Use of Sedative Medications in the Intensive Care Unit

Stanley A. Nasraway Jr

doi:10.1055/s-2001-13830

Seminars in Respiratory and Critical Care Medicine, Inhaltsverzeichnis

Semin Respir Crit Care Med 2001; 22(2): 165-174
DOI: 10.1055/s-2001-13830

Use of Sedative Medications in the Intensive Care Unit

Stanley A. Nasraway Jr.

Department of Surgery, Tufts-New England Medical Center, Tufts University School of Medicine, Boston, Massachusetts

Abstract

ABSTRACT

Current choices for sustained sedation in the critically ill include the benzodiazepines, the opiates, and propofol. Each of these groups of medications has their particular benefits: benzodiazepines provide the greatest amnesia, opiates are the only agents to provide analgesia, and propofol is the most easily titratable and the least likely to excessively accrue. The literature seems to favor propofol over the benzodiazepines as the most cost-effective solution to sustained sedation. A newly approved agent, dexmedetomidine, holds promise as a continuous infusion that can provide both anxiolysis and analgesia, but without the ventilatory depression seen in the other classes of sedatives. Further research is needed to determine the role of dexmedetomidine in the ICU. The emerging standard of care for sustained sedation is the use of standardized protocols, formulated with the help of clinical practice guidelines, and titrated with the guidance of sedation monitoring.

