Semin Respir Crit Care Med 2001; 22(2): 189-198
DOI: 10.1055/s-2001-13832
Copyright © 2001 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA. Tel.: +1(212) 584-4662

Monitoring Sedation, Agitation, Analgesia, Neuromuscular Blockade, and Delirium in Adult ICU Patients

Richard R. Riker, Gilles L. Fraser
  • Department of Critical Care, Maine Medical Center, Portland, Maine
Further Information

Publication History

Publication Date:
31 December 2001 (online)

ABSTRACT

Preliminary evidence suggests that closely monitoring sedation may have a positive effect on patient outcomes, including reductions in intensive care unit (ICU) stay, duration of mechanical ventilatory support, and number of diagnostic tests requested to assess central nervous system function. In the last few years, subjective instruments to assess agitation and sedation have been developed and tested for reliability and validity, including the Sedation-Agitation Scale and the Motor Activity Assessment Scale. Similar efforts directed to delirium among ICU patients have produced several assessment tools to help clinicians with this difficult area of patient care. Promising techniques for objective assessment of sedation (such as the bispectral index) and strategies to guide neuromuscular blockade with train-of-four (TOF) or clinical exam monitoring have emerged. Future efforts should focus on evaluating the impact of these monitoring techniques on specific outcomes in an effort to improve patient comfort, minimize adverse events, and reduce resource consumption.

