Analgesia and Sedation in the ICU

EM/CC LECTURE SERIES

​

​

​

LOGAN CALDWELL, DO

LT, MC, USN

NMCP EMERGENCY MEDICINE

OUTLINE

• General Analgesia Concepts
• Pure Analgesics
• Analgosedatives
• Sedalgesics
• Pure sedatives
• Antipsychotics/anti-agitation

​

​

​

​

​

​

​

Why this lecture?

Good morning Doc,

​

​

​

​

Room 23 has been fighting the vent this morning. What would you like to do with her sedation?

​

We’re planning to extubate today, what’s our plan?

​

​

This is my third visit this week for back pain, can you fix me? The other doctor just said take motrin and tylenol, the next doctor gave me robaxin.

You ready to intubate this guy? What do you want to use?

​

​

Want to cardiovert, okay you do the sedation, what’s your go to med?

��General Analgesia Concepts - Sorting out the cause�

• Differentiate pain from anxiety from delirium, each should be assessed separately
• Use a quantitative tool to assess each and be goal directed in interventions to treat

​

​

​

​

​

��General Analgesia Concepts - Sorting out the cause�

Sedation and Delirium in the Intensive Care Unit | New England Journal of Medicine (nejm.org)

��General Analgesia Concepts - Sorting out the cause�

• Tools: CPOT, BPS
• Indirect
• Vital signs
• Proxy reporting (family, caregivers)
• Direct
• Communicative pt:
• Ask about pain
• Additional questioning about anxiety versus agitated delirium
• Get the nurse insight
• Uncommunicative pt:
• behavioral pain scores: Facial expressions, Vocalization, Movement of limbs, Compliance with ventilation

​

​

​

​

​

​

��General Analgesia Concepts – Behavioral Pain Score� (BPS)

​

​

​

​

​

​

��General Analgesia Concepts - Sorting out the cause�

• Anxiety -> RASS score
• Prevent and treat pain
• Involve family and provider reassurance
• Delirium -> CAM-ICU score
• Minimize delirium provoking meds
• Maintain circadian cycle
• Avoid restraints, tubes/lines, noise as able
• Optimize vision, hearing, mobility
• Treat pain and anxiety

​

​

​

​

​

General Analgesia Concepts

• Low to moderate dosing to optimize risk/benefit

​

​

​

​

​

​

General Analgesia Concepts

• Synergism
• i.e., 1+1 = 3

​

• Multi-modal therapy
• Using low to moderate doses of several different agents, allowing us to maximize efficacy while minimizing toxicity

​

​

​

​

​

​

General Analgesia Concepts - Analgesic Ladder�

• No one-size fits all solution in the ICU

​

​

​

​

General Analgesia Concepts – Daily sedation/analgesic interruption�

• Re-assess the sedation/pain regimen frequently (min daily – but ideally more often).
• Always seek to use the lowest dose possible.
• Don't shut off everything in a robotic fashion.
• Ex: If the patient is awake and comfortable (RASS = 0), then shutting off all the sedation could cause them to become agitated with no real benefit.

​

​

​

General Analgesia Concepts – Mechanism Overview�

​

​

​

Opioids�

​

• 1^st line for non-neuropathic pain in ICU
• Dose titration
• Avoid infusions, start with prns
• Use po as able (oxycodone, morphine)
• IV (fent, morphine, dilaudid). See table on next slide.
• High doses, opioid-induced hyperalgesia
• Opioid rotation and multimodal approach will avoid many of the pitfalls of opioids
• Anesthesia literature with strong evidence that avoidance of opioids improves recovery

​

​

Opioids�

Opioid Complications

• Complications
• Resp depression: increased risk in COPD (hypercapnia), blunted resp drive (obesity hypoventilation syndrome)
• This can be advantageous for facilitating ventilator synchrony
• Decreased GI transit (N/V, gastroparesis, ileus, colonic pseudo-obstruction)
• Dependence/withdrawal
• Delirium
• Opioid-induced Hyperalgesia
• Fentanyl accumulation in fat…delayed extubation

​

FITR - Fentanyl induced chest wall (thoracic) rigidity –

• Can occur at any dose (more common in pediatrics)
• Can lead to respiratory distress causing hypercapnia, hypoxemia, bradycardia
• May present as laryngospasm.
• Treatment is reversal with Naloxone.
• If respiratory failure not reversed with Naloxone, intubation should be performed with sedation and neuromuscular blockade
• The mechanism of action is not known but suspected to be neuraxis dopamine antagonism.

