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Disclaimer: CME certification for these activities has expired. All information is pertinent to the timeframe in which it was released.


Emerging Concepts in Managing Intensive Care Unit Sedation


GOAL
To provide current information on managing sedation in intensive care unit (ICU) patients.

TARGET AUDIENCE
This activity is designed for critical care physicians, anesthesiologists, and other health care professionals who treat ICU patients.

LEARNING OBJECTIVES
After reading this issue, the participant should be able to:

  • Clarify the definition of agitation and discuss its causes and implications in the ICU patient.
  • Understand the pathophysiological and physiological mechanisms related to ICU sedative use.
  • Discuss the benefits of lower lipid and fluid load in ICU sedative agents.
  • Understand the important pharmaceutical factors affecting infusion safety in the ICU.
  • Discuss a pharmacoeconomic review of ICU sedative agents.
  • Understand the clinical consideration of pharmacoeconomics in the ICU.
  • Review recent studies on emerging ICU sedative agents and techniques.
  • Discuss appropriate use of sedative agents in the ICU based upon newly revised American College of Critical Care Medicine guidelines.

ACCREDITATION STATEMENT
This activity has been planned and produced in accordance with the Essential Areas and Policies of the Accreditation Council for Continuing Medical Education. The Johns Hopkins University School of Medicine is accredited by the Accreditation Council for Continuing Medical Education to sponsor continuing medical education for physicians. The Johns Hopkins University School of Medicine takes responsibility for the content, quality, and scientific integrity of this CME activity.

CREDIT DESIGNATION STATEMENT
The Johns Hopkins University School of Medicine designates this educational activity for a maximum of 1 hour in Category 1 credit toward the American Medical Association (AMA) Physician's Recognition Award. Each physician should only claim those hours of credit that he/she actually spends on this educational activity. Credits are available until the expiration date of June 30, 2004.

This continuing education activity was produced under the supervision of Todd Dorman, MD, FCCM, Associate Professor, Departments of Anesthesiology and Critical Care Medicine, Medicine, and Surgery; Director, Adult Critical Care Medicine Division; Co-director, Surgical Intensive Care Units; Director, Adult Post-Anesthesia Care Units; Medical Director, Respiratory Care Services; and Medical Director, Critical Care Information Systems, Johns Hopkins University School of Medicine, Baltimore, Maryland.

This program is supported by an unrestricted educational grant from AstraZeneca LP.

Publisher's Note and Disclaimer: The opinions expressed in this issue are those of the authors, presenters, and/or panelists and are not attributable to the publisher, editor, advisory board of Advanced Studies in Medicine, or The Johns Hopkins University School of Medicine or its Office of Continuing Medical Education. Clinical judgment must guide each professional in weighing the benefits of treatment against the risk of toxicity. Dosages, indications, and methods of use for products referred to in this issue are not necessarily the same as indicated in the package insert for the product and may reflect the clinical experience of the authors, presenters, and/or panelists or may be derived from the professional literature or other clinical sources. Consult complete prescribing information before administering.

FACULTY ADVISOR

    Todd Dorman, MD, FCCM
    Associate Professor
    Departments of Anesthesiology and Critical Care Medicine, Medicine, and Surgery
    Director, Adult Critical Care Medicine Division
    Co-director, Surgical Intensive Care Units
    Director, Adult Post-Anesthesia Care Units
    Medical Director, Respiratory Care Services
    Medical Director, Critical Care Information Systems
    Johns Hopkins University School of Medicine
    Baltimore, Maryland
    • Dr Dorman reports no financial or advisory relationship with any pharmaceutical companies.

PARTICIPATING FACULTY

    Louis Brusco, Jr, MD
    Assistant Professor of Clinical Anesthesiology
    Columbia University College of Physicians & Surgeons
    Director, Critical Care Anesthesiology
    Co-director, Surgical Intensive Care Unit
    Medical Director, Post-Anesthesia Care Unit
    St. Luke's-Roosevelt Hospital Center
    New York, New York
    • Dr Brusco reports serving as a consultant to AstraZeneca LP and Ortho-Biotech.

    I. Larry Cohen, MD, FCCP, FCCM
    Associate Professor of Surgery & Medicine
    Department of Anesthesia
    State University of New York at Buffalo
    Roswell Park Cancer Institute
    Buffalo, New York
    • Dr Cohen reports no financial or advisory relationship with any pharmaceutical company.

    David F. Driscoll, PhD
    Assistant Professor of Medicine
    Harvard Medical School
    Boston, Massachusetts
    • Dr Driscoll reports receiving grant/research support from AstraZeneca LP and B. Braun.

