Sedation and Anagesia in Critical Care John Dade Pharmacist SJUH

Sedation & Analgesia Relieve anxiety Alleviate pain Facilitate distressing or painful procedures Intubation & Ventilation Augment treatments Ventilation Treatment itself Anticonvulsant, Reducing ICP Control agitation

Opioids – alfentanil, morphine Intravenous anaesthetics - propofol Benzodiazepines - midazolam Muscle Relaxants - atracurium α agonists – clonidine, dexmedetomidine Neuroleptics – haloperidol, olanzepine

Analgesia - opioid Analgesia + Sedative/anaesthetic Analgesia + Sedative/anaesthetic + Muscle Relaxant

Opioids Analgesic Sedative Respiratory Depressant, anti-tussive Remifentanil Alfentanil Fentanyl Oxycodone Morphine Short acting – no metabolites Longer acting – active metabolites

Alfentanil Opioid Start at 1-2mg/hr and titrate Potent analgesic, sedative, & respiratory depressant Short acting Low risk accumulation (except liver disease) Start at 1-2mg/hr and titrate Lower dose in elderly, liver disease Typically in combination with propofol Side effects Sedation, constipation, confusion, nausea/vomiting

Alternative opioids Morphine Remifentanil longer acting, prone to accumulation Remifentanil Very short duration – continuous infusion Can be used as single agent Used more in other centres

Propofol GABA anaesthetic agent Short duration of action Low risk of accumulation Start at 5-10 ml/hr (100-200mg/hr) and titrate Avoid high doses >4mg/kg/hr Side effects Hypotension Hypertriglyceridaemia Propofol Infusion Syndrome (PRIS) Associated with high dosages (>4mg/kg/hr) for >48hrs Brady-arrythmia, cardiac dysfunction, Metabolic acidosis, acute kidney failure

Benzodiazepines Midazolam Lorazepam Diazepam Single dose or infusion Short acting Prone to accumulation Lorazepam Diazepam

Muscle Relaxants Augment ventilation Neuro-protective sedation Asthma, critical oxygenation Neuro-protective sedation Must use with adequate sedation and analgesia Monitor BP, HR, movement BIS Score Atracurium Rocuronium

Alpha 2 Agonists Clonidine, Dexmedetomidine Analgesic, sedative, anxiolytic More rousable and communicative than with other agents. Dexmedetomidine Up to 1.4mcg/kg/hr Better sedative than clonidine. Similar extubation recovery profile to propofol Too expensive for a first line agent Very useful in agitation, or were this is likely Clonidine Up to 2mcg/kg/hr Useful if withdrawing from sedation, alcohol, nicotine or opioids Helpful analgesic in acute pain. More cost effective than dexmedetomidine

Over Sedation Risks of over sedation Ratchet prescribing Failure to review / set targets Sedation scoring Red/Amber/Green sedation goals Sedation holds Accumulation – kidney or liver impairment Risks of over sedation Hypotension Prolonged recovery Critical Care myopathy, muscle wasting Increased risk delirium  PTSD Pneumonia , Ileus, Thrombosis

Richmond Agitation-Sedation Score Term Description +4 Combative Overtly combative or violent; immediate danger to staff +3 Very agitated Pulls on or removes tube(s) or catheter(s) or has aggressive behaviour toward staff +2 Agitated Frequent no purposeful movement or patient–ventilator dyssynchrony +1 Restless Anxious or apprehensive but movements not aggressive or vigorous Alert and calm Spontaneously pays attention to caregiver -1 Drowsy Not fully alert, but has sustained (more than 10 seconds) awakening, with eye contact, to voice -2 Light sedation Briefly (less than 10 seconds) awakens with eye contact to voice -3 Moderate sedation Any movement (but no eye contact) to voice -4 Deep sedation No response to voice, but any movement to physical stimulation -5 Unarousable No response to voice or physical stimulation