Opioid PCA�

• Allows for finer dose titration/theoretical reduced opioid doses
• Designed to MAINTAIN analgesia, not rescue
• Basic principles:
• Small bolus doses, no basal (always set to zero)
• Defined lock-out interval (pushing button will not deliver med-> prevents dose stacking)
• Patient who receives too much will fall asleep and stop activating PCA
• Discontinue all other opioid orders and sedative medications

**chronic user= use calculator to determine daily rate, always err on low side

Fentanyl gtt***�

• Typical dose for nurse-driven PRN dosing
• Bolus: ~50–100 mcg q30–60 min.
• Infusion: ~ 25–100 mcg/hour.
• Initial PCA dosing
• Demand 20–50 mcg.
• Lockout 5–10 minutes.

Onset & duration of action

• Onset ~1–2 minutes.
• Peak ~6–15 minutes.
• Duration: ~0.5–2 hours (longer in liver failure or after prolonged infusion).

Transition Opioids in ICU

• Methadone
• Antihyperalgesic agent
• **QTc prolongation
• Potential role for transition from short acting agents to facilitate weaning
• Oxycodone
• Limited to oral route
• Meperidine
• Weak analgesic with severe adverse risk profile (delirium, serotonin syndrome, seizures)
• Use limited to low dose for rigors/shivering

​

Methylnaltrexone �

• Subcutaneous methylnaltrexone (Relistor) rapidly induce bowel movement in patients with opioid-induced constipation.
• Usually does not affect central analgesia or precipitate opioid withdrawal.
• Methylnaltrexone is a quaternary amine selective antagonist of opioid binding at the mu-opioid receptor, which not cross the blood–brain barrier. Thus this agent functions as a peripherally acting mu-opioid receptor antagonist in areas such as the gastrointestinal tract, minimizing constipation effects of opioids, without affecting opioid-modulated analgesic effects within the central nervous system

Opioid Final Thoughts

• If starting a fentanyl infusion for sedation, do not try to treat pain by increasing infusion rate. Use bolus doses (infusion takes 4-5 half-lives to reach steady state)
• 25 mcg/hr fentanyl = 120 mg oxycodone per day. 25-50 mcg/hr of fentanyl should be sufficient, do not push these opioid infusions higher

​

• Don’t forget sedation/narcotic holidays…wean down min once/daily

​

• Rotate your opioids

​

• Your ICU patients should already be on a bowel regimen (two agents ideally), but just a reminder to keep the bowels moving.

​

• Ketamine may reduce development of tolerance and opioid induced hyperalgesia

Acetaminophen�

• MOA: centrally acting, non-competitive reversible inhibitor of COX, analgesic and antipyretic effects
• Routes: PO, PR, IV
• Typical dose: 650-1000 mg q6 hr (max 4 grams/day)
• *Max dose 2 grams in: severe alcoholism, stable cirrhosis, low body weight <50 kg.
• Avoid completely in acute liver injury, decompensated cirrhosis
• Schedule for ongoing pain, don’t do this if worried about fever curve
• IV acetaminophen should be used cautiously due to IV acetaminophen-associated hypotension, which can occur in up to 50% of patients.