Advanced Studies in Medicine provides disclosure information from contributing authors, lead presenters, and participating faculty. Advanced Studies in Medicine does not provide disclosure information from authors of abstracts and poster presentations. The reader shall be advised that these contributors may or may not maintain financial relationships with pharmaceutical companies

Emerging Concepts in Managing Intensive Care Unit Sedation
Todd Dorman, MD, FCCM*

Sedation is often required for critically ill patients in the intensive care unit (ICU) to manage pain and agitation and, equally important, to maintain an optimal level of comfort. Finding a sedative regimen particularly suited for each ICU patient is difficult, yet imperative, and demands a multifaceted treatment approach that addresses various environmental and clinical issues. Important factors to be considered in the sedation of ICU patients include duration of therapy and length of ICU stay, minimization of side effects, post-ICU morbidity, safety of parenteral infusion, and cost effectiveness.

With evolving monitoring and systems management, advanced studies on pathophysiology and the diagnoses of post-ICU syndromes, and recently revised guidelines by the American College of Critical Care Medicine (ACCM) that provide parameters for the use of analgesics and sedatives in the ICU, clinicians are better equipped than ever before to tailor sedative regimens most effectively and efficiently to individual patient needs. However, there is no ideal sedative for any given patient; therefore, further investigation and monitoring are necessary for safe and effective sedation. This issue of Advanced Studies in Medicine provides insights into these topics by highlighting presentations from "Emerging Concepts in Managing Intensive Care Sedation," a satellite symposium held January 27, 2002, in San Diego in conjunction with the 31st Critical Care Congress of the Society of Critical Care Medicine.

Management of the agitated patient in the ICU has become an increasingly critical issue. Common to the agitated patient are attempts at self-extubation if ventilated; constant movement; disorientation to place, time, and identity; unintelligible conversation; abnormal vital signs; and an exaggerated sense of pain. Dr I. Larry Cohen addresses these concerns in his article, "Current Issues in Agitation Management," as well as the underlying causes of agitation, which include the ICU environment itself. Sedated patients in the ICU require frequent assessment and reevaluation. Dr Cohen discusses the scales used for this purpose, including the Ramsay Sedation Scale, Riker Sedation-Agitation Scale, Motor Activity Assessment Scale, and the Confusion Assessment Method for ICU. The selection of pharmacological agents, as well as post-ICU depression and stress syndromes, are also addressed in Dr Cohen's article.

Dr David Driscoll notes that while manufacturing processes for drugs are closely monitored by regulatory authorities, improper compounding and preparation of commercial dosage forms might occur within pharmacies and critical care settings. These factors greatly affect the fragile ICU patient, who requires great attention in regard to the physicochemical stability and compatibility of intravenous formulations; thus, Dr Driscoll outlines the crucial characteristics required to safely administer sedative intravenous therapy.

Dr Driscoll also addresses the stability, compatibility, sterility, and dosing of sedative drugs to ICU patients, as well as the importance of the clinician to increase infusion safety through adherence to expiration and beyond-use dates, and aseptic technique. With attention to these important issues, clinicians can significantly influence the overall process of a safe intravenous administration and uneventful recovery for the sedated ICU patient.

Ideally, an ICU sedative should have minimal effect on cardiovascular function, no interactions with other medications, be safe for all ages, and cost effective. However, Dr Louis Brusco, Jr, reinforces that such an ideal ICU sedative does not exist. Therefore, sedative regimens must be determined by evidence-based medicine, which may not always be available. Dr Brusco discusses analgesics as well as comparison studies on propofol, midazolam, and lorazepam. In addition, Dr Brusco addresses the ACCM guidelines, which recommend lorazepam for sedation of most patients, midazolam for short-term sedation, and propofol when rapid wakening for assessment or extubation is desired, or in the elderly.

The cost effectiveness of drug therapy in the ICU has led to pharmacoeconomic comparisons of commonly used sedatives. Dr Brusco offers such comparisons through several studies that have evaluated the pharmacoeconomics of propofol and midazolam and/or lorazepam.

The articles included in this issue reinforce the importance of close monitoring and individual tailoring of sedative regimens for the sedated ICU patient. Tolerance, safety, side effects, and cost effectiveness must all factor into the selection of an appropriate sedative. The presentations highlighted in the pages ahead will address these concerns and offer the clinician practical approaches for effective sedation of the ICU patient.

*Associate Professor, Departments of Anesthesiology and Critical Care Medicine, Medicine, and Surgery; Director, Adult Critical Care Medicine Division; Co-Director, Surgical Intensive Care Units; Director, Adult Post-Anesthesia Care Units; Medical Director, Respiratory Care Services; and Medical Director, Critical Care Information Systems, Johns Hopkins University School of Medicine, Baltimore, Maryland.





Johns Hopkins Advanced Studies in Medicine (ISSN-1558-0334), is published by Galen Publishing, LLC, d/b/a ASiM, PO Box 340, Somerville, NJ 08876. (908) 253-9001. Copyright ©2012 by Galen Publishing. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, without first obtaining permission from the publisher. ASiM is a registered trademark of The Healthcare Media Group, LLC.