Skip to main content
Book cover

Surgical Intensive Care Medicine pp 147–162Cite as

Analgesia and Sedation

  • Chapter

  • 163 Accesses

Abstract

Sedative hypnotic and analgesic agents are widely used in critical care units. In a survey of 164 medical intensive care units (ICUs) (1), virtually all provided sedative medications to patients receiving mechanical ventilation. In 36% of these units, sedation was administered routinely to more than 70% of patients. The most frequently used agents were morphine sulfate, lorazepam, and diazepam, and the most common indications were “to improve oxygenation or to reduce peak airway pressure” and “to treat anxiety.”

Keywords

  • Epidural Analgesia
  • Alcohol Withdrawal
  • Epidural Hematoma
  • Epidural Abscess
  • Thoracic Epidural Anesthesia

These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

This is a preview of subscription content, access via your institution.

Chapter
USD   29.95
Price excludes VAT (USA)
  • DOI: 10.1007/978-1-4757-6645-5_9
  • Chapter length: 16 pages
  • Instant PDF download
  • Readable on all devices
  • Own it forever
  • Exclusive offer for individuals only
  • Tax calculation will be finalised during checkout
eBook
USD   74.99
Price excludes VAT (USA)
  • ISBN: 978-1-4757-6645-5
  • Instant PDF download
  • Readable on all devices
  • Own it forever
  • Exclusive offer for individuals only
  • Tax calculation will be finalised during checkout
Learn about institutional subscriptions

Preview

Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.

References

  1. Hansen-Flaschen JH, Brazinsky S, Basile C, Lanken PN. Use of sedating drugs and neuromuscular blocking agents in patients requiring mechanical ventilation for respiratory failure. A national survey. JAMA 1991; 266: 2870–5.

    PubMed  CrossRef  CAS  Google Scholar 

  2. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders: DSMIV, 4th ed. Washington, DC: American Psychiatric Association, 1994.

    Google Scholar 

  3. Ramsay MA, Savege TM, Simpson BR, Goodwin R. Controlled sedation with alphaxalonealphadolone. Br Med J 1974; 2: 656–9.

    PubMed  CrossRef  CAS  Google Scholar 

  4. Hansen-Flaschen J, Cowen J, Polomano RC. Beyond the Ramsay scale: need for a validated measure of sedating drug efficacy in the intensive care unit. Crit Care Med 1994; 22: 732–3.

    PubMed  CrossRef  CAS  Google Scholar 

  5. Riker RR, Picard JT, Fraser GL. Prospective evaluation of the Sedation-Agitation Scale for adult critically ill patients. Crit Care Med 1999; 27: 1325–9.

    PubMed  CrossRef  CAS  Google Scholar 

  6. Stoelting RK. Pharmacology and Physiology in Anesthetic Practice, 2nd ed. Philadelphia: Lippincott, 1991.

    Google Scholar 

  7. Shapiro BA, Warren J, Egol AB, Greenbaum DM, Jacobi J, Nasraway SA, Schein RM, Spevetz A, Stone JR. Practice parameters for intravenous analgesia and sedation for adult patients in the intensive care unit: an executive summary. Crit Care Med 1995; 23: 1596–600.

    PubMed  CrossRef  CAS  Google Scholar 

  8. Swart EL, van Schijndel RJ, van Loenen AC, Thijs LG. Continuous infusion of lorazepam versus medazolam in patients in the intensive care unit: sedation with lorazepam is easier to manage and is more cost-effective. Crit Care Med 1999; 27: 1461–5.

    Google Scholar 

  9. Pohlman AS, Simpson KP, Hall JB. Continuous intravenous infusions of lorazepam versus midazolam for sedation during mechanical ventilatory support: a prospective, randomized study. Crit Care Med 1994; 22: 1241–7.

    PubMed  CrossRef  CAS  Google Scholar 

  10. Smith I, White PF, Nathanson M, Gouldson R. Propofol. An update on its clinical use. Anesthesiology 1994; 81: 1005–43.

    PubMed  CrossRef  CAS  Google Scholar 

  11. Albanese J, Martin C, Lacarelle B, Saux P, Durand A, Gouin F. Pharmacokinetics of long-term propofol infusion used for sedation ICU patients. Anesthesiology 1990; 73: 214–7.