REFERENCES

  • 1 Fraser G L, Prato B S, Riker R R, Berthiaume D, Wilkins M L. Evaluation of agitation in ICU patients: incidence, severity and treatment in the young versus the elderly.  Pharmacotherapy . 2000;  20 75-82
  • 2 Fraser G L, Riker R R, Wilkins M L, Prato B S. The incidence and cost of patient-initiated device removal in the ICU.  Pharmacotherapy . 2001;  21 1-6
  • 3 Bergbom-Engberg I, Haljamae H. Assessment of patients' experience of discomforts during respirator therapy.  Crit Care Med . 1989;  17 1068-1072
  • 4 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
  • 5 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
  • 6 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.  N Engl J Med . 2000;  342 1471-1477
  • 7 Brook A D, Ahrens T S, Schaiff R. Effect of a nursing-implemented sedation protocol on the duration of mechanical ventilation.  Crit Care Med . 1999;  27 2609-2615
  • 8 Watling S M, Johnson M, Yanos J. A method to produce sedation in critically ill patients.  Ann Pharmacother . 1996;  30 1227-1231
  • 9 De Jonghe B, Cook D, Appere-De-Vecchi, Guyatt G, Meade M, Outin H. Using and understanding sedation scoring systems: a systematic review.  Intensive Care Med . 2000;  26 275-285
  • 10 Ostermann M E, Keenan S P, Seiferling R A, Sibbald W J. Sedation in the intensive care unit.  JAMA . 2000;  283 1451-1459
  • 11 Young C, Knudsen N, Hiltion A, Reeves J G. Sedation in the intensive care unit.  Crit Care Med . 2000;  28 854-866
  • 12 Ramsay M A, Savege T M, Simpson B RJ, Goodwin R. Controlled sedation with Alphaxalone-alphadolone.  Br Med J . 1974;  2 656-659
  • 13 Hansen-Flaschen J, Cowen J, Polomano R C. Beyond the Ramsay scale: need for a validated measure of sedating drug efficacy in the intensive care unit.  Crit Care Med . 1994;  22 732-733
  • 14 Riker R R, Picard J T, Fraser G L. Prospective evaluation of the sedation-agitation scale in adult ICU patients.  Crit Care Med . 1999;  27 1325-1329
  • 15 Riker R R, Fraser G L, Cox P M. Continuous infusion of haloperidol controls agitation in critically ill patients.  Crit Care Med . 1994;  22 89-97
  • 16 Simmons L E, Riker R R, Prato B S, Fraser G L. Assessing sedation levels in mechanically ventilated ICU patients with the bispectral index and the sedation-agitation scale.  Crit Care Med . 1999;  27 1499-1504
  • 17 Riker R R, Simmons, L E, Wilkins M L, Fraser G L. Validation of the sedation-agitation scale with the bispectral index and visual analog scale in the ICU.  Intensive Care Med 2001 (in press).
  • 18 Brandl K M, Langley K A, Riker R R. Confirming the reliability of the Sedation-Agitation Scale in ICU nurses without prior experience in its use.  Pharmacotherapy. 2001;  21 (in press)
  • 19 Clemmer T P, Wallace J C, Spuhler V J, Bailey P P, Devlin J W. Origins of the Motor Activity Assessment Scale score: a multi-institutional process.  Crit Care Med . 2000;  28 3124
  • 20 Devlin J W, Boleski G, Mlynarek M. 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 1271-1275
  • 21 Laing A. The applicability of a new sedation scale for intensive care.  Intensive and Critical Care Nursing . 1992;  8 149-152
  • 22 Olleveant N, Humphris G, Roe B. A reliability study of the modified New Sheffield Sedation Scale.  Nursing in Critical Care . 1998;  3 83-88
  • 23 Harris C E, O'Donnell C, Macmillan R R. Use of propofol by infusion for sedation of patients undergoing haemofiltration: assessment of the effect of haemofiltration on the level of sedation and on blood propofol concentration.  J Drug Dev . 1991;  4(suppl 3) 37-39
  • 24 Chernik D A, Gillings D, Laine H. Validity and reliability of the observer's assessment of alertness/sedation scale: study with intravenous midazolam.  J Clin Psychopharmacol . 1990;  10 244-251
  • 25 de Lemos J, Tweeddale M, Chittock D. Measuring quality of sedation in adult mechanically ventilated critically ill patients: the Vancouver interaction and calmness scale.  J Clin Epidemiology . 2000;  53 908-919
  • 26 Ambuel B, Hamlett K W, Marx C M, Blumer J L. Assessing distress in pediatric intensive care environments: the COMFORT scale.  J Pediatr Psychology . 1992;  17 95-109
  • 27 Sessler C N, Gosnell M, Grap M J. A new agitation- sedation scale for critically ill patients: development and testing of validity and inter-rater reliability.  Am J Respir Crit Care Med . 2000;  161 A506
  • 28 Sessler C N, Keane K. Validity and reliability of a new agitation-sedation scale in a medical ICU population.  Chest . 2000;  118 95S
  • 29 Schulte-Tamburen A M, Scheier J, Briegel J, Schwender D, Peter K. Comparison of five sedation scoring systems by means of auditory evoked potentials.  Intensive Care Med . 1999;  25 377-382
