Recent Advances in Sedation and Analgesia in Mechanically Ventilated Surgical Patients in ICU

Abstract

Sedation and analgesia are important components of care for the mechanically ventilated patient in the intensive care unit (ICU). Objective assessments of pain, sedation and agitation have been validated for use in the ICU for assessment and titration of medications. An evidence-based strategy for administering these drugs can lead to improvements in short- and long term outcomes for patients. To choose an optimal strategy of medication use, it is necessary to understand the body of literature that forms the groundwork for evidence-based recommendations. Treating pain in criti¬cally ill patients depends on a clinician’s ability to perform a reproducible pain assessment and to monitor patients over time to determine the adequacy of therapeutic interventions to treat pain. Pain can be experienced as a consequence of intubation and mechanical ventilation itself, trauma, postoperative pain or it can be a consequence of other routine clinical care. Although the need for direct patient communication is self evident, it may be difficult for a mechanically ventilated patient to communicate symptoms of pain. Several tools are available to assess pain objectively. The Numeric Rating Scale, The Behavioral Pain Scale and Critical Care Pain Observation Tool, all use clinician observations of behavioral pain responses, have been validated for use in mechanically ventilated patients by comparing variability and correlation to the self reported Numeric Rating Scale. Validated sedation scales and protocols should be used to guide titration of these medications. The Ramsay Sedation Scale (RSS), The Sedation–Agitation Scale (SAS) and The Adaptation to the Intensive Care Environment (ATICE) Scale is a more comprehensive tool that assesses both the consciousness of the patient and tolerance of the ICU environment. Opioids, such as fentanyl, hydromorphone, methadone, morphine and remifentanil, are the primary medications for managing pain in critically ill patients. The optimal choice of opioid and the dosing regimen used for an individual patient depends on many factors, including the drug’s pharmacokinetic and pharmacodynamic properties.