    PubMed  CrossRef  CAS  Google Scholar 

  12. Bailie GR, Cockshott ID, Douglas EJ, Bowles BJ. Pharmacokinetics of propofol during and after long-term continuous infusion for maintenance of sedation in ICU patients. Br J Anaesth 1992; 68: 486–91.

    PubMed  CrossRef  CAS  Google Scholar 

  13. Beller JP, Pottecher T, Lugnier A, Mangin P, Otteni JC. Prolonged sedation with propofol in ICU patients: recovery and blood concentration changes during periodic interruptions in infusion. Br J Anaesth 1988; 61: 583–8.

    PubMed  CrossRef  CAS  Google Scholar 

  14. Bennett SN, McNeil MM, Bland LA, Arduino MJ, Villarino ME, Perrotta DM, Burwen DR, Weibel SF, Pegues DA, Stroud L, Zeitz PS, Jarvis WR. Postoperative infections traced to contamination of an intravenous anesthetic, propofol. N Engl J Med 1995; 333: 147–54.

    PubMed  CrossRef  CAS  Google Scholar 

  15. Webb SA, Roberts B, Breheny FX, Golledge CL, Cameron PD, van Heerden PV. Contamination of propofol infusions in the intensive care unit: incidence and clinical significance. Anaesth Intensive Care 1998; 26: 162–4.

    Google Scholar 

  16. McLeod G, Dick J, Wallis C, Patterson A, Cox C, Colvin J. Propofol 2% in critically ill patients: effect on lipids. Crit Care Med 1997; 25: 1976–81.

    PubMed  CrossRef  CAS  Google Scholar 

  17. Myles PS, Buckland MR, Morgan DJ, Weeks AM. Serum lipid and glucose concentrations with a propofol infusion for cardiac surgery. J Cardiothorac Vasc Anesth 1995; 9: 373–8.

    PubMed  CrossRef  CAS  Google Scholar 

  18. Gottardis M, Khunl-Brady KS, Koller W, Sigl G, Hackl JM. Effect of prolonged sedation with propofol on serum triglyceride and cholesterol concentrations. Br J Anaesth 1989; 62: 393–6.

    PubMed  CrossRef  CAS  Google Scholar 

  19. Wahr JA, Plunkett JJ, Ramsay JG, Reeves J, Jain U, Ley C, Wilson R, Mangano DT. Cardiovascular responses during sedation after coronary revascularization. Incidence of myocardial ischemia and hemodynamic episodes with propofol versus midazolam. Institutions of the McSPI Research Group. Anesthesiology 1996; 84: 1350–60.

    PubMed  CrossRef  CAS  Google Scholar 

  20. Roekaerts PM, Huygen FJ, de Lange S. Infusion of propofol versus midazolam for sedation in the intensive care unit following coronary artery surgery. J Cardiothorac Vasc Anesth 1993; 7: 142–7.

    Google Scholar 

  21. Plunkett JJ, Reeves JD, Ngo L, Bellows W, Shafer SL, Roach G, Howse J, Herskowitz A, Mangano DT. Urine and plasma catecholamine and cortisol concentrations after myocardial revascularization. Modulation by continuous sedation. Multicenter Study of Perioperative Ischemia (McSPI) Research Group, and the Ischemia Research and Education Foundation (IREF). Anesthesiology 1997; 86: 785–96.

    PubMed  CrossRef  CAS  Google Scholar 

  22. Carrasco G, Molina R, Costa J, Soler JM, Cabre L. Propofol vs midazolam in short-, medium-, and long-term sedation of critically ill patients. A cost-benefit analysis. Chest 1993; 103: 557–64.

    PubMed  CrossRef  CAS  Google Scholar 

  23. Aitkenhead AR, Pepperman ML, Willatts SM, Coates PD, Park GR, Bodenham AR, Collins CH, Smith MB, Ledingham IM, Wallace PG. Comparison of propofol and midazolam for sedation in critically ill patients. Lancet 1989; 2: 704–9.

    PubMed  CrossRef  CAS  Google Scholar 

  24. Barrientos-Vega R, Mar Sanchez-Soria M, Morales-Garcia C, Robas-Gomez A, Cuena-Boy R, Ayensa-Rincon A. Prolonged sedation of critically ill patients with midazolam or propofol: impact on weaning and costs. Crit Care Med 1997; 25: 33–40.

