Sedation and Analgesia

Jacobi J, Fraser GL, Coursin DB, et al. Clinical practice guidelines for the sustained use of sedatives and analgesics in the critically ill patient. Crit Care Med 2002;30:119-41.  Combines expert opinion and literature review to make recommendations. This topic is due for updated guidelines. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=11902253

Kress JP, Pohlman AS, O'Connor MF, Hall JB. Daily interruption of sedative infusions in critically ill patients undergoing mechanical ventilation. N Engl J Med 2000; 342:1471-7. RCT found daily interruption of sedation in a MICU population resulted in shorter duration of mechanical ventilation and ICU stay, less total dose of sedation, and less use of diagnostic tests to work-up impaired mental status compared to the control group. No increase in short term adverse outcomes in the intervention group identified but patients were not evaluated for subtle or long-term adverse outcomes. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=10816184

Kress JP, Gehlbach B, Lacy M, et al. The long-term psychological effect of daily sedative interruption on critically ill patients. Am J Respir Crit Care Med 2003; 168:1457-61. Daily sedation interruption to facilitate ventilator weaning is widely accepted, but little is known about the risk of subsequent adverse psychological effects. This study is often cited and provides some reassurance that sedation holidays do not pose a psychological risk, but includes only 32 of 105 screened patients
http://www.ncbi.nlm.nih.gov/pubmed/14525802?ordinalpos=23&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum

Kollef MH, Levy NT, Ahrens TS, et al. Use of continuous vs. bolus IV sedation. Chest 1998;114:541-8. Surveillance study of 157 patients on ventilator found bolus sedation resulted in shorter duration of mechanical ventilation, and ICU and hospital stays. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=9726743

Riker RR, Shehabi Y, Bokesch PM, et al. Dexmedetomidine vs midazolam for sedation of critically ill patients: a randomized trial. JAMA 2009; 301:489-99. This study is noteworthy for finding use of dexmedetomidine reduced the prevalence of delirium (54% vs 77% with midazolam) and for providing further evidence of the safety of using dexmedetomidine at higher doses and longer duration than currently approved by the FDA. There was no difference in the primary outcome, time spent at target level of sedation. Duration of mechanical ventilation was shorter with dexmedetomidine but length of ICU stay was similar. http://www.ncbi.nlm.nih.gov/pubmed/19188334?ordinalpos=3&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum

 
*See also Invasive Mechanical Ventilation and Neurology Critical Care