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Semin Respir Crit Care Med 2001; 22(2): 199-210
DOI: 10.1055/s-2001-13833
Copyright © 2001 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA. Tel.: +1(212) 584-4662

Cost Considerations in Sedation, Analgesia, and Neuromuscular Blockade in the Intensive Care Unit

John P. Kress, Jesse B. Hall
  • Department of Medicine, Section of Pulmonary and Critical Care, University of Chicago, Chicago, Illinois
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Publication History

Publication Date:
31 December 2001 (online)

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ABSTRACT

Sedation of critically ill patients is a costly endeavor. Costs of commonly used intensive care unit (ICU) sedatives range from pennies to more than $500 per day. Although the agents account for some of this expense, complications related to the use of these drugs in the ICU produce even greater costs. Prolongation of mechanical ventilation and length of stay are some of the common complications resulting from non-ideal use of these drugs. Sedative agents also impair neurological evaluation in many critically ill patients, which may mask detection of acute delirium resulting from intercurrent illness or intracranial catastrophes and can lead to excessive diagnostic testing. Opiates may result in gastrointestinal dysfunction with resulting malnutrition and perhaps bacterial translocation and sepsis. Neuromuscular blocking agents may cause prolonged paralysis and disability in critically ill patients who receive them. Simple dosing strategies based on pharmacological principles may decrease the incidence of these costly problems.

KEYWORD

Sedation - benzodiazepines - opiates - neuromuscular blocking agents - critical care - costs and cost analysis