    Google Scholar 

  25. Riker RR, Fraser GL, Cox PM. Continuous infusion of haloperidol controls agitation in critically ill patients. Crit Care Med 1994; 22: 433–40

    PubMed  CrossRef  CAS  Google Scholar 

  26. Kriwisky M, Perry GY, Tarchitsky D, Gutman Y, Kishon Y. Haloperidol-induced torsades de pointes. Chest 1990; 98: 482–4.

    PubMed  CrossRef  CAS  Google Scholar 

  27. O’Brien JM, Rockwood RP, Suh LU. Haloperidol-induced torsade de pointes. Ann Pharmacother 1999; 33: 1046–50.

    PubMed  CrossRef  Google Scholar 

  28. Imai Y, Mammoto T, Murakami K, Kita T, Sakai T, Kagawa K, Kirita T, Sugimura M, Kishi Y. The effects of preanesthetic oral clonidine on total requirement of propofol for general anesthesia. J Clin Anesth 1998; 10: 660–5.

    Google Scholar 

  29. Park J, Forrest J, Kolesar R, Bhola D, Beattie S, Chu C. Oral clonidine reduces postoperative PCA morphine requirements. Can J Anaesth 1996; 43: 900–6.

    PubMed  CrossRef  CAS  Google Scholar 

  30. Bohrer H, Bach A, Layer M, Werning P. Clonidine as a sedative adjunct in intensive care. Intensive Care Med 1990; 16: 265–6.

    PubMed  CrossRef  CAS  Google Scholar 

  31. Ip Yam PC, Forbes A, Kox WJ. Clonidine in the treatment of alcohol withdrawal in the intensive care unit. Br J Anaesth 1992; 68: 106–8.

    Google Scholar 

  32. Spies CD, Dubisz N, Neumann T, Blum S, Muller C, Rommelspacher H, Brummer G, Specht M, Sanft C, Hannemann L, Striebel HW, Schaffartzik W. Therapy of alcohol withdrawal syndrome in intensive care unit patients following trauma: results of a prospective, randomized trial. Crit Care Med 1996; 24: 414–22.

    PubMed  CrossRef  CAS  Google Scholar 

  33. Baumgartner GR, Rowen RC. Transdermal clonidine versus chlordiazepoxide in alcohol withdrawal: a randomized, controlled clinical trial. South Med J 1991; 84: 312–21.

    PubMed  CrossRef  CAS  Google Scholar 

  34. Inouye SK, Charpentier PA. Precipitating factors for delirium in hospitalized elderly persons. Predictive model and interrelationship with baseline vulnerability. JAMA 1996; 275: 852–7.

    PubMed  CrossRef  CAS  Google Scholar 

  35. Inouye SK, Bogardus ST Jr, Charpentier PA, Leo-Summers L, Acampora D, Holford TR, Cooney LM Jr. A multicomponent intervention to prevent delirium in hospitalized older patients. N Engl J Med 1999; 340: 669–76.

    PubMed  CrossRef  CAS  Google Scholar 

  36. Liu S, Carpenter RL, Neal JM. Epidural anesthesia and analgesia. Their role in postoperative outcome. Anesthesiology 1995; 82: 1474–506.

    Google Scholar 

  37. Wu CL, Jani ND, Perkins FM, Barquist E. Thoracic epidural analgesia versus intravenous patient- controlled analgesia for the treatment of rib fracture pain after motor vehicle crash. J Trauma 1999; 47: 564–7.

    PubMed  CrossRef  CAS  Google Scholar 

  38. Moon MR, Luchette FA, Gibson SW, Crews J, Sudarshan G, Hurst JM, Davis K Jr, Johannigman JA, Frame SB, Fischer JE. Prospective, randomized comparison of epidural versus parenteral opioid analgesia in thoracic trauma. Ann Surg 1999; 229: 684–91.

    PubMed  CrossRef  CAS  Google Scholar 

  39. Wisner DH. A stepwise logistic regression analysis of factors affecting morbidity and mortality after thoracic trauma: effect of epidural analgesia. J Trauma 1990; 30: 799–805.

    PubMed  CrossRef  CAS  Google Scholar 

  40. Miller HA, Taylor GA, Harrison AW, Maggisano R, Hanna S, de Lacy JL, Shulman H, Management of flail chest. Can Med Assoc J 1983; 129: 1104–7.

    Google Scholar 

  41. Dittmann M, Keller R, Wolff G. A rationale for epidural analgesia in the treatment of multiple rib fractures. Intensive Care Med 1978; 4: 193–7.

