Sedation in The Icu
Sedation in The Icu
Sedation in The Icu
To control delirium
Acutely confused patients are a potential risk to themselves and
their caregivers. Patients with hyperactive delirium may make an
The goals of sedation injurious attempt to climb out of bed, assault staff or inadver-
Analgesia tently remove airways, catheters and devices essential for their
Analgesia must be the primary concern. Surgical wounds, line care. It is also pertinent to mention, however, that some seda-
insertion and tracheal suctioning can make life very uncomfort- tives (e.g. benzodiazepines) are also causes of delirium.
able for critically ill patients. In addition to unnecessary If sedation is not administered carefully the patient can be put
suffering, untreated pain may result in neurohumoural stress, at considerable risk (see Box 1).
pulmonary dysfunction (secondary to guarding of chest wall
and/or abdomen), inadequate sleep, agitation, exhaustion and
potentially long-term psychological damage.
The hazards of under- and over-sedation
The relief of dyspnoea
The feeling of not being able to breathe is intensely frightening. Risks of under-sedation
The resulting increased respiratory drive has the potential for C Severe anxiety and agitation
ventilator dyssynchrony and worsening hypoxaemia. In health, C Cardiovascular instability (hypertension, tachycardia, increased
coughing is an important reflex that is essential for sputum oxygen consumption)
clearance but, in a critically ill, mechanically ventilated patient, C Stress response (hypercoagulability, immunosuppression,
coughing can compromise gas exchange and risks barotrauma. catabolism)
This reflex can be suppressed by deep sedation. C Ventilator dyssynchrony
C Hypoxaemia
To permit mechanical ventilation C Inadvertent removal of essential devices and catheters
Un-physiological strategies such as inverse-ratio, low tidal C Unplanned extubations
volume, pressure-control ventilation with permissive hyper-
capnia and prone positioning are all intolerable without adequate Risks of over-sedation
levels of sedation. C Drug-induced coma
C Undetected intracranial, intrathoracic or intra-abdominal
catastrophes
C Unnecessary investigations (e.g. CT brain)
Marcus Peck MRCP FRCA is a Senior Registrar in anaesthesia and inten- C Cardiovascular instability (hypotension, bradycardia)
sive care medicine at King’s College Hospital, London, UK. Conflicts of C Drug accumulation
interest: none declared. C Prolonged mechanical ventilation
C Prolonged ICU length of stay
Jim Down FRCA EDIC is a Consultant Anaesthetist and Intensivist, and
Director of ICU at University College Hospitals, London. Conflicts of
interest: none declared. Box 1
ANAESTHESIA AND INTENSIVE CARE MEDICINE 11:1 12 Ó 2009 Elsevier Ltd. All rights reserved.
INTENSIVE CARE
Propofol CNS: excellent dose-dependent sedation throughout spectrum, CNS: deliriogenic, not analgesic
potent anxiolytic, amnestic and anticonvulsant properties, RS: readily induces apnoea
readily titratable by infusion CVS: significant hypotension mainly due to preload
reduction and some myocardial depression
Metabolic: hypertriglyceridaemia and syndrome
of dysrhythmias, heart failure, metabolic acidosis,
hyperkalaemia and rhabdomyolysis in adults on
high doses
Haloperidol CNS: induces a dissociative mental indifference CNS: cataleptic immobility is possible,
to the environment in those with hyperactive delirium, extra-pyramidal effects can occur, may reduce
potentiates analgesic effects of opioids seizure threshold
GIT: has anti-emetic properties RS: mild depression with opioids
CVS: prolonged QT interval with torsades de pointes
Metabolic: rarely causes neuroleptic malignant
syndrome
Alpha 2 agonists CNS: strong analgesic and good anxiolytic CVS: initial hypertension followed by prolonged
(e.g. clonidine, effects, not deliriogenic hypotension, rebound hypertension possible on
dexmedetomidine) RS: no significant depression withdrawal
GIT: reduced gastric motility
CNS: central nervous system; RS: respiratory system; CVS: cardiovascular system; GIT: gastrointestinal tract.
Table 1
ANAESTHESIA AND INTENSIVE CARE MEDICINE 11:1 13 Ó 2009 Elsevier Ltd. All rights reserved.
INTENSIVE CARE
intubation rates when compared with bolus dosing in one un- critically ill patients and if unrecognized has potentially injurious
randomized, retrospective study.1 consequences.
Interest in protocolized sedation led to the multidisciplinary
Maintaining goals of sedation development of several sedation scoring systems that were
validated in terms of reliability, validity, and responsiveness
Establishing and maintaining clear goals are essential for the
across samples, settings and observers. The most widely used are
management of sedation in critically ill patients.
the Sedation Agitation Scale (SAS; Table 3) and the Richmond
Analgesia is the primary concern but assessment of analgesia
Agitation Sedation Scale (RASS; Table 4); both are similar in that
is often crude and subjective (e.g. looking for facial grimacing) or
they have discreet numerical scales with the central position
indirect (e.g. looking for signs of sympathetic stimulation). In
representing a calm and cooperative state and escalating degrees
lightly sedated patients, it can be enhanced by the use of
of sedation or agitation on either side.3,4
numerical or visual analogue pain scales. Mechanically venti-
lated patients who are unable to communicate provide a chal-
Sedation holds
lenge in this regard. However, a psychometric scoring system
known as the Behavioural Pain Scale has been validated to This approach encourages focused down-titration of infusion
monitor pain behaviours in this group and it evaluates facial rates in a timely manner to reduce the complications of drug
expression, upper limb movements and compliance with venti- accumulation.
