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KEY POINTS
Older paradigms of analgesia and sedation in the intensive care unit (ICU) have evolved to incorporate patient-centered outcomes, such as quality of life and functional status after ICU discharge in survivors.
Techniques for appropriate pain management must be individualized to each patient, starting with an appropriate assessment of its severity. Based upon their psychometric properties (reliability and validity), the Critical Care Pain Observation Tool and Behavioral Pain Scale are currently recommended for use in adults over other reported scales.
Systemic opioids (fentanyl, morphine, and hydromorphone) are traditionally the cornerstone of postoperative and critical care pain management. The ideal method of opioid administration will vary considerably with the clinical context and include opioids by mouth or parenteral administration either via intermittent intravenous or via patient-controlled infusion pumps.
Regional analgesia should be considered in certain ICU scenarios: (1) thoracic epidural analgesia in open abdominal aortic aneurysm surgery and (2) thoracic epidural analgesia in traumatic rib fractures, especially in the elderly.
Compared with propofol and dexmedetomidine, benzodiazepines (midazolam and lorazepam) have significantly longer context-sensitive half-times at both short- and long-duration infusions. Caution should be used when using benzodiazepines in the elderly, both because these agents can cause paradoxical agitation and because altered pharmacokinetic factors, such as increased volume of distribution and decreased elimination half-life often increase time to awakening.
The depth of sedation should be routinely monitored and quantified using a validated assessment tool. Sedative medications should be titrated to keep patients continuously lightly sedated unless a contraindication exists (severe acute respiratory distress syndrome [ARDS], refractory intracranial hypertension, status asthmaticus, or epilepticus) appears noninferior to standard therapy with daily sedative interruptions.
Neuromuscular blocking agents (cisatracurium) may still play an important role in management of critically ill patients in well-defined situations including to facilitate tracheal intubation, minimize systemic oxygen consumption in the setting of severe and refractory hypoxemia, improve outcomes in moderate and severe ARDS, treat shivering in patients undergoing targeted temperature management therapy, or treat refractory intracranial hypertension.
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In addition to providing vital organ support and treatment of the underlying condition responsible for admission to the intensive care unit (ICU), the health care team must assure patient comfort and limitation of further stress on the patient. Failure in this regard may result in physiologic derangement and unwanted cognitive side effects. In order to attain these goals, a thorough knowledge of the pharmacokinetics (what the body does to the drug) and pharmacodynamics (what the drug does to the body) of a variety of medications is necessary; many of these agents are used exclusively in the ICU or by anesthesiologists in the operating room.
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Over the past decade, an expanding body of basic science and clinical research has changed the way intensivists think about the treatment of pain and the management of sedation in the ICU. The use of newer drugs, such as dexmedetomidine as well as newfound indications for older drugs (eg, ketamine and lidocaine), have improved ...