  • 30 Haberthur C, Lehmann F, Ritz R. Assessment of depth of midazolam sedation using objective parameters.  Intensive Care Med . 1996;  22 1385-1390
  • 31 Rampil I J. A primer for EEG signal processing in anesthesia.  Anesthesiology . 1998;  89 980-1002
  • 32 Drummond J C. Monitoring depth of anesthesia.  Anesthesiology . 2000;  93 876-882
  • 33 Rosow C, Manberg P J. Bispectral index monitoring.  Anesthesiology Clinics of North America . 1998;  2 89-107
  • 34 Liu J, Singh H, White P F. Electroencephalographic bispectral index correlates with intraoperative recall and depth of propofol-induced sedation.  Anesth Analg . 1997;  84 185-189
  • 35 Doi M, Gajraj R J, Mantzaridis H, Kenny G N. Relationship between calculated blood concentration of propofol and electrophysiological variables during emergence from anesthesia: comparison of bispectral index, spectral edge frequency, median frequency, and auditory evoked potential index.  Br J Anaesth . 1997;  78 180-184
  • 36 Liu J, Singh H, White P F. Electroencephalogram bispectral analysis predicts the depth of midazolam-induced sedation.  Anesthesiology . 1996;  84 64-69
  • 37 Gan T J, Glass P S, Windsor A. Bispectral index monitoring allows faster emergence and improved recovery from propofol, alfentanil, and nitrous oxide anesthesia.  Anesthesiology . 1997;  87 808-815
  • 38 Billard V, Gambus P L, Chamoun N, Stanski D R, Shafer S L. A comparison of spectral edge, delta power, and bispectral index as EEG measures of alfentanil, propofol, and midazolam drug effect.  Clin Pharmacol Ther . 1997;  61 45-58
  • 39 Gajraj R J, Doi M, Mantzaridis H, Kenny G N. Analysis of the EEG bispectrum, auditory evoked potentials and the EEG power spectrum during repeated transitions from consciousness to unconsciousness.  Br J Anaesth . 1998;  80 46-52
  • 40 Struys M, Versichelen L, Byttebier G, Mortier E, Moerman A, Rolly G. Clinical usefulness of the bispectral index for titrating propofol target effect-site concentration.  Anaesthesia . 1998;  53 4-12
  • 41 De Deyne C, Struys M, Decruyenaere J, Creupelandt J, Hoste E, Colardyn F. Use of continuous bispectral EEG monitoring to assess depth of sedation in ICU patients.  Intensive Care Med . 1998;  24 1294-1298
  • 42 O'Connor M, Kress J P, Pohlman A, Tung A, Hall J. Pitfalls of monitoring sedation in the ICU with the bispectral index.  Anesthesiology . 1998;  89 A461
  • 43 Sebel P S, Lang E, Rampil I J. A multicenter study of bispectral electroencephalogram analysis for monitoring anesthetic effect.  Anesth Analg . 1997;  84 891-899
  • 44 Bruhn J, Bouillon T W, Shafer S L. Electromyographic activity falsely elevates the bispectral index.  Anesthesiology . 2000;  92 1485-1487
  • 45 Gallagher J D. Pacer-induced artifact in the bispectral analysis for the electroencephalogram.  Anesthesiology . 1999;  90 636
  • 46 Guignard B, Chauvin M. Bispectral index increases and decreases are not always signs of inadequate anesthesia.  Anesthesiology . 2000;  92 903
  • 47 Kaplan L, Bailey H. Bispectral index (BIS) monitoring of ICU patients on continuous infusions of sedatives and paralytics reduces sedative drug utilization and cost.  Critical Care . 2000;  4 S110
  • 48 Song D, Joshi G P, White P F. Titration of volatile anesthetics using bispectral index facilitates recovery after ambulatory anesthesia.  Anesthesiology . 1997;  87 842-848
  • 49 Thornton C, Sharpe R M. Evoked responses in anesthesia.  Br J Anaesth . 1998;  81 771-781
  • 50 Whipple J K, Lewis K S, Quebbeman E J. Analysis of pain management in critically ill patients.  Pharmacotherapy . 1995;  15 592-599
  • 51 Hamill-Ruth R J, Marohn M L. Evaluation of pain in the critically ill patient.  Critical Care Clinics . 1999;  15 35-54
  • 52 Acute Pain Management Guideline Panel. Acute Pain Management: Operative or Medical Procedures and Trauma, Clinical Practice Guideline. AHCPR Pub. No. 92-0032. Rockville, MD: Agency for Health Care Policy and Research, Public Health Service, U.S. Department of Health and Human Services. Feb. 1992
  • 53 Melzack R, Katz J. Pain measurement in persons in pain. In: Wall PD, Melczack R, eds. Textbook of Pain Edinburgh: Churchill Livingstone 1999: 337-351
  • 54 Paice J A, Cohen F L. Validity of a verbally administered numeric rating scale to measure cancer pain intensity.  Cancer Nurs . 1995;  18 292-298
  • 55 Terai T, Yukioka H, Asada A. Pain evaluation in the intensive care unit: observer-reported faces scale compared with self-reported visual analog scale.  Reg Anesth Pain Med . 1998;  23 147-151