REFERENCES

  • 1 Hansen-Flashen J H, Brazinsky 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
    CrossrefPubMedGoogle Scholar
  • 2 Christensen B V, Thunedborg L P. Use of sedatives, analgesics and neuromuscular blocking agents in Danish ICUs 1996/97: a national survey.  Intensive Care Med . 1999;  25 186-191
    CrossrefPubMedGoogle Scholar
  • 3 Chamorro C, de Latorre J F, Montero A, Sanchez-Izquierdo J A, Jareno A, Moreno J A, Gonzalez E, Barrios M, Carpintero J L, Martin-Santos F, Otero B, Ginestal R. 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
    CrossrefPubMedGoogle Scholar
  • 4 Carrasco G, Molina R, Costa J, Soler J M, Cabre L. Propofol vs midazolam in short-, medium-, and long-term sedation of critically ill patients: a cost-benefit analysis.  Chest . 1993;  103 557-564
    CrossrefPubMedGoogle Scholar
  • 5 Kress J P, O'Connor M F, Pohlman A S, Olson D, LaVoie A, Toledano A, Hall J B. Sedation of critically ill patients during mechanical ventilation: a comparison of propofol and midazolam.  Am J Respir Crit Care Med . 1996;  153 1012-1018
    PubMedGoogle Scholar
  • 6 Puntillo K A. Pain experiences of intensive care unit patients.  Heart Lung . 1990;  19 526-533
    PubMedGoogle Scholar
  • 7 Shapiro B A, Warren J, Egol A B, Greenbaum D M, Jacobi J, Nasraway S A, Schein R M, Spevetz A, Stone J R. 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
    CrossrefPubMedGoogle Scholar
  • 8 The Acute Respiratory Distress Syndrome Network. Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome.  N Engl J Med . 2000;  342 1301-1308
    CrossrefPubMedGoogle Scholar
  • 9 Bidani A, Tzouanakis A E, Cardenas V J, Zwischenberger J B. Permissive hypercapnia in acute respiratory failure.  JAMA . 1994;  272 957-962
    CrossrefPubMedGoogle Scholar
  • 10 Feihl F, Perret C. Permissive hypercapnia: how permissive should we be?.  Am J Respir Crit Care Med . 1994;  150 1722-1737
    CrossrefPubMedGoogle Scholar
  • 11 Halpern N A, Bettes L, Greenstein R. Federal and nationwide intensive care units and healthcare costs: 1986-1992.  Crit Care Med . 1994;  22 2001-2007
    PubMedGoogle Scholar
  • 12 Gundlach C A, Faulkner T P, Souney P F. Drug usage patterns in the ICU: profile of a major metropolitan hospital and comparison with other ICUs.  Hosp Formul . 1991;  26 132-136
    PubMedGoogle Scholar
  • 13 Cheng E Y. The cost of sedating and paralyzing the critically ill patient.  Crit Care Clin . 1995;  11 1005-1019
    PubMedGoogle Scholar
  • 14 1999 New York Times Almanac. New York: Penguin Reference Books; 1998: 316
  • 15 Craig C P, Connelly S. Effect of intensive care unit nosocomial pneumonia on duration of stay and mortality.  Am J Infect Control . 1984;  12 233-238
    PubMedGoogle Scholar
  • 16 Beyt B E, Troxler S, Cavaness J. Prospective payment and infection control.  Infect Control . 1985;  6 161-164
    PubMedGoogle Scholar
  • 17 Baker A M, Meredith J W, Haponik E F. Pneumonia in intubated trauma patients: microbiology and outcomes.  Am J Respir Crit Care Med . 1996;  153 343-349
    PubMedGoogle Scholar
  • 18 Noseworthy T W, Konopad E, Shustack A, Johnston R, Grace M. Cost accounting of adult intensive care: methods and human and capital inputs.  Crit Care Med . 1996;  24 1168-1172
    PubMedGoogle Scholar
  • 19 Montazeri M, Cook D J. Impact of a clinical pharmacist in a multidisciplinary intensive care unit.  Crit Care Med . 1994;  22 1044-1048
    PubMedGoogle Scholar
  • 20 Hess D, Burns E, Romagnoli D, Kacmarek R M. Weekly ventilator circuit changes: a strategy to reduce costs without affecting pneumonia rates.  Anesthesiology . 1995;  82 903-911
    PubMedGoogle Scholar
  • 21 Fagon J Y, Chastre J, Domart Y, Trouillet J L, Pierre J, Darne C, Gibert C. Nosocomial pneumonia in patients receiving continuous mechanical ventilation: prospective analysis of 52 episodes with use of a protected specimen brush and quantitative culture techniques.  Am Rev Respir Dis . 1989;  139 877-884
    PubMedGoogle Scholar
  • 22 Cook D J, Walter S D, Cook R J, Griffith L E, Guyatt G H, Leasa D, Jaeschke R Z, Brun-Buisson C. Incidence of and risk factors for ventilator-associated pneumonia in critically ill patients.  Ann Intern Med . 1998;  129 433-440
    CrossrefPubMedGoogle Scholar