KEYWORD

Dexmedetomidine - benzodiazepines - propofol

Volltext

Referenzen

REFERENCES

1 Shapiro B A, Warren J, Egol A B. Practice parameters for intravenous analgesia and sedation for adult patients in the intensive care unit: an executive summary. Crit Care Med . 1995; 23 1596-1600
2 Schelling G, Stoll C, Haller M. Health-related quality of life and posttraumatic stress disorder in survivors of the acute respiratory distress syndrome. Crit Care Med . 1998; 26 651-659
3 Krachman S L, D'Alonzo G E, Criner G J. Sleep in the intensive care unit. Chest . 1995; 107 1713-1720
4 Meyer T J, Eveloff S E, Bauer M S, Schwartz W A, Hill N S, Millman R P. Adverse environmental conditions in the respiratory and medical ICU settings. Chest . 1994; 105 1211-1216
5 Schein R MH, Hazday N, Pena M, Ruben B H, Sprung C L. Clinical antecedents to in-hospital cardiopulmonary arrest. Chest . 1990; 98 1388-1392
6 Franklin C, Mathew J. Developing strategies to prevent inhospital cardiac arrest: analyzing responses of physicians and nurses in the hours before the event. Crit Care Med . 1994; 22 244-247
7 Johnson K L, Cheung R B, Johnson S B, Roberts M, Niblett J, Manson D. Therapeutic paralysis of critically ill trauma patients: perceptions of patients and their family members. Am J Crit Care . 1999; 8 490-498
8 Bailie G R, Cockshott I D, Douglas E J, Bowles B J. Pharmacokinetics of propofol during and after long-term continuous infusion for maintenance of sedation in ICU patients. Br J Anaesth . 1992; 68 486-491
9 Langley M S, Heel R C. Propofol: a review of its pharmacodynamic and pharmacokinetic properties and use as an intravenous anesthetic. Drugs . 1988; 35 334-372
10 MacKenzie S J, Kapadia F, Grant I S. Propofol infusion for control of status epilepticus. Anaesthesia . 1990; 45 1043-1045
11 Brown L A, Levin G M. Role of propofol in refractory status epilepticus. Ann Pharmacother . 1998; 32 1053-1059
12 Kelly D F, Goodale D B, Williams J. Propofol in the treatment of moderate and severe head injury: a randomized, prospective double-blinded pilot trial. J Neurosurg. . 1999; 90 1042-1052
13 Wagner B KJ, O'Hara D A, Hammond J S. Drugs for amnesia in the ICU. Am J Crit Care . 1997; 6 192-201
14 McCowan C, Marik P. Refractory delirium tremens treated with propofol: a case series.Crit Care Med. . 2000; 28(6) 1781-1784
15 Coomes T R, Smith S W. Successful use of propofol in refractory delirium tremens. Ann Emerg Med. . 1997; 30(6) 825-828
16 Kanto J, Gepts E. Pharmacokinetic implications for the clinical use of propofol. Clin Pharmacokinet . 1989; 17 308-326
17 Kowalski S D, Rayfield C A. A post hoc descriptive study of patients receiving propofol. Am J Crit Care . 1999; 8 507-513
18 Foex P, Diedericks J, Sear J W. Cardiovascular effects of propofol. J Drug Dev . 1991; 4(suppl 3) 3-9
19 Carrasco G, Molina R, Costa J. Propofol versus midazolam in short-, medium-, and long-term sedation of critically ill patients. Chest . 1993; 103 557-564
20 Kumar A N, Achwartz D E, Lim K G. Propofol-induced pancreatitis: recurrence of pancreatitis after rechallenge. Chest . 1999; 115 1198-1199
21 Bennett S N, McNeil M M, Bland L A. Postoperative infections traced to contamination of an intravenous anesthetic, propofol. N Engl J Med . 1995; 333 147-154
22 Webb S A, Roberts B, Breheny F X, Golledge C L, Cameron P D, van Heerden P V. Contamination of propofol infusions in the intensive care unit: incidence and clinical significance. Anaesth Intensive Care . 1998; 26 162-164
23 Valente J F, Anderson G L, Branson R D, Johnson D J, Davis K, Porembka D T. Disadvantages of prolonged propofol sedation in the critical care unit. Crit Care Med . 1994; 22 710-712
24 Au J, Walker W S, Scott D HT. Withdrawal syndrome after propofol infusion. Anaesthesia . 1990; 45 741-742
25 Bodenham A, Culank L S, Park G R. Propofol infusion and green urine. Lancet . 1987; 2 740
26 Greenblatt D J. Sedation: intravenous benzodiazepines in critical care medicine. In:Chernow B, ed. The Pharmacologic Approach to the Critically Ill Patient. 3rd ed. Baltimore: Williams & Wilkins 1994: 321-326
27 Gilliland H EM, Prasad B K, Mirakhur R K, Fee J PH. An investigation of the potential morphine sparing effect of midazolam. Anaesthesia . 1996; 51 808-811
28 Ostermann M E, Keenan S P, Seiferling R A, Sibbald W J. Sedation in the intensive care unit: a systematic review. JAMA . 2000; 283 1451-1459
29 Kress J P, Pohlman A S, O'Connor M F, Hall J B. Daily interruption of sedative infusions in critically ill patients undergoing mechanical ventilation. New Engl J Med . 2000; 342 1471-1477
30 Kollef M H, Levy N T, Ahrens T S, Schaiff R, Prentice D, Sherman G. The use of continuous IV sedation is associated with prolongation of mechanical ventilation. Chest . 1998; 114 541-548
31 Hojer J, Baehrendtz S, Magnusson A, Gustafsson L L. A placebo controlled trial of flumazenil given by continuous infusion in severe benzodiazepine overdosage. Acta Anaesthesiol Scand . 1991; 35 584-590
32 Shelly M P, Sultan M A, Bodenham A, Park G R. Midazolam infusions in critically ill patients. Eur J Anaesthesiol . 1991; 8 21-27
33 Cammarano W B, Pittet J-F, Weitz S, Schlobohm R M, Marks J D. Acute withdrawal syndrome related to the administration of analgesic and sedative medications in adult intensive care unit patients. Crit Care Med . 1998; 26 676-684
34 Finley P R, Nolan P E. Precipitation of benzodiazepine withdrawal following sudden discontinuation of midazolam. Annals of Pharmacotherapy . 1989; 23 151-152
35 Grossman M, Abiose A, Tangphao O. Morphine-induced venodilation in humans. Clin Pharmacol Ther . 1996; 60 554-560
