in the event of metabolic acidosis, rhabdomyolysis, acute renal insufficiency, hyperkaliemia or increase in the blood triglyceride levels. The use of thiopental is restricted to the most severe cases. Its use as a monotherapy at high doses is abandoned to the profit of a co-administration with midazolam or even with the combination of midazolam and propofol. Thiopental overdose is very frequent in the event of associated hypothermia. Etomidate does not have its place apart from induction in fast sequence. The neuro-protective effects of ketamine require to be demonstrated in man before being recommended routinely. Withdrawal of sedation can be responsible for a state of agitation which can be controlled by neuroleptics.
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PMID:[Sedation and analgesia for the brain-injured patient]. 1861 62


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