Sedation in the ICU
Prof. Bahaa Ewees
Ain Shams University
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Contents
1
Definition of Sedation
2
Importance of Sedation in the ICU
3
Monitoring of Sedation
4
Mode of Sedation
5
Delivery of Sedation
5
Examples of Sedation Protocol
1
Definition of Sedation
Sedation: depression of awareness and
reduction of the response to external stimuli
2
Importance of Sedation
Plays a vital role in the care of critically-ill
patients and encompasses wide spectrum of
symptom management.
Heavy sedation is used to facilitate ETT insertion
and M.V. (replacing NMBA)
3
Monitoring of Sedation
Done Hourly
To avoid:
UnderSedation
↑ catecholamines 
Coagulopathy and
Immune Suppression
Heavy
Sedation
* ↑ duration of ICU
stay and M.V.
* Side Effects of
sedationdrug
3
1. Scoring Systems
2. Instrumental
EEG
BIS
Monitoring of Sedation
4
Mode of Sedation
Non Pharmacological
Pharmacological
4
Mode of Sedation
Non Pharmacological
1. Continuous communication with the patient
2. Good Hydration
3. Good Nutritional Support
4. Physiotherapy Ve………..ry
Important
4
Mode of Sedation
Pharmacological
A.
B.
C.
D.
E.
Drugs used for Induction of Anaesthesia
Benzodiazepines
Neuroleptic Agents
Opioids
Clonidine and Dexmedetomedine
Pharmacological
A. Drugs used for Induction of Anaesthesia
A. Propofol



Widely used due to high clearance and metabolism.
Dose: 0.5 – 4 mg/kg/h.
Problems



↓ HR
↓ BP
Propofol Infusion Syndrome
Pharmacological
 Propofol Infusion Syndrome
 Rare
 Manifestations





↓ pH
Arrhythmias
Cardiovacular collapse
Acute renal Failure
Hyperkalaemia
 Risk factors



Sepsis
Severe Cerebrovascular Stroke
High propofol doses (> 5 mg/kg/h.)
Pharmacological
 Propofol Infusion Syndrome (cont.)
 Recommendations




Once suspected, stop infusion
Dose should be < 4mg/kg/h.
Duration should be less than 24 h.
Daily monitoring of triglyceride levels and renal
function.
Pharmacological
A. Drugs used for Induction of Anaesthesia
B. Thiopental
 used by infusion (for status epilepticus to control
convulsions)
 Problems:




Low clearance
Metabolized by redistribution
Myocardial depression
Accumulation
Pharmacological
A. Drugs used for Induction of Anaesthesia
C. Etomidate
 Infusion Only
function
BUT, ↓↓↓↓ adrenocortical
Pharmacological
A. Drugs used for Induction of Anaesthesia
D. Ketamine
 Can be used for intubation in the ICU
 Sedation especially in asthmatic patient
 BUT, ↑↑ CMRO2, Delirium, and hallucination
Pharmacological
B. Benzodiazepines
 Acting on GABA receptors (the main inhibitory
neurotransmitter in CNS)
1. Midazolam



Metabolized in liver to active metabolite
Highest clearance among BZs
Suitable for infusion (0.04 – 0.2 mg/kg/h.)
2. Diazepam



Metabolized to active metabolite by liver
Lowest clearance among BZs
Suitable for oral use or bolus injection (2- 10 mg)
Pharmacological
C. Neuroleptic Agents
 Haloperidol or Chloropromazine
 Used for delirium and psychosis in the ICU
 Can cause:



Respiratory depression
Prolonged QT interval
Arrhythmias
Pharmacological
D. Opioids
 Provide analgesia and anxiolysis
 Better used by infusion
 Remifentanil (ultrashort acting opioid)

0.1 – 0.15 ug/kg/min.
Pharmacological
E. Clonidine and Dexmedetomedine
 Alpha 2 Agonists
 Can be used for sedation in both spontaneous and
mechanically ventilated patients.
 Dexmedetomedine is


more potent than clonidine
Shorter elimination t1/2
 So, it is widely used nowadays for sedation
5
Delivery of Sedation
Intermittent Injection
Bolus Injection
1
Constant
Level of
sedation
Infusion
2
Less chance
Of
Intermittent
agitation
5
Delivery of Sedation
Sedation Holiday
Stopping the sedation infusion and allowing the
patient to awake.
Restarted once:
 Patient fully awake and obeying commands, or
 Patient becoming agitated or uncomfortable
Should be done on a daily basis!
This strategy  ↓ duration of MV and Length of
stay in ICU.
6
Example of Sedation Protocols
Short term therapy
< 72 h.
Hemodynamically stable?
YES
* Propofol infusion
* Opioid
- Remifentanil
- Fentanil
NO
* Alfentanil infusion
If necessary consider
propofol infusion.
6
Example of Sedation Protocols
Long-term therapy
> 72 h.
CONSIDER
1. Opioid
- morphine infusion
- Alfentanil infsion (if Renal failure)
2. Benzodiazepine
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