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Chapter 14: Analgesia, Sedation, Delirium, and Coma

A 48-year-old man is admitted to the ICU with community-acquired pneumonia. He is mechanically ventilated and started on a midazolam infusion for sedation. He develops ARDS, and a continuous neuromuscular blockade is started. On day 11, the intensivist determines that the patient is ready for weaning since the fraction of inspired oxygen (FIO2) has been lowered to 40% and the positive end-­expiratory pressure (PEEP) to 5 mmH2O. The midazolam infusion is stopped, but the patient does not have improvement in his mental status and his RASS remains at –4. The patient requires a tracheostomy at day 14 of mechanical ventilation. Which of the following sedation strategies would have lowered the possibility of tracheostomy in this patient?

A. Slow titration of midazolam infusion to avoid withdrawal

B. Avoidance of neuromuscular blocker

C. Use of alternative sedation strategy with fentanyl, propofol, or dexmedetomidine

D. Use of the Ramsay Sedation Scale rather than the RASS

C. Use of alternative sedation strategy with fentanyl, propofol, or dexmedetomidine

As recommended by the SCCM, pain, agitation, and delirium (PAD) guidelines, analgosedation should be attempted first. Fentanyl is preferred due to its quick onset and offset, lack of dependence on the renal system for elimination, and lack of an active metabolite. In the ICU, critically ill patients are often hemodynamically unstable and have either hepatic or renal impairment. Propofol or dexmedetomidine may be added if fentanyl provides inadequate sedation.

A multicenter double-blinded study showed that neuromuscular blockers have improved adjusted 90-day survival and time away from mechanical ventilator (choice B). Midazolam should be weaned off slowly rather than being stopped abruptly in order to avoid withdrawal symptoms (choice A). However, the drug has an active metabolite that accumulates with prolonged infusion, especially in the presence of renal and hepatic impairment. This makes weaning the patient off midazolam a challenge. The use of the RASS or the SAS has been recommended as validated and reliable tools for monitoring sedation in adult patients compared to the Ramsay Sedation Scale. In 2012, Riessen et al investigated whether the RASS allowed a better monitoring of sedation depth than the Ramsay score in measuring depth of sedation in ICU patients receiving analgosedation and concluded that the Ramsay score performed poorly compared to the RASS (choice D).

Which of the following statements is NOT true with regard to the use of benzodiazepine infusions for sedation in the ICU?

A. Diazepam can cause thrombophlebitis.

B. Midazolam, lorazepam, and diazepam infusion can cause hemolysis, hypotension, soft tissue necrosis, ...

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