​

​

NSAIDs�

• MOA: Inhibit prostaglandin synthesis via COX, antipyretic, analgesic, anti-inflammatory
• Not preferred in medical ICU, more common in surgical ICU
• Consider for selective pts: no other nephrotoxic meds, excellent & stable kidney fxn, no hemodynamic instability, absence of cirrhosis/GI disease, no hx of GI bleed, no active hemorrhage or severe coagulopathy
• All have similar safety/efficacy, Toradol considerably faster onset
• Avoid prolonged courses, <5 days
• “Dose Ceiling” see next slide

​

​

NSAIDs�

• Ketorolac (Toradol)
• Most toxic (GI bleed, MI)
• available IV
• Limit <5 days, ideally only 3 days
• 15 mg IV/IM/oral
• Naproxen
• 500 mg q12 or 250 q12 (older pts)
• Ibuprofen (motrin)
• 400 mg q6 hr
• Meloxicam (mobic)
• Once a day: 5-10 mg

​

​

NSAID “Dose Ceiling:

• Above certain dose, further increases only increase toxicity, w/o efficacy:
• Ketorolac 10 mg IV q6 hr prn
• Ibuprofen 400 mg po q6 hr prn

Lidocaine�

​

• Lidocaine patches (local)
• IV
• Loading dose: 1.5 mg/kg over 10-30 mins, infusion at 1 mg/kg/hr ideal body weight
• Very Narrow therapeutic window, HIGH RISK for TOXICITY
• Very LIMITED data
• AEs: Bradycardia, seizure, metallic taste, tinnitus, numbness/tingling
• CIs: Heart block, hepatic/renal dysfunction, multiorgan failure
• Might see in post-op patients, probably contraindicated in all medical ICU patients

​

*IV Lidocaine not suggested for routine use per SCCM 2018 guidelines

​

Gabapentinoids�

• MOA: Inhibit voltage-dependent calcium channels, no interaction with GABA
• Agents
• Gabapentin 300-1200 mg q8 hr
• Pregablin 75-150 mg q12 hr
• Uses
• Neuropathic pain (GBS, Neuropathy, SCI, Post-herpatic, SAH, Central pain)
• Anxiolytic
• Post-op pain/somatic pain…not much evidence

​

​

Gabapentinoids Complications

• Somnolence, respiratory depression, hypoactive delirium, myoclonus
• Dose reduction needed in renal dysfunction
• Rapid discontinuation can produce withdrawal symptoms (if on at home, low dose should likely be continued in the ICU)

Gabapentinoids�

• Pesonen 2011: Lyrica 150 mg before surgery, then 75 mg bid till POD 5. On the vent for roughly 2 hrs longer, but reduced post-op consumption of opioids by 44-48%.

​

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6513586/pdf/CD009642.pdf

Carbamazepine

• Oral anticonvulsant used for neuropathic pain
• Less effective than gabapentinoids but consider when gabapentinoids are not tolerated
• Starting dose: 100 mg bid to 100 mg QID
• AEs: N/V, ataxia, dizziness, SJS

Alpha-2 Agonists�

• MOA: Act on both centra alpha-2 receptors and imidazoline receptors. Spectrum of overlapping clinical effects
• Mild analgesic, but often synergistic with other agents
• Offer varying levels of sedation without respiratory suppression
• Drawbacks: bradycardia, hypotension, withdrawal syndrome (tachy, HTN, anxiety)

​

​

​

Alpha-2 Agonists�

• Dexmedetomidine: IV agent, 0-1.4 mcg/kg/hr
• If on long infusion, can transition to oral clonidine to avoid withdrawal symptoms
• Advantages: BiPAP anxiolytic (no resp suppression), bridge to extubation, patients often are fully arousable
• Clonidine: oral and patch
• Uses: Sedation/transition off Dex, opioid withdrawal, multimodal analgesia, restless leg, hypertension
• Typical starting dose around 0.1-0.2 mg q12 hr
• Among these agents, clonidine may cause the greatest degree of hypotension. This may be useful for patients with hypertension.
• Guanfacine: utilized primarily as insomnia aid (no analgesic properties)
• Starting dose: 0.5 mg q12 hr
• Tizanidine: utilized primarily as an analgesic and muscle relaxant.
• Typical starting dose: 4 mg q8 hr