  • 56 Puntillo K A. Dimensions of procedural pain and its analgesic management in critically ill surgically patients.  Am J Crit Care . 1994;  3 116-128
  • 57 Meehan D A, McRae M E, Rourke D A, Eisenring C, Imperial F A. Analgesia administration, pain intensity, and patient satisfaction in cardiac surgical patients.  Am J Crit Care . 1995;  4 435-442
  • 58 Tittle M, McMillan S C. Pain and pain-related side effects in an ICU and on a surgical unit: nurses management.  Am J Crit Care . 1994;  3 25-39
  • 59 Mateo O M, Krenzischek D A. A pilot study to assess the relationship between behavioural manifestations of pain and self-report of pain in post-anesthesia care unit patients.  J Post Anesth Nurs . 1992;  7 15-21
  • 60 Puntillo K A, Miaskowski C, Kehrle K, Stannard D, Gleeson S, Nye P. Relationship between behavioral and physiological indicators of pain, critical care patients' self-reports of pain, and opioid administration.  Crit Care Med . 1997;  25 1159-1166
  • 61 Caswell D R, Williams J P, Vallejo M. Improving pain management in critical care.  Jt Comm J Qual Improv . 1996;  22 702-712
  • 62 Hansen-Flaschen J H, Brazinski S, Basile C, Lanken P N. Use of sedating drugs and neuromuscular blocking agents in patients requiring mechanical ventilation for respiratory failure: a national survey.  JAMA . 1991;  266 2870-2875
  • 63 Watling S M, Dasta J F, Seddl E C. Sedatives, analgesics, and paralytics in the ICU.  Ann Pharmacotherapy . 1997;  31 148-153
  • 64 Coursin D B. Neuromuscular blockade: should patients be relaxed in the ICU?.  Chest . 1992;  102 988-989
  • 65 Pigazzi A, Manfredi P L. Case presentation: undertreatment of pain: a risk associated with neuromuscular blockade in the intensive care unit.  J Pain Symptom Manage . 2000;  19 154
  • 66 Wagner B K, Zavotsky K E, Sweeney J B, Palmeri B A, Hammond J S. Patient recall of therapeutic paralysis in a surgical critical care unit.  Pharmacotherapy . 1998;  18 358-363
  • 67 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;  7 490-498
  • 68 Shapiro B A, Warren J, Egol A B. Practice parameters for sustained neuromuscular blockade in the adult critically ill patient: an executive summary.  Crit Care Med . 1995;  23 1601-1605
  • 69 Klessig H T, Geiger H J, Murray M J, Coursin D B. A national survey on the practice patterns of anesthesiologist intensivists in the use of muscle relaxants.  Crit Care Med . 1992;  20 1341-1345
  • 70 Report of the Anesthesia Drugs Advisory Panel. Bethesda, MD: US Food and Drug Administration; 1992
  • 71 Package insert. Norcuron (vecuronium).  West Orange, NJ: Organon; 1994
  • 72 Tschida S J, Hoey L L, Mather D, Vance-Bryan K. Train- of-four: to use or not to use.  Pharmacotherapy . 1995;  15 546-550
  • 73 Rudis M I, Guslits B G, Zarowitz B J. Technical and interpretive problems of peripheral nerve stimulation in monitoring neuromuscular blockade in the intensive care unit.  Ann Pharmacother . 1996;  30 165-172
  • 74 Frankel H, Jeng J, Tilly E, St Andre A, Champion H. The impact of implementation of neuromuscular blockade monitoring standards in a surgical intensive care unit.  Am Surg . 1996;  62 503-506
  • 75 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
  • 76 Rudis M I, Sikora C A, Angus E. A prospective, randomized, controlled evaluation of peripheral nerve stimulation versus standard clinical dosing of neuromuscular blocking agents in critically ill patients.  Crit Care Med . 1997;  25 575-583
  • 77 Strange C, Vaughan L, Franklin C, Johnson J. Comparison of train-of-four and best clinical assessment during continuous paralysis.  Am J Respir Crit Care Med . 1997;  156 1556-1561
  • 78 de Lemos M J, Carr R R, Shalansky K F, Bevan D R, Ronco J J. Paralysis in the critically ill: intermittent bolus pancuronium compared with continuous infusion.  Crit Care Med . 1999;  27 2648-2655
  • 79 Behbehani N A, Al-Mane F, D'yachkova Y, Pare P, FitzGerald J M. Myopathy following mechanical ventilation for acute severe asthma.  Chest . 1999;  115 1627-1631
  • 80 American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Washington, DC: American Psychiatric Association; 1994
  • 81 Trepacz P T. Delirium: advances in diagnosis, pathophysiology, and treatment.  Psychiatry Clinics of North America . 1996;  19 3:429-448
  • 82 Hart R P, Levenson J L, Sessler C N, Best A M, Schwartz S M, Rutherford L E. Validation of a cognitive test for delirium in medical ICU patients.  Psychosomatics . 1996;  37 533-546
  • 83 Hart R P, Best A LN, Sessler C N, Levenson J L. Abbreviated cognitive test for delirium.  J Psychosom Res . 1997;  43 417-423
  • 84 Ely E W, Margolin R, Francis J. Delirium in the ICU: measurement and outcomes.  Am J Respir Crit Care Med . 2000;  161 A506