    PubMed  CrossRef  CAS  Google Scholar 

  42. Dittmann M, Steenblock U, Kranzlin M, Wolff G. Epidural analgesia or mechanical ventilation for multiple rib fractures? Intensive Care Med 1982; 8: 89–92.

    PubMed  CrossRef  CAS  Google Scholar 

  43. Gramling-Babb P, Miller MI, Reeves ST, Roy RC, Zile MR. Treatment of medically and surgically refractory angina pectoris with high thoracic epidural analgesia: initial clinical experience. Am Heart J 1997; 133: 648–55.

    PubMed  CrossRef  CAS  Google Scholar 

  44. Blomberg S, Curelaru I, Emanuelsson H, Herlitz J, Ponten J, Ricksten SE. Thoracic epidural anaesthesia in patients with unstable angina pectoris. Eur Heart J 1989; 10: 437–44.

    PubMed  CAS  Google Scholar 

  45. Blomberg SG. Long-term home self-treatment with high thoracic epidural anesthesia in patients with severe coronary artery disease. Anesth Analg 1994; 79: 413–21.

    PubMed  CrossRef  CAS  Google Scholar 

  46. Blomberg S, Emanuelsson H, Kvist H, Lamm C, Ponten J, Waagstein F, Ricksten SE. Effects of thoracic epidural anesthesia on coronary arteries and arterioles in patients with coronary artery disease. Anesthesiology 1990; 73: 840–7.

    PubMed  CrossRef  CAS  Google Scholar 

  47. Kock M, Blomberg S, Emanuelsson H, Lomsky M, Stromblad SO, Ricksten SE. Thoracic epidural anesthesia improves global and regional left ventricular function during stress-induced myocardial ischemia in patients with coronary artery disease. Anesth Analg 1990; 71: 625–30.

    PubMed  CrossRef  CAS  Google Scholar 

  48. Blomberg S, Emanuelsson H, Ricksten SE. Thoracic epidural anesthesia and central hemodynamics in patients with unstable angina pectoris. Anesth Analg 1989; 69: 558–62.

    PubMed  CrossRef  CAS  Google Scholar 

  49. Horlocker TT. Regional anesthesia and coagulation. In: Schwartz, AJ, ed. Refresher Courses in Anesthesiology. Philadelphia: Lippincott, 1998.

    Google Scholar 

  50. Vandermeulen EP, Van Aken H, Vermylen J. Anticoagulants and spinal-epidural anesthesia. Anesth Analg 1994; 79: 1165–77.

    PubMed  CrossRef  CAS  Google Scholar 

  51. Mikkola KM, Patel SR, Parker JA, Grodstein F, Goldhaber SZ. Increasing age is a major risk factor for hemorrhagic complications after pulmonary embolism thrombolysis. Am Heart J 1997; 134: 69–72.

    PubMed  CrossRef  CAS  Google Scholar 

  52. Rao AK, Pratt C, Berke A, Jaffe A, Ockene I, Schreiber TL, Bell WR, Knatterud G, Robertson TL, Terrin ML. Thrombolysis in Myocardial Infarction (TIMI) Trial-phase I: hemorrhagic manifestations and changes in plasma fibrinogen and the fibrinolytic system in patients treated with recombinant tissue plasminogen activator and streptokinase. J Am Coll Cardiol 1988; 11: 1–11.

    PubMed  CrossRef  CAS  Google Scholar 

  53. Horlocker TT, Wedel DJ, Schlichting JL. Postoperative epidural analgesia and oral anticoagulant therapy. Anesth Analg 1994; 79: 89–93.

    PubMed  CAS  Google Scholar 

  54. Rao TL, El-Etr AA. Anticoagulation following placement of epidural and subarachnoid catheters: an evaluation of neurologic sequelae. Anesthesiology 1981; 55: 618–20.

    PubMed  CrossRef  CAS  Google Scholar 

  55. Wu CL, Perkins FM. Oral anticoagulant prophylaxis and epidural catheter removal. Reg Anesth 1996; 21: 517–24.

    PubMed  CAS  Google Scholar 

  56. Sandhu H, Morley-Forster P, Spadafora S. Epidural hematoma following epidural analgesia in a patient receiving unfractionated heparin for thromboprophylaxis. Reg Anesth Pain Med 2000; 25: 72–5.