​

​

Dexmedetomidine*** aka Dex aka Precedex �

• Disadvantages & contraindications:
• High rate of bradycardia
• Sympatholytic effects may be poorly tolerated among patients with systolic heart failure.
• Cannot achieve deep sedation (e.g., dexmedetomidine isn't a good choice for ARDS or COPD if you're trying to suppress the respiratory drive).
• High-dose dexmedetomidine may eventually cause tachyphylaxis and subsequent withdrawal.
• Advantages:
• [Beneficial for delirium:
• Promotes physiological, restorative sleep.
• Reduces the rate of delirium.
• Avoids deep sedation that may occur with high-dose propofol.
• Facilitates extubation:
• May decrease the duration of mechanical ventilation.
• Helps bridge agitated patients through extubation (may be continued after extubation).
• Promotes analgesia:
• Directly provides some adjunctive analgesia.
• Synergizes well with ketamine.
• If dexmedetomidine is well tolerated and helpful, it can be transitioned to enteral clonidine or guanfacine.

​

Baclofen

• MOA: GABA B agonist
• 5 to 10 mg TID po
• Hepatotoxicity
• AEs: Drowsiness, dizziness confusion
• Withdrawal common (hyperthermia, seizures, AMS) so will need to be tapered off

Muscle Relaxants

• Methocarbamol (po, IV, IM); cyclobenzaprine (po)
• Mechanisms poorly understood but pretty clear that they do not actually work on muscle itself
• Cyclobenzaprine likely carries a mechanism similar to TCAs
• If using these, limit to short courses
• AEs: dizziness, drowsiness, confusions,

SNRIs

• Useful in chronic neuropathic pain, MSK pain and fibromyalgia
• Duloxetine (Cymbalta) – most data to support analgesic efficacy
• 30 mg po daily
• Venlafaxine (Effexor)
• Cardiac side effects more pronounced(elevated BP)
• 37.5 mg po daily
• AEs: nausea, dry mouth, insomnia, constipation, dizziness, HTN
• Avoid in renal or hepatic insufficiency
• Must be tapered off

Tricyclic Antidepressants�

• Amitriptyline, po 10-100 mg.
• Nortriptyline, po 10 mg/day(lowest risk of discontinuation/withdrawal side effects)
• Useful for neuropathic pain
• SEs: Dry mouth, sedation, blurred vision, arrhythmias, postural hypotension, QTc prolongation
• Slow tapering schedule recommended

​

​

Ketamine*** 1-2 mg/kg (intubation) 0.3 mg/kg (pain)�

• MOA: NMDA-receptor antagonist.
• At very low doses, ketamine provides analgesia without other neurologic effects.
• At higher doses, ketamine has anti-seizure effects and dissociative effects.
• Half-life of 2-3 hours. Hepatic metabolism.
• Consider dose reduction in hepatic impairment.

Ketamine*** 1-2 mg/kg (intubation) 0.3 mg/kg (pain)�

• Infusion Pain Dosing
• 0.1-0.3 mg/kg/hr
• Will need to monitor for psychomimetic side effects (agitation, hallucinations)
• Adding Dexmedetomidine or clonidine can help prevent these psychomimetic effects
• Bolus Pain Dosing
• 0.1-0.3 mg/kg IV administered SLOWLY over 5-15 mins
• Complete Dissociative Sedation
• Infusion at rate of 1-5 mg/kg/hr

​

Ketamine*** 1-2 mg/kg (intubation) 0.3 mg/kg (pain)�

• Contraindications:
• HTN, hepatic dysfunction, pregnancy, active psychosis or delirium
• Side Effects:
• HTN, hypersalivation/increased secretions, psychomimetic effects
• Advantages:
• Hemodynamic stability, no respiratory suppression, bronchodilation, antiseizure effect

Ketamine in Heart Failure�

• Potential for up to 21% decrease in cardiac index (Christ article) despite increased BP
• Ketamine will increase afterload and MAP may look good, but be cognizant of what this may do to the LV.

