Pharmacological Responses

Minimal and well-targeted sedation may reduce the risk of delirium, shorten time on mechanical ventilation and improve outcomes, compared to prolonged or heavier sedation.([FOOTNOTE=Frontera JA. Delirium and sedation in the ICU. Neurocrit Care. 2011;14:463-474.],[ANCHOR=],[LINK=])^,([FOOTNOTE=Barr J, Fraser GL, Puntillo K, et al; American College of Critical Care Medicine. Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit. Crit Care Med. 2013;41(1):263-306.],[ANCHOR=],[LINK=])^,([FOOTNOTE=Hogarth DK, Hall J. Management of sedation in mechanically ventilated patients. Curr Opin Crit Care. 2004;10(1):40-46.],[ANCHOR=],[LINK=])^,([FOOTNOTE=Brush DR, Kress JP. Sedation and analgesia for the mechanically ventilated patient. Clin Chest Med. 2009;30(1):131-41,ix.],[ANCHOR=],[LINK=]) Research has shown that careful pre-sedation evaluation, appropriate match of medication to patient needs, and close monitoring can have an impact on patient comfort, recovery and post-ICU health.^1,2,3,4

Evaluate before you sedate.^1,2,3,4

The brief moments you spend seeking the cause of agitation in a mechanically ventilated patient may help you to select the most appropriate response.^1,2,3,4 If sedation is warranted, your evaluation may help you choose the right medication and dosage to best meet your patient’s present need and reduce the risk of complications.^1,2,3,4

If your clinical setting hasn't adopted a sedation protocol, it may be worth considering. Following a standard protocol for evaluation, sedation and monitoring can improve outcomes.^1,2,3,4  Clinical studies have shown that a caregiver-implemented protocol providing an algorithm for assessments and treatment can reduce patient pain and agitation, shorten ventilator time and hospital stays, and decrease the risk of ventilator associated pneumonia.⁴

Most sedation protocols include some combination of the following:²

Safety: If the patient is posing a danger to self or others, treat with sedative (e.g., IV bolus) and then proceed.²

Comfort:  Reassure and reorient the patient, as needed. Check the patient’s physical comfort. Does he or she need to change position? Is tape or tubing causing chafing?²

Synchrony: Check synchrony with the ventilator and adjust the ventilatory modes and settings as needed.²

Pain management: Evaluate the patient for pain, using a scale for patient self-reporting, if possible, or a rating tool based on physiological signs, behavior and facial expressions.²  Risk assessments for pain and even surrogate reporting from family members or others who know the patient well can be of benefit for patients who can't self report.([FOOTNOTE=Puntillo K, Pasero C, Li D, et al. Evaluation of pain in ICU patients. Chest. 2009;135(4):1069-1074.],[ANCHOR=],[LINK=])

Environment: Consider potential environmental causes of agitation, such as bright lights, cool or warm temperature, or loud alarms and equipment. Do what you can to lessen these.^2,([FOOTNOTE=Wenham T, Pittard A. Intensive care unit environment. Continuing Education Anaesth Crit Care Pain. 2009;9(6):178-183.],[ANCHOR=],[LINK=])

Physiology and pharmacology:  Evaluate for possible medical or pharmacological causes of agitation.^2,([FOOTNOTE=Epstein SK. How often does patient-ventilator asynchrony occur and what are the consequences? Respir Care. 2011;56(1):25-38.],[ANCHOR=],[LINK=])  Check oxygen saturation, blood pressure and sugar.² Is withdrawal from alcohol or tobacco a possibility? Might your patient be suffering from sleep deprivation or an adverse drug reaction?

Psychology/anxiety:  Is your patient anxious or frightened? Agitation, increased blood pressure, increased heart rate, patient’s verbalization of anxiety, and restlessness may be signs.^2,([FOOTNOTE=Cohen IL. Current issues in agitation management. Advanced Studies Med. 2002;2(9):332-337.],[ANCHOR=],[LINK=]) Assessment scales such as the RAMSEY assessment,([FOOTNOTE=Riker RR, Picard JT, Fraser GL. Prospective evaluation of the Sedation-Agitation Scale for adult critically ill patients. Crit. Care Med. 1999;27(7):1325-1329.],[ANCHOR=],[LINK=]) RASS([FOOTNOTE=Sessler CN, Gosnell MS, Grap MJ, et al. The Richmond Agitation-Sedation Scale: validity and reliability in adult intensive care unit patients. Am J Respir Crit Care Med. 2002;166(10):1338-1344.  ],[ANCHOR=],[LINK=]) and MAAS([FOOTNOTE=Devlin JW, Boleski G, Mlynarek M, et al. Motor Activity Assessment Scale: a valid and reliable sedation scale for use with mechanically ventilated patients in an adult surgical intensive care unit. Crit Care Med. 1999;27(7):1271-1275.],[ANCHOR=],[LINK=])  sedation guideline may be helpful.

