Sedation & analgesia

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Complications of pain and anxiety

• stress response
  • increased heart rate, blood pressure and myocardial oxygen consumption
  • hypercoagulability
  • insulin resisitance
  • increased metabolic rate
  • protein catabolism
• psychological difficulties
  • nightmares
  • hallucinations
  • paranoid delusions
  • post traumatic stress disorder

Assessment

Difficult

• visual analogue score
  • simple and reliable
  • many ICU patients cannot use scale because of severity of their illness
• behavioural signs (eg grimacing, posturing) or physiological signs (eg tachycardia, hypertension)
  • inexact
  • cultural differences
  • physiological signs affected by many other factors
• Glasgow coma scale
  • validity only established in patients with neurological injury
• Ramsay sedation scale
  • based only on motor response and therefore not suitable for patients with motor deficits
  • no consensus on what score represents an adequate level of sedation
• Sedation-Agitation scale and Motor Activity Assessment scale
  • similar disadvantages
• Bispectral index
  • not validated in critically ill patients
  • some studies show a poor correlation with established methods

Drugs

Analgesia

Suitable agents include:

• morphine
• fentanyl
• ketamine

Sedation

Suitable agents include:

• dexmedetomidine
• midazolam
• lorazepam
• propofol

Anti-psychotic

Suitable agent:

• haloperidol

Further reading

Liu L, Gropper MA. Postoperative analgesia and sedation in the adult intensive care unit. A guide to drug selection. Drugs, 2003;63(8):755-67

©Charles Gomersall, September, 2008 unless otherwise stated. The author, editor and The Chinese University of Hong Kong take no responsibility for any adverse event resulting from the use of this webpage.
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