Mount Sinai Expert Guides. Группа авторов
different volume of periphery that it can fill at a different rate. Accordingly, we see that a medication like remifentanil which has virtually no CSHT will wear off in a few minutes regardless of the administration duration, while midazolam may take days after a sufficiently long infusion.
Monitoring
Sedation
Two methods have been well validated for monitoring sedation levels with equivalent results:The Richmond Agitation‐Sedation Scale (Table 2.1) extends from –5 (unarousable) to +4 (combative) with zero representing a calm and alert patient. A typical goal is a light sedation of –1 to –2.The Riker Sedation‐Agitation Scale (Table 2.2), extends from 1 (unarousable) to 7 (dangerous agitation), with 4 representing the calm and alert patient. A typical goal is a light sedation of 3.
Objective monitoring modalities such as EEG, bispectral index, or patient state index are not recommended by the Society of Critical Care Medicine guidelines as a regular monitoring tool. However, if the patient is paralyzed (through neuromuscular blockers or clinical condition), then use of an objective monitoring device is suggested.
Table 2.1 Richmond Agitation‐Sedation Scale.
| 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 non‐purposeful movement or patient–ventilator dyssynchrony |
| 1 | Restless | Anxious or apprehensive but movements not aggressive or vigorous |
| 0 | Alert and calm | |
| –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 |
Table 2.2 Riker Sedation‐Agitation Scale.
| Score | Term | Description |
|---|---|---|
| 7 | Dangerous agitation | Pulling at endotracheal tube, trying to remove catheters, striking staff |
| 6 | Very agitated | Does not calm down despite verbal instructions, requires physical restraints |
| 5 | Agitated | Anxious or mildly agitated, calms with verbal instructions |
| 4 | Calm and cooperative | Arouses easily and follows commands |
| 3 | Sedated | Does arouse to verbal or physical stimulus, able to follow simple commands |
| 2 | Very sedated | Does not follow commands but arouses to physical stimulation |
| 1 | Unarousable | Little or no response to noxious stimuli |
Pain
Use of a validated pain scale is recommended for identifying treatment needs. Both verbal and non‐verbal scales should be used based on the patient's condition.
A numeric ranking scale is a subjective method of ranking pain. A typical method is the visual analog scale which uses a line 10 cm long with every centimeter marked as a number. The patient is asked to rank their pain along this scale, with 10 being the worst possible pain. For patients who are cognitively unable to make this association, the faces pain scale is an option with a series of six faces with differing expressions of distress shown. The patient is asked to point to the face that most approximates their current state.
An objective pain scale can also be used as many patients are unable to actively participate in their own pain assessment due to intubation and sedation or cognitive problems. The two best validated methods are the behavioral pain scale (BPS) and the critical care pain observation tool (CPOT). Additionally, the CPOT has recently been shown to be valid in patients with traumatic brain injury.
The BPS is comprised of three domains: facial expression, upper limb movement, and compliance with ventilation, each scored from 1 through 4. A total score of 5 or less is considered acceptable pain control.
The CPOT is comprised of four domains: facial expression, body movements, compliance with the ventilator or vocalization, and muscle tension, each scored from 0 to 2 with a total possible score of 8.
Medications for sedation and analgesia
Recommended doses are from the Society of Critical Care Medicine (SCCM) 2013 Pain, Agitation, and Delirium Guidelines.
Opioids
Considered the first line analgesic by the SCCM guidelines for ICU patients.
As a class, they have some sedative properties when given in high enough doses, but have no amnestic effects.
Side effects are reasonably universal and include respiratory depression, hypotension, itching, nausea and vomiting, miosis, and decreased gastric motility.
Choice of opioid and dosage must be tailored to the individual patient. For example, a 24‐year‐old patient in a trauma ICU who was actively taking suboxone at the time of admission may require an order of magnitude more opioid for the first 24 hours than a 72‐year‐old patient with renal failure.
Fentanyl
Pharmacology:Synthetic opioid with no active metabolites.Broken