  • 23 Colice G L, Stukel T A, Dain B. Laryngeal complications of prolonged intubation.  Chest . 1989;  96 877-884
    CrossrefPubMedGoogle Scholar
  • 24 Dreyfuss D, Soler P, Basset G, Saumon G. High inflation pressure pulmonary edema: respective effects of high airway pressure, high tidal volume, and positive end-expiratory pressure.  Am Rev Respir Dis . 1988;  137 1159-1164
    CrossrefPubMedGoogle Scholar
  • 25 Amato M BP, Barbas C SV, Medeiros D M, Magaldi R B, Schettino G P, Lorenzi-Filho G, Kairalla R A, Deheinzelin D, Munoz C, Oliveira R, Takagaki T Y, Carvalho C R. Effect of a protective ventilation strategy on mortality in the acute respiratory distress syndrome.  N Engl J Med . 1998;  338 347-354
    CrossrefPubMedGoogle Scholar
  • 26 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
    CrossrefPubMedGoogle Scholar
  • 27 Brook A D, Ahrens T S, Schaiff R, Prentice D, Sherman G, Shannon W, Kollef M H. Effect of a nursing-implemented sedation protocol on the duration of mechanical ventilation.  Crit Care Med . 1999;  27 2609-2615
    CrossrefPubMedGoogle Scholar
  • 28 Ramsay M AE, Savage T M, Simpson B RJ, Goodwin R. Controlled sedation with alphaxalone-alphadolone.  BMJ . 1974;  2 656-659
    CrossrefPubMedGoogle Scholar
  • 29 Kress J P, Pohlman A, 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
    CrossrefPubMedGoogle Scholar
  • 30 Braman S S, Dunn S M, Amico C A, Millman R P. Complications of intrahospital transport in critically ill patients.  Ann Int Med . 1987;  107 469-473
    PubMedGoogle Scholar
  • 31 Indeck M, Peterson S, Smith J, Brotman S. Risk, cost, and benefit of transporting ICU patients for special studies.  J Trauma . 1988;  28 1020-1025
    PubMedGoogle Scholar
  • 32 Prokop E, Caride V, Winchenbach K, Troncale F J, McCallum R W. Scintigraphic determiniation of the effect of metoclopramide and morphine on small intestinal transit time.  Am J Physiol Imaging . 1988;  3 201-204
    PubMedGoogle Scholar
  • 33 Chang R WS, Jacobs S, Lee B. Gastrointestinal dysfunction among intensive care unit patients.  Crit Care Med . 1987;  15 909-914
    PubMedGoogle Scholar
  • 34 Dive A, Moulart M, Jonard P, Jamart J, Mahieu P. Gastroduodenal motility in mechanically ventilated patients: a manometric study.  Crit Care Med . 1994;  22 441-447
    PubMedGoogle Scholar
  • 35 Evans D, DiSipio N, Barot L, Rombeau J L, Crosby L, Mullen J. Comparison of gastric and jejunal tube feedings.  J Parenter Enteral Nutr . 1980;  4 596A
    PubMedGoogle Scholar
  • 36 Spitz J C, Ghandi S, Taveras M, Aoys E, Alverdy J C. Characteristics of the intestinal epithelial barrier during dietary manipulation and glucocorticoid stress.  Crit Care Med . 1996;  24 635-641
    PubMedGoogle Scholar
  • 37 Alverdy J. The effect of nutrition on gastrointestinal barrier function.  Semin Respir Infec . 1994;  9 248-255
    PubMedGoogle Scholar
  • 38 Hillman K M, Riordan T, O'Farrell S M, Tabaqchali S. Colonization of the gastric contents in critically ill patients.  Crit Care Med . 1982;  109 444-447
    PubMedGoogle Scholar
  • 39 Hadfield R J, Sinclair D G, Houldsworth P E, Evans T W. Effects of enteral and parenteral nutrition on gut mucosal permeability in the critically ill.  Am J Respir Crit Care Med . 1995;  152 1545-1548
    CrossrefPubMedGoogle Scholar
  • 40 Yuan C S, Foss J F, Osinski J, Toledano A, Roizen M F, Moss J. The safety and efficacy of oral methylnaltrexone in preventing morphine-induced delay in oral-cecal transit time.  Clin Pharm Therap . 1997;  61 467-475
    PubMedGoogle Scholar
  • 41 Foss J F, Yuan C S, Roizen M F, Goldberg L I. Prevention of apomorphine- or cisplatin-induced emesis in the dog by a combination of methylnaltrexone and morphine.  Cancer Chemother Pharmacol . 1998;  42 287-291
    CrossrefPubMedGoogle Scholar
  • 42 Yuan C S, Foss J F, O'Connor M F, Osinski J, Karrison T, Moss J, Roizen M F. Methylnaltrexone for reversal of constipation due to chronic methadone use: a randomized controlled trial.  JAMA . 2000;  283 367-372
    CrossrefPubMedGoogle Scholar
  • 43 Griffiths R D, Jones C. ABC of intensive care: recovery from intensive care.  BMJ . 1999;  319 427-429
    PubMedGoogle Scholar
  • 44 Russell S. An exploratory study of patients' perceptions, memories and experiences of an intensive care unit.  J Adv Nursing . 1999;  29 783-791