    PubMed  CAS  Google Scholar 

  57. Horlocker TT, Heit JA. Low molecular weight heparin: biochemistry, pharmacology, perioperative prophylaxis regimens, and guidelines for regional anesthetic management. Anesth Analg 1997; 85: 874–85.

    PubMed  CAS  Google Scholar 

  58. Wang LP, Hauerberg J, Schmidt JF. Incidence of spinal epidural abscess after epidural analgesia: a national 1-year survey. Anesthesiology 1999; 91: 1928–36.

    PubMed  CrossRef  CAS  Google Scholar 

  59. Sarubbi FA, Vasquez JE. Spinal epidural abscess associated with the use of temporary epidural catheters: report of two cases and review. Clin Infect Dis 1997; 25: 1155–8.

    PubMed  CrossRef  CAS  Google Scholar 

  60. Strong WE. Epidural abscess associated with epidural catheterization: a rare event? Report of two cases with markedly delayed presentation. Anesthesiology 1991; 74: 943–6.

    PubMed  CrossRef  CAS  Google Scholar 

  61. Dahlgren N, Tornebrandt K. Neurological complications after anaesthesia. A follow-up of 18,000 spinal and epidural anaesthetics performed over three years. Acta Anaesthesiol Scand 1995; 39: 872–80.

    Google Scholar 

  62. Auroy Y, Narchi P, Messiah A, Litt L, Rouvier B, Samii K. Serious complications related to regional anesthesia: results of a prospective survey in France. Anesthesiology 1997; 87: 479–86.

    PubMed  CrossRef  CAS  Google Scholar 

  63. Nordberg G, Mark H. Epidural abscess after epidural analgesia treated successfully with antibiotics. Acta Anaesthesiol Scand 1998; 42: 727–31.

    PubMed  CrossRef  CAS  Google Scholar 

  64. Darchy B, Forceville X, Bavoux E, Soriot F, Domart Y. Clinical and bacteriologic survey of epidural analgesia in patients in the intensive care unit. Anesthesiology 1996; 85: 988–98.

    PubMed  CrossRef  CAS  Google Scholar 

  65. akobsen KB, Christensen MK, Carlsson PS. Extradural anaesthesia for repeated surgical treatment in the presence of infection. Br J Anaesth 1995; 75: 536–40.

    CrossRef  Google Scholar 

  66. Schelling G, Stoll C, Haller M, Briegel J, Manert W, Hummel T, Lenhart A, Heyduck M, Polasek J, Meier M, Preuss U, Bullinger M, Schuffel W, Peter K. Health-related quality of life and posttraumatic stress disorder in survivors of the acute respiratory distress syndrome. Crit Care Med 1998; 26: 651–9.

    PubMed  CrossRef  CAS  Google Scholar 

  67. Kress JP, Pohlman AS, O’Connor MF, Hall JB. Daily interruption of sedative infusions in critically ill patients undergoing mechanical ventilation. N Engl J Med 2000; 342: 1471–7.

    PubMed  CrossRef  CAS  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Harvard Medical School, Massachusetts General Hospital, Boston, MA, 02114, USA

    Jean Kwo M.D.

Authors
  1. Jean Kwo M.D.
    View author publications

    You can also search for this author in PubMed Google Scholar

Editor information

Editors and Affiliations

  1. Director, Chairman, Surgical Intensive Care Unit, Department of Surgical Critical Care, Lahey Clinic Medical Center, Burlington, MA, USA

    John Merritt O’Donnell M.D.

  2. Senior Fellow, Department of Surgical Critical Care, Lahey Clinic Medical Center, Burlington, MA, USA

    Flávio Eduardo Nácul M.D.

Rights and permissions

Reprints and Permissions

Copyright information

© 2001 Springer Science+Business Media New York

About this chapter

Cite this chapter

Kwo, J. (2001). Analgesia and Sedation. In: O’Donnell, J.M., Nácul, F.E. (eds) Surgical Intensive Care Medicine. Springer, Boston, MA. https://doi.org/10.1007/978-1-4757-6645-5_9

Download citation

  • DOI: https://doi.org/10.1007/978-1-4757-6645-5_9

  • Publisher Name: Springer, Boston, MA

  • Print ISBN: 978-1-4757-6647-9

  • Online ISBN: 978-1-4757-6645-5

  • eBook Packages: Springer Book Archive