Sedation and Analgesia
in the ICU
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34 year old man was admitted to the intensive
are unit 3 days ago for increasing respiratory
failure from community acquired pneumonia.
He is intubated and ventilated in an ARDSNet
lung protective strategy and on 5 mcg/min of
levophed.
The bedside nurse calls you at 0342 because the
patient is distressed.
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When you examine the patient, his eyes are open
and he is pulling at the restraints.
His blood pressure is 193/90, heart rate 120,
respiratory rate 34, oxygen saturations 91%.
Last ABG: pH 7.37, PCO2 43, PO2 84, BE-1.
Physical exam is unchanged from your last
examination in the morning.
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What are some physiological reasons for the patient’s
current condition?
You rule out any obvious physical causes for this
behavior. What are 5 possible causes for patient
distress?
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Anxiety
Pain
Delirium
Dyspnea
Neuromuscular paralysis while aware
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What is the definition of anxiety?
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What is the definition of delirium?
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State of apprehension and autonomic arousal in
response to real of perceived threats.
Acute, reversible, impairment of consciousness and
cognitive function that fluctuates in severity.
Can a patient with normal blood gases be
dyspneic? Why?
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The patient is obviously not paralyzed and the nurse
really wants you to do something as the patient is
getting worse and becoming a danger to himself.
What non-pharmacological methods of treating distress
may help?
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Fix reversible causes identified
Minimize irritating stimuli such as pulling on the ETT
Reassurance
Communication to and from the patient
Family visits
Sleep cycle hygiene
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Your attempts at reassurance has been met with
marginal success.
What four drug types are used to treat patient
distress?
Benzodiazepines
 Opiods
 Neuroleptics
 Propofol
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What is the mechanism of action of
benzodiazepines?
Are they indicated for anxiety, pain, delirium,
dyspnea, or awake paralysis?
What benzodiazepines are usually available in
the ICU?
How are they different from each other?
What are the doses for each of these?
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What factors determine Ativan and Verseds’ differences
between each other?
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Receptor binding affinity
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Lipophilicity
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Versed is more lipophilic and therefore crosses the blood-brain
barrier faster giving it a more rapid onset. Can store in adipose tissue
Elimination kinetics
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Ativan is higher and therefore is more potent.
Versed undergoes rapid hepatic oxidation.
Ativan has a low hepatic clearance and Vd and is glucuronide
conjugation and excreted in the kidneys
Why is Ativan not generally given by continuous
infusion?
What happens to the kinetics of Versed if given
continuously over several days? Why?
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While you are up, another nurse approaches you about
his patient.
He is taking care of a 56 year old woman who is one
day post op for a bowel resection due to ischemic
colitis.
The patient has awoken and complaints of diffuse
abdominal pain particularly around the wound.
She is hemodynamically stable and physical exam finds
diffuse tenderness but no rebound or guarding.
WBC is going down and her creatinine and ABG are
normal.
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What are some causes for this pain?
How do opiods work?
What types of opiods are commonly used in the ICU?
What is the usual dose range for bolus and infusion of
morphine, fentanyl, and hydromorphone?
What is the time to peak effect and elimination of each
of these drugs?
Why is transdermal fentanyl usually not used in the
ICU?
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The nurse for the first patient comes over to get
you. Her patient is now much more combative
and confused after being given 2 mg of ativan
twice in the last hour.
Why is this patient more agitated?
What alternative treatment can be used in this
case?
What is the mechanism of action of
haloperidol?
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What is the usual dosage range for haloperidol?
What is the half-life and elimination for
haloperidol?
What are the two most important side effects of
haloperidol?
Prolonged QT and Torsade de pointes
 Extrapyramidal effects
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As you are wandering back to bed, you check in
on a patient who was admitted two days ago
with epiglottis.
She is sedated on a propofol infusion.
What is the mechanism of action of propofol?
What are the indications for propofol use in the
ICU?
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What is the usual dose range for propofol?
What are the contraindications for propofol?
What are three of the most important side
effects of propofol?
Hypotension
 Hypertriglyceridemia
 Lactic acidosis and rhabdomyolysis
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Why is the patient’s urine bag green?
How many calories/mL are in propofol?
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In the morning, you come back to see and
examine your patient with agitation and
pneumonia. He is now completely unresponsive
to voice or pain.
Overnight he has received 15 mg of ativan and
25 mg of haloperidol.
His nurse now states that the patient is
comfortable and wants to continue the current
plan.
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What methods or tools can we use to measure
depth of sedation?
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Consider
SAS
 RASS
 MSAT
 MAAS
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How is the sedation tools at this site performed?
What is a BIS monitor?
What role do they have in the ICU?
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What are the consequences to oversedation in critically
ill patients?
What are some methods to avoid oversedation?
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Consider
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Intermittent bolus dosing, no continuous infusions
Daily interruption of sedation
What are the long term psychological consequences of
ICU?
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PTSD
Cognitive dysfunction
Dementia
Questions??