Adverse Cardiovascular Effects of Ketamine Infusion in Patients with Catecholamine-Dependent Heart Failure - G. Christ, G. Mundigler, C. Merhaut, M. Zehetgruber, C. Kratochwill, G. Heinz, P. Siostrzonek, 1997 (sagepub.com)

https://journals.sagepub.com/doi/10.1177/108925320601000108?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%20%200pubmed

Purely sedatives/anxiolytics

​

Propofol*** 1-2 mg/kg�

• Ideally low-dose to avoid hypertriglyceridemia & over-sedation; perhaps ≦~40 mcg/kg/min
• Disadvantages:
• Hypertriglyceridemia
• Excessive suppression of brain activity at high doses may cause or prolong delirium
• Hypotension
• Advantages:
• May achieve deeper sedation (if this is the goal, which it usually isn't). Suppression of respiratory drive may improve ventilator synchrony
• Ease of titration: Propofol's shorter half-life may make it easier to titrate (especially easier to rapidly achieve adequate sedation)
• Niche neurologic indications:
• Antiepileptic activity
• May reduce intracranial pressure
• May treat alcohol withdrawal

Adjunctive Sedatives

• Hydroxyzine : 50-100 mg PO Q6hr.
• Melatonin: 3 mg PO QHS.
• Trazodone: 25-100 mg PO QHS.

Adjunctive Sedatives - Continued

• Antipsychotic:
• Haloperidol IV PRN: use if tempted to give IV lorazepam
• Quetiapine:scheduled QHS or Q12.
• Olanzapine: either PRN or scheduled; be careful about accumulation, given long half-life

These agents aren't readily titratable, so they cannot be immediately stopped when the patient is ready for extubation. Consequently, low doses should usually be used (doses that wouldn't compromise respiration or airway protection). Using excessively high doses may delay extubation.

• Valproic acid: may be helpful in refractory agitation.
• Dissociative ketamine infusion: e.g., 1-5 mg/kg/hour
• This may be necessary for patients with profound hypotension, which limits the ability to give sedatives (e.g., propofol or phenobarbital). After the patient is fully dissociated with ketamine, other sedatives and analgesics should be discontinued.

Benzodiazepines

• Benzodiazepines likely most deleriogenic sedative agent, acting as a risk factor for the development of post-traumatic stress disorder (PTSD). (30672819)
• Benzodiazepines have been shown to increase the duration of mechanical ventilation (when compared to dexmedetomidine or propofol).
• Benzodiazepines may cause paradoxical agitation (potentially leading to a vicious spiral of increased benzodiazepine use, leading to obtundation).
• Lorazepam infusions tend to cause propylene glycol intoxication.

Benefits of Benzos

• Hemodynamically stable
• Antiseizure activity
• Cheap and widely available

Benzos role in the ICU

• Sedative of last resort
• The practice of bolusing patients with PRN lorazepam at night should be avoided like the plague. This will often work in the short-term, but lorazepam will actually worsen delirium and agitation eventually.
• Niche roles in a few situations:
• Sedative of choice for intoxication, especially with sympathomimetics (due to muscle-relaxant and antiseizure properties).
• Profound hypotension (who are too unstable to receive propofol or dexmedetomidine). However, ketamine may be more useful in this situation.
• Alcohol withdrawal (although phenobarbital is generally better).

​

Benzo Half-Life

• Midazolam (Versed): 1.5-2.5 hrs
• Lorazepam (Ativan): 10-20 hrs
• Diazepam (Valium): 20-50 hrs
• if using for alcohol withdrawal this would be benzo of choice

Midazolam (Versed)

• Rapid and short
• Best IM benzo/fastest absorption
• Status epilepticus: 10 mg IV/IM. Preferred IM medication for seizures (works faster than IM lorazepam)
• Sedation in an intubated patient:
• Usual dosing: 2-5 mg IV q15-30 min PRN.
• Infusion: 0.02-0.1 mg/kg/hr (but this is undesirable; PRN dosing may be preferred to avoid over-sedation).