36 Flacke J W, Flacke W E, Bloor B C, Van Etten P A, Kripke B J. Histamine release by four narcotics: a double-blind study in humans. Anesth Analg . 1987; 66 723-730
37 McArdle P Intravenous analgesia. Crit Care Clinics . 1999; 15 89-105
38 Balestrieri F, Fisher S. Analgesics. In: Chernow B, ed. The Pharmacologic Approach to the Critically Ill Patient 3rd ed. Baltimore: Williams & Wilkins 1994: 640-650
39 Smith D C, Bergen J M, Smithline H, Kirschner R. A trial of etomidate for rapid sequence intubation in the emergency department. J Emerg Med . 2000; 18 13-16
40 Migden D R, Reardon R F. Etomidate sedation for intubation. Am J Emerg Med . 1998; 16 101-102
41 Van Hamme J M, Ghoneim N M, Amber J J. Pharmacokinetics of etomidate, a new intravenous anesthetic. Anesthesiol . 1978; 49 274
42 Wagner R L, White P F. Etomidate inhibits adrenocortical function in surgical patients. Anesthesiol . 1984; 60 647
43 Kress J P, O'Connor M F, Pohlman A S. Sedation of critically ill patients during mechanical ventilation. Am J Resp Crit Care Med . 1996; 153 1012-1018
44 McCollam J S, O'Neil M G, Norcross E D, Byrne T K, Reeves S T. Continuous infusions of lorazepam, midazolam and propofol for sedation of the critically ill surgery trauma patient: a prospective, randomized comparison. Crit Care Med . 1999; 27 2454-2458
45 Barrientos-Vega R, Sanchez-Soria M M, Morales-Garcia C, Robas-Gomez A, Cuena-Boy R, Ayensa-Rincon A. Prolonged sedation of critically ill patients with midazolam or propofol: impact on weaning and costs. Crit Care Med . 1997; 25 33-40
46 Chamorro C, DeLatorre F J, Montero A. Comparative study of propofol versus midazolam in the sedation of critically ill patients: results of a prospective, randomized, multicenter trial. Crit Care Med . 1996; 24 932-939
47 Pohlman A S, Simpson K P, Hall J B. Continuous intravenous infusions of lorazepam versus midazolam for sedation during mechanical ventilatory support: a prospective, randomized study. Crit Care Med . 1994; 22 1241-1247
48 Weinbroum A A, Halpern P, Rudick V, Sorkine P, Freedman M, Geller E. Midazolam versus propofol for long-term sedation in the ICU: a randomized prospective comparison. Intensive Care Med . 1997; 23 1258-1263
49 Sanchez-Izquierdo-Riera J A, Caballero-Cubedo R E, Perez-Vela J L, Ambros-Checa A, Cantalapiedra-Santiago J A, Alted-Lopez E. Propofol versus midazolam: safety and efficacy for sedating the severe trauma patient. Anesth Analg . 1998; 86 1219-1224
50 Swart E, Strack van Schijndel J M R, van Loenen C A, Thijs L G. Continuous infusion of lorazepam versus midazolam in patients in the intensive care unit: sedation with lorazepam is easier to manage and is more cost effective. Crit Care Med . 1999; 27 1461-1465
51 Jacobi J, Bjerke H S, Chalfin D. Revised clinical practice guidelines for the sustained use of sedatives and analgesics in the critically ill adult. Crit Care Med 2001 (in press).
52 Brook A D, Ahrens T S, Schaiff R, Prentice D, Sherman G, Shannon W. Effect of a nursing-implemented sedation protocol on the duration of mechanical ventilation. Crit Care Med . 1999; 27 2609-2615
53 Eisenach J C, DeKock M, Klimscha W. Alpha-2-adrenergic agonists for regional anesthesia: a clinical review of clonidine (1984-1995). Anesthesiology . 1996; 85 655-674
54 Kamibayashi T, Maze M. Clinical uses of α₂-adrenergic agonists. Anesthesiology . 2000; 93 1345-1349
55 Franowicz J S, Arnsten A F. The alpha-2a noradrenergic agonist, guanfacine, improves delayed response performance in young adult rhesus monkeys. Psychopharmacology . 1998; 136 8-14
56 Hall J E, Uhrich T D, Barney J A, Arain S R, Ebert T J. Sedative, amnestic, and analgesic properties of small-dose dexmedetomidine infusions. Anesth Analg . 2000; 90 699-705
57 Venn R M, Bradshaw C J, Spencer R. Preliminary UK experience of dexmedetomidine, a novel agent for postoperative sedation in the intensive care unit. Anaesthesia . 1999; 54 1136-1142
58 Precedex (dexmedetomidine hydrochloride injection), package insert. Manufactured by Abbott Laboratories, North Chicago, IL, February 2000
59 Scheinin H, Aantaa R, Anttila M, Hakola P, Helminen A, Karhuvaara S. Reversal of the sedative and sympatholytic effects of dexmedetomidine with a specific alpha-2-adrenoceptor antagonist atipamezole: a pharmacodynamic and kinetic study in healthy volunteers. Anesthesiol . 1998; 89 574-584
60 Maze M, Virtanen R, Daunt D, Banks S J, Stover E P, Feldman D. Effects of dexmedetomidine, a novel imidazole sedative-anethetic agent, on adrenal steroidogenesis: in vivo and in vitro studies. Anesth Analg . 1991; 73 204-208
61 Bhana N, Goa K L, McClellan K J. Dexmedetomidine. Drugs . 2000; 59 263-268
62 Bachand R, Scholz J, Pinaud M. The effects of dexmedetomidine in patients in the intensive care setting. Intensive Care Medicine . 1999; 25(suppl 1) S160
63 Martin E, Lehot J J, Manikis P. Dexmedetomidine: a novel agent for patients in the intensive care setting. Intensive Care Medicine . 1999; 25(suppl 1) S160
64 Nasraway S A, Jacobi J, Murray M J. Sedation, analgesia and neuromuscular blockade of the critically ill adult: revised clinical practice guidelines for 2001. Crit Care Med 2001; in press.
65 Riker R R, Picard J T, Fraser G L. Prospective evaluation of the Sedation-Agitation Scale for adult critically ill patients. Crit Care Med . 1999; 27 1325-1329
66 Luce J. Reducing the use of mechanical ventilation. N Engl J Med . 1996; 335 1916-1917
67 Mascia M F, Koch M, Medicis J J. Pharmacoeconomic impact of rational use guidelines on the provision of analgesia, sedation and neuromuscular blockade in critical care. Crit Care Med . 2000; 28 2300-2306