    CrossrefPubMedGoogle Scholar
  • 45 Hopkins R O, Weaver L K, Pope D, Orme Jr F J, Bigler E D, Larson-Lohr V. Neuropsychological sequelae and impaired health status in survivors of severe acute respiratory distress syndrome.  Am J Respir Crit Care Med . 1999;  160 50-56
    CrossrefPubMedGoogle Scholar
  • 46 Jones C, Griffiths R D, Humphris G. Disturbed memory and amnesia related to intensive care.  Memory . 2000;  8 79-94
    CrossrefPubMedGoogle Scholar
  • 47 Griffiths R D, Jones C, MacMillan R R. Where is the harm in not knowing?.  <~>Care after intensive care. Clin Intensive Care . 1996;  7 144-145
    PubMedGoogle Scholar
  • 48 Mascia M, 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
    PubMedGoogle Scholar
  • 49 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
    CrossrefPubMedGoogle Scholar
  • 50 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
    CrossrefPubMedGoogle Scholar
  • 51 Cernaianu A C, DelRossi A J, Flum D R, Vassilidze T V, Ross S E, Cilley J H, Grosso M A, Boysen P G. Lorazepam and midazolam in the intensive care unit: a randomized, prospective, multicenter study of hemodynamics, oxygen transport, efficacy, and cost.  Crit Care Med . 1996;  24 222-228
    CrossrefPubMedGoogle Scholar
  • 52 Gyldmark M. A review of cost studies of intensive care units: problem with the cost concept.  Crit Care Med . 1995;  23 964-972
    PubMedGoogle Scholar
  • 53 Hoyt J W. A new day is coming: sedation issues in critical care.  Crit Care Med . 1999;  27 2584
    PubMedGoogle Scholar
  • 54 Blacher R S. On awakening paralyzed during surgery: a syndrome of traumatic neurosis.  JAMA . 1975;  234 67-68
    CrossrefPubMedGoogle Scholar
  • 55 Nielsen C H, Johnson G A. The experience of complete neuromuscular blockade in awake patients.  Journal of Clinical Anesthesia . 1994;  6 450
    PubMedGoogle Scholar
  • 56 MacFarlane I A, Rosenthal F D. Severe myopathy after status asthmaticus.  Lancet . 1977;  2 615
    PubMedGoogle Scholar
  • 57 Kupfer Y, Okrent D G, Twersky R A, Tessler S. Disuse atrophy in a ventilated patient with status asthmaticus receiving neuromuscular blockade.  Crit Care Med . 1987;  15 795-796
    PubMedGoogle Scholar
  • 58 Segredo V, Caldwell J E, Matthay M S, Sharma M L, Gruenke L D, Miller R D. Persistent paralysis in critically ill patients after long-term administration of vecuronium.  N Engl J Med . 1992;  327 524-528
    CrossrefPubMedGoogle Scholar
  • 59 Raps E C, Bird S J, Hansen-Flaschen J. Prolonged muscle weakness after neuromuscular blockade in the intensive care unit.  Crit Care Clin . 1994;  10 799-812
    PubMedGoogle Scholar
  • 60 Manthous C A, Chatila W. Prolonged weakness after the withdrawal of atracurum.  Am J Respir Crit Care Med . 1994;  150 1441-1443
    PubMedGoogle Scholar
  • 61 Griffin D, Fairman N, Coursin D, Rawsthorne L, Grossman J E. Acute myopathy during treatment of status asthmaticus with steroids and steroidal muscle relaxants.  Chest . 1992;  102 510-514
    PubMedGoogle Scholar
  • 62 Hoyt J W. Persistent paralysis in critically ill patients after the use of neuromuscular blocking agents.  New Horiz . 1994;  2 48-55
    PubMedGoogle Scholar
  • 63 Barohn R J, Jackson C E, Rogers S J, Ridings L W, McVey A L. Prolonged paralysis due to nondepolarizing neuromuscular blocking agents and corticosteroids.  Muscle Nerve . 1994;  17 647-654
    PubMedGoogle Scholar
  • 64 Leatherman J W, Fluegel W L, David W S. Muscle weakness in mechanically ventilated patients with severe asthma.  Am J Respir Crit Care Med . 1996;  153 1686-1690
    CrossrefPubMedGoogle Scholar
  • 65 Hansen-Flaschen J H, Cowen J, Raps E C. Neuromuscular blockade in the intensive care unit: more than we bargained for.  Am Rev Respir Dis . 1993;  147 234-236
    PubMedGoogle Scholar
  • 66 Rudis M I, Guslits B J, Peterson E L, Hathaway S J, Angus E, Beis S, Zarowitz B J. Economic impact of prolonged motor weakness complicating neuromuscular blockade in the intensive care unit.  Crit Care Med . 1996;  24 1749-1756
    PubMedGoogle Scholar
  • 67 Rudis M I, Sikora C A, Angus E, Peterson E, Popovich J, Hyzy R, Zarowitz B J. 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
    CrossrefPubMedGoogle Scholar
  • 68 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
    PubMedGoogle Scholar