lation each on a 4-point scale. The daily interruption of sedative infusions was shown by
Once analgesia has been optimized, other physiological cau- Kress and colleagues in 2000 to significantly reduce days on
ses of agitation must be excluded or corrected. These might mechanical ventilation, days on ICU and the number of diag-
include hypoxaemia, hypoglycaemia, hypotension and with- nostic studies to investigate alterations in mental status when
drawal from alcohol or other substances. A pre-defined sedation compared with those managed without interruptions.5 They also
goal or endpoint should then be set and regularly monitored. increased patient-days spent awake and able to follow
Recognition of failure to meet these goals should lead to drug commands, enhanced physicianepatient communication and
titration or a change in regimen. improved physical examination. To achieve this, the sedation
infusions were switched off (usually in the morning) and patient
Sedation scoring systems allowed to emerge until they responded to commands (a Ramsay
score 3 in the Kress study). If the patient required re-sedation at
This approach to sedation management recognizes that different
any time, the infusion was restarted at half of its former rate.
patients have differing needs for sedation and that these needs
Sedation holds or ‘spontaneous awakening trials’ (SATs) risk
also vary over time for an individual patient. Sedation scoring
abrupt waking with agitation, cardiopulmonary instability and
systems are tools that can be performed rapidly at the bedside
self-extubation, and the practice requires adequate training of the
and used to enhance titration of therapy and improve patient
comfort, physiology, understanding and communication.
In 1999, Brook and colleagues demonstrated that a nurse-led,
protocol-driven approach to the sedation of patients with respi-
ratory failure reduced their time on the ventilator, tracheostomy The Sedation Agitation Scale (SAS)
rate, and ICU and hospital length of stay.2 They used the Ramsay
scale (see Table 2), which was first published in 1974 and Score Term Description
remains un-validated but still in widespread use largely because
of its simplicity.3 It is limited, however, in that it doesn’t assess 7 Dangerous Pulling at ET tube, trying to remove catheters,
the degree of agitation, which is a frequent observation in agitation climbing over bedrail, striking at staff, thrashing
side-to-side
6 Very agitated Does not calm despite frequent verbal
reminding of limits, requiring physical restraints,
biting ETT
5 Agitated Anxious or physically agitated, calms to verbal
The Ramsay Sedation Scale instructions
4 Calm and Calm, easily rousable, follows commands
Score Description cooperative
3 Sedated Difficult to arouse but awakens to verbal stimuli
1 Patient anxious and agitated or restless or both or gentle shaking, follows simple commands
2 Patient cooperative, orientated or tranquil but drifts off again
3 Patient responds to commands only 2 Very sedated Arouses to physical stimuli but does not
4 A brisk response to a light glabellar tap or loud auditory communicate or follow commands, may move
stimulus spontaneously
5 A sluggish response to the above 1 Unrousable Minimal or no response to noxious stimuli,
6 No response to the above does not communicate or follow commands
Table 2 Table 3
ANAESTHESIA AND INTENSIVE CARE MEDICINE 11:1 14 Ó 2009 Elsevier Ltd. All rights reserved.
INTENSIVE CARE
Conclusion
The Richmond Agitation Sedation Scale (RASS) Sedation is both necessary and problematical in critically ill
patients. It has many goals, and failure to achieve them may
Score Term Description
result in significant morbidity. Much can be done to optimize
sedation non-pharmacologically and the shift towards a more
þ4 Combative Overtly combative, violent, immediate
judicious approach, using scoring systems or daily interruptions,
danger to staff
has been shown to reduce the time patients spend both on
þ3 Very agitated Pulls or removes tube(s) or catheter(s);
a ventilator and in the unit. These strategies have improved the
aggressive
quality of patient care and become an essential part of modern
þ2 Agitated Frequent non-purposeful movement,
critical care practice. A
fights ventilator
þ1 Restless Anxious but movements not aggressive
vigorous
0 Alert and calm REFERENCES
1 Drowsy Not fully alert, but has sustained 1 Kollef MH, Levy NT, Ahrens TS, Schaiff R, Prentice D, Sherman G. The
awakening (eye-opening/eye contact) use of continuous IV sedation is associated with prolongation of
to voice (>10 s) mechanical ventilation. Chest 1998; 114: 541e8.
2 Light sedation Briefly awakens with eye contact to 2 Ramsay MAE, Savage TM, Simpson R, Goodwin R. Controlled sedation
voice (<10 s) with alphalaxoneealphadolone. BMJ 1974; 3: 656e9.
3 Moderate sedation Movement or eye opening to voice 3 Riker RR, Picard JT, Fraser GL. Prospective evaluation of the sedation-
(but no eye contact) agitation scale in adult ICU patients. Crit Care Med 1999; 27: 1325e9.
4 Deep sedation No response to voice, but movement 4 Sessler CN, Gosnell M, Grap MJ, et al. The Richmond Agitatione
or eye opening to physical stimulation Sedation Scale: validity and reliability in adult intensive care patients.
5 Unrousable No response to voice or physical Am J Respir Crit Care Med 2002; 166: 1338e44.
stimulation 5 Kress JP, Pohlman AS, O’Connor MF, Hall JB. Daily interruption of
sedative infusions in critically ill patients undergoing mechanical
Table 4 ventilation. N Eng J Med 2000; 342: 1471e7.
ANAESTHESIA AND INTENSIVE CARE MEDICINE 11:1 15 Ó 2009 Elsevier Ltd. All rights reserved.