**Morbid obesity: An increased volume of distribution with unchanged clearance may lead to an extended half-life. Use an ideal body weight or adjusted body weight

Lorazepam (Ativan)

• A slow onset time may be problematic (15-20 mins), potentially leading to dose stacking
• Propylene glycol toxicity
• PO:IV:IM has 1:1:1 conversion (despite differing lag time to Tmax)
• Status epilepticus:
• 0.1 mg/kg lorazepam IV is supported by the best evidence
• 4 mg IV initially, with a repeat dose if this isn't effective
• Sedation of intubated patient:
• 1-4 mg IV q30-60 min PRN.

Diazepam (Valium)

• Very rapid effect, but long duration
• Ideal for alcohol withdrawal if not using phenobarb
• Alcohol withdrawal
• typically dosed with escalating doses as needed Q5-10 minutes (e.g. 10 mg, 10 mg, 20 mg, 20 mg, 20 mg, 40 mg, 40 mg, 40 mg)

Droperidol

• D2 antagonist
• Use: 2.5 > 5 > 10 mg IM/IV
• 1.25 mg IM
• Onset 3-10 IV, ~15 IM
• Effective for rapid control of agitation, less resp depression compared to benzos
• Risk: QTc, extrapyramidal

Etomidate

• GABA-A agonist
• Indications: pure sedative for procedural sedation/induction
• Advantages
• Hemodynamic stability.
• Relatively short duration of activity.
• SEs:
• Adrenal suppression
• myoclonus
• Dosing:
• procedural sedation: 0.1-0.15 mg/kg
• induction: 0.3 mg/kg, decrease dose to 0.15 mg/kg if hypotensive

​

Other Adjuncts to consider

• Epidural
• Peripheral nerve blocks/nerve block catheters

Non-pharmaceutical adjuncts to consider

• Massage therapy
• Music therapy
• Cold therapy
• Relaxation therapy

​

*All conditional recommendations with low quality of evidence per 2018 SCCM Pain guidelines

Case 1

72 yo M with history of HTN, HLD, CAD, COPD on home O2, PTSD, chronic opioid use disorder for low back pain, history of alcohol use disorder is currently on Day 5 of the vent for multifocal pneumonia and acute on chronic hypoxic and hypercapnic respiratory failure. He struggled during his SBT yesterday due to “agitation” and needed multiple prn Ativan and fentanyl boluses. He is currently on a precedex and fentanyl infusion. He is on a phenobarbital taper for alcohol withdrawal.

What is your sedation and pain management plan for his SBT/extubation today?

Case 2

37 yo M s/p MCC found to have L hemo/pneumo 2/2 multiple rib fractures s/p L chest tube complicated by acute hypoxic respiratory failure requiring intubation, POD 1 Ex-lap with splenectomy. Currently patient is vent day 2, he is currently sedated with propofol, fentanyl.

You would like to extubate today, what would your sedation/pain management plan be for extubation and post-extubation?

​

What would you do if this patient became agitated and did not tolerate his SBT?

Case 3

43 yo M otherwise healthy s/p 35% TBSA flash flame burn sustained from propane grill, now complicated by acute hypoxic respiratory failure currently vent day 4. Currently sedated with propofol, fent but nurses are concerned that he is intermittently agitated.

​

Using a multimodal approach, what recommendations/changes would you make to his sedation/pain regimen to address this issue?

Bonus - IV drips in Austere Environments

• Need to know:
• drop factor (# drops = 1 mL)
• typically on IV tubing packaging
• typically around 10-20 drops = 1 mL
• Desired dose over what time
• Formula

IV Flow rate (gtts/min) = (Desired dose/Concencentration)*Drop factor (gtts/mL)

You’re deployed at a Role 2 surgical facility in a remote location.� A 28-year-old male Marine underwent an emergent exploratory laparotomy for a perforated bowel secondary to blast injury. The operation was successful, but post-op day 5, he becomes increasingly hypotensive (BP 78/42, MAP ~54) despite 3L LR and 500 mL albumin. His skin is mottled, cap refill delayed, HR 128, and he becomes very confused and is eventually intubated. Labs are limited, but you're confident this is septic shock.