Psychology/delirium:  Perform an assessment for delirium, such as the Confusion Assessment Method for the ICU (CAM-ICU)([FOOTNOTE=Spronk PE, Riekerk B, Hofhuis J, Rommes JH. Occurrence of delirium is severely underestimated in the ICU during daily care. Intensive Care Med. 2009;35(7):1276-1280.],[ANCHOR=],[LINK=])  or Intensive Care Delirium Screening Checklist (ICDSC).([FOOTNOTE=Tomasi CD, Grandi C, Salluh J, et al. Comparison of CAM-ICU and ICDSC for the detection of delirium in critically ill patients focusing on relevant clinical outcomes. J Crit Care. 2012;27(2):212-217.],[ANCHOR=],[LINK=]) Look for the four main features to identify delirium: fluctuations in mental status, inattention, disorganized thinking and altered state of consciousness.^12,13 Consider possible causes such as benzodiazepine medication.^12,13

Select treatment options based on the outcome of your evaluation.

Monitor sedation depth and patient status regularly.²

You may want to consider addressing your patient's physical comfort and potential physiological, psychological and environmental causes of agitation as your first line of treatment.² If your patient is still agitated, choose sedation appropriate to the cause, based on your evaluation.² Also consider the sedation goals. For example, do you need a longer-acting medication or rapid awakening?

Traditional sedation often relied on a benzodiazepine with an opioid for pain.^1,2,3,4 Care may be needed here: In addition to addictive potential, narcotics and psychoactive medications and notably the benzodiazepine lorazepan have been shown to be a major risk factor for delirium in the ICU.^1,2,3,4, ([FOOTNOTE=Zhang Z, Pan L, Ni H. Impact of delirium on clinical outcome in critically ill patients: a meta-analysis.Gen Hosp Psychiatry. 2013;35(2):105-111.],[ANCHOR=],[LINK=])^,([FOOTNOTE=Girard TD, Pandharipande PP, Ely EW. Delirium in the intensive care unit. Crit Care. 2008;12 Suppl 3:S3.],[ANCHOR=],[LINK=])

For efficacy against anxiety without treating pain, some still do rely on anxiolytic medications, such as the benzodiazepines, instead of anesthetic, hypnotic or analgesic options. For the delirious patient, since psychoactive medications are themselves risk factors for delirium, Girard et al.¹⁵ recommend non-pharmacological alternatives be tried first; should that fail, standard practice relies on the antipsychotic Haloperidol, and more recently, the newer sedative dexmedetomidine.^1,2,3,4

For pain, many sedate using an analgesic alone rather than a hypnotic or anxiety medication.^1,2,3,4  Increasingly, ICU caregivers are turning to analgesic sedation to co-manage pain and agitation, with good results.([FOOTNOTE=Devabhakthuni S, Armahizer MJ, Dasta JF, Kane-Gill SL. Analgosedation: a paradigm shift in intensive care unit sedation practice. Ann Pharmacother. 2012;46(4):530-540.],[ANCHOR=],[LINK=])

Pill, IV, or bolus? If your patient's condition allows, consider sedation in pill or IV bolus formulation.([FOOTNOTE=Luetz A, Goldmann A, Weber-Carstens S, Spies C. Weaning from mechanical ventilation and sedation. Curr Opin Anaesthesiol. 2012;25(2):164-169.],[ANCHOR=],[LINK=])^,([FOOTNOTE=Kollef MH, Levy NT, Ahrens TS, Schaiff R, Prentice D, Sherman G. The use of continuous i.v. sedation is associated with prolongation of mechanical ventilation. Chest. 1998;114(2):541-548.],[ANCHOR=],[LINK=])  Continuous IV sedation has been associated with extended time on mechanical ventilation, compared to IV bolus sedation or IV infusion with daily interruptions.^17,18 (See "Daily Sedation Holiday" for more on daily sedative breaks.)

See Hogarth et al.³  and Fuchs et al.([FOOTNOTE=Fuchs EM, Von Rueden K. Sedation management in the mechanically ventilated critically ill patient. AACN Adv Crit Care. 2008;19(4):421-432  ],[ANCHOR=],[LINK=]) for recent reviews of options for sedative selection and protocols for sedation, monitoring and weaning.

With the right choice of medication and protocol for evaluation, sedation, monitoring and weaning, you can bring comfort to your patients while possibly shortening their time on mechanical ventilation and in the hospital.^1,2,3,4