There are no infusion pumps available—you need to start Levophed manually to support his MAP. You want to start levophed.

Start Levophed at 10 mcg/min via gravity tubing.� You're given:

• 1 vial of Levophed: 4 mg�
• 1 bag of D5W: 250 mL�
• IV tubing with a drip factor of 20 gtt/mL

​

​

You are forward deployed with limited resources and no infusion pumps available. You have an intubated trauma patient who was involved in an IED explosion who is post-op from a craniectomy and EX-Lap and needs ongoing sedation with a ketamine drip.

You want to start ketamine at 2 mg/kg/hr for sedation. But your new nurse says there are no IV pumps available.� The patient weighs 70 kg.� You create a bag of ketamine by mixing 500 mg of high concentration ketamine in 250 mL of NS.� You’re using tubing with a drip factor of 20 gtt/mL.

What’s your drip rate?

​

References

• Devlin JW, Skrobik Y, Gélinas C, et al. Clinical practice guidelines for the prevention and management of pain, agitation/sedation, delirium, immobility, and sleep disruption in adult patients in the ICU. Crit Care Med. 2018 Sep.
• Guidelines on the Use of Intravenous Ketamine Infusions for Chronic Pain From the American Society of Regional Anesthesia and Pain Medicine, the American Academy of Pain Medicine, and the American Society of Anesthesiologists. Reg Anesth Pain Med. 2018;43(5):521-546.
• IBCC: Analgesia and sedation for the critically ill patient
• Uptodate: Pain control in the critically ill adult patient
• Reade MC, Finfer S. Sedation and delirium in the intensive care unit. N Engl J Med. 2014;370(5):444-454.
• SCCM Pain Guidelines 2018

Bonus Case

A 24-year-old male is admitted following a motor vehicle collision resulting in a traumatic brain injury with a subdural hematoma and cerebral edema. He underwent emergent craniotomy and has an intracranial pressure (ICP) monitor in place. The patient is intubated and mechanically ventilated but exhibits frequent episodes of agitation associated with ICP spikes. Current sedation includes propofol and fentanyl; however, he is developing bradycardia and hypotension.

Bonus Case

A 68-year-old female with advanced chronic obstructive pulmonary disease (COPD) and chronic ventilator dependence via tracheostomy is admitted with pneumonia. She has a history of chronic opioid use managed with a fentanyl patch and PRN opioids at home. During admission, she requires escalating doses of fentanyl infusion and dexmedetomidine for comfort. Attempts to wean sedation and analgesia precipitate severe withdrawal symptoms, including hypertension and agitation.

Bonus Case

A 58-year-old male with known alcohol use disorder is intubated following an aspiration event after a witnessed seizure. He is receiving a phenobarbital taper, fentanyl infusion, and PRN lorazepam. He exhibits alternating periods of agitation and over-sedation and has not progressed toward extubation.

Bonus Case

A 72-year-old male with end-stage pulmonary fibrosis, not a candidate for lung transplantation, develops severe acute respiratory distress syndrome (ARDS). The family has opted for comfort-focused care and terminal extubation. The patient’s sedation needs to be managed to ensure relief of suffering without hastening death or complete unresponsiveness.

Bonus Case

An 82-year-old female with a history of profound hearing loss and baseline aphasia from prior stroke is admitted with urosepsis and requires intubation. She becomes agitated and attempts to remove lines, despite no clear evidence of pain or withdrawal.

Bonus Case

A 40-year-old male on veno-venous extracorporeal membrane oxygenation (VV ECMO) for influenza-related ARDS is minimally ventilated and deeply sedated with midazolam and fentanyl. Physical therapy requests lighter sedation to allow patient participation in mobilization.

Quiz

https://docs.google.com/forms/d/e/1FAIpQLSe_FKqDr2eYqakc8u2eWsTZS1zFRHZD3shgccKBAqiNw2JH4w/viewform?usp=sf_link

​

​