Sedation, analgesia, and neuromuscular blockade in sepsis: An evidence-based review

An Assessment of the Practice of Neuromuscular Blockade and the Association Between Its Prophylactic Use and Outcomes Among Postoperative Pediatric Cardiac Patients

OBJECTIVES

The authors investigated the management of neuromuscular blocking agents (NMBAs) for pediatric patients after cardiac surgery, and compared the outcomes of patients who received prophylactic NMBA (pNMBA) infusions and patients without pNMBA infusions.

DESIGN

A retrospective cohort study.

SETTING

At a tertiary teaching hospital.

PARTICIPANTS

Patients younger than 18, with congenital heart disease, who underwent cardiac surgery.

INTERVENTIONS

Commencement of NMBA infusion in the first 2 hours after surgery MEASUREMENTS AND MAIN RESULTS: The primary endpoint was a composite of one or more of the following major adverse events (MAEs) that occurred within 7 days after surgery: death from any cause, a circulatory collapse that needed cardiopulmonary resuscitation, and requirement for extracorporeal membrane oxygenation. The secondary endpoints included the total duration of mechanical ventilation for the first 30 days after surgery. A total of 566 patients were included in this study. The MAEs occurred in 13 patients (2.3%). An NMBA was commenced within 2 hours after surgery in 207 patients (36.6%). There were significant differences in the incidence of postoperative MAEs between the pNMBA group and the non-pNMBA group (5.3% v 0.6%; p < 0.001). In multivariate regression models, pNMBA infusion was not significantly associated with the incidence of MAEs (odds ratio: 1.79, 95% CI: 0.23-13.93, p = 0.58), but was significantly associated with prolonged mechanical ventilation by 3.85 days (p < 0.001).

CONCLUSIONS

Postoperative prophylactic neuromuscular blockade after cardiac surgery can be associated with prolonged mechanical ventilation, but has no association with MAEs among pediatric patients with congenital heart disease.

Successful weaning of a patient with severe COVID-19 pneumonia under prolonged midazolam sedation using morphine

The coronavirus disease 2019 (COVID-19) pandemic continues to spread around the world. In April 2021, Japan experienced a fourth wave of COVID-19 infections, which led to the breakdown of the medical system. Osaka, Japan, was particularly affected, with many severe cases and the highest number of COVID-19-associated deaths in Japan. Herein, we present a patient with severe COVID-19 infection who received prolonged midazolam (MDZ) treatment since propofol was not available due to shortage of medical resources. Moreover, the duration of mechanical ventilation was extended due to the development of a pneumothorax. When MDZ tapering was initiated, tachypnea was observed, which resulted failure in ventilator weaning. However, the use of continuous morphine infusion led a successful weaning off the ventilator. We suggest that the administration of morphine may allow for a smoother weaning process for some patients with severe COVID-19 infection.

Patterns of vascular response immediately after passive mobilization in patients with sepsis: an observational transversal study

Sepsis is a serious organ dysfunction leading to endothelial damage in critical patients. Physiologically, there is an augment of vascular diameter in response to increased vascular blood flow and shear stress stimulus. However, the pattern of vascular response in face of passive mobilization (PM), an early mobilization physical strategy, has not yet been explored in patients with sepsis. To explore patterns of vascular response to PM and associations with clinical and cardiovascular profile in patients with sepsis. Cross-sectional, single-arm study. Thirty-two patients diagnosed with sepsis were enrolled. Vascular response was assessed by flow-mediated dilation (FMD) using brachial artery ultrasound, before and after PM. The PM (to assess the response pattern) and SR (shear rate) were also calculated. PM protocol consisted of knees, hips, wrists, elbows, shoulders, dorsiflexion/plantar flexion movements 3 × 10 repetitions each (15 min). Arterial stiffness was assessed by Sphygmocor®, by analyzing the morphology and pulse wave velocity. Cardiac autonomic modulation (CAM) was assessed by analyzing heart rate variability indexes (mean HR, RMSSD, LF, HF, ApEn, SampEn, DFA). Different vascular responses were observed after PM: (1) increased vascular diameter (responders) (n = 13, %FMD = 11.89 ± 5.64) and (2) reduced vascular diameter (non-responders) (n = 19, %FMD= -7.42 ± 6.44). Responders presented a higher non-linear DFA2 index (p = 0.02). There was a positive association between FMD and DFA (r = 0.529; p = 0.03); FMD and SampEn (r = 0.633; p < 0.01). A negative association was identified between FMD and LF (Hz) (r= -0.680; p < 0.01) and IL-6 (r= -0.469; p = 0.037) and SR and CRP (r= -0.427; p = 0.03).

The acute respiratory distress syndrome

Acute respiratory distress syndrome (ARDS) is a prevalent cause of acute respiratory failure with high rates of mortality, as well as short- and long-term complications, such as physical and cognitive impairment. Therefore, early recognition of this syndrome and application of well-demonstrated therapeutic interventions are essential to change the natural course of this entity and bring about positive clinical outcomes. In this article, we review updated concepts in ARDS. Specifically, we discuss the current definition of ARDS, its risk factors, and the evidence supporting ventilation management, adjunctive therapies, and interventions required in refractory hypoxemia.

Short-term effects of passive mobilization on the sublingual microcirculation and on the systemic circulation in patients with septic shock

Background

Active mobilization is not possible in patients under deep sedation and unable to follow commands. In this scenario, passive therapy is an interesting alternative. However, in patients with septic shock, passive mobilization may have risks related to increased oxygen consumption. Our objective was to evaluate the impact of passive mobilization on sublingual microcirculation and systemic hemodynamics in patients with septic shock.

Methods

We included patients who were older than 18 years, who presented with septic shock, and who were under sedation and mechanical ventilation. Passive exercise was applied for 20 min with 30 repetitions per minute. Systemic hemodynamic and microcirculatory variables were compared before (T0) and up to 10 min after (T1) passive exercise. p values <0.05 were considered significant.

Results

We included 35 patients (median age [IQR 25–75%]: 68 [49.0–78.0] years; mean (±SD) Simplified Acute Physiologic Score (SAPS) 3 score: 66.7 ± 12.1; median [IQR 25–75%] Sequential Organ Failure Assessment (SOFA) score: 9 [7.0–12.0]). After passive mobilization, there was a slight but significant increase in proportion of perfused vessels (PPV) (T0 [IQR 25–75%]: 78.2 [70.9–81.9%]; T1 [IQR 25–75%]: 80.0 [75.2–85.1] %; p = 0.029), without any change in other microcirculatory variables. There was a reduction in heart rate (HR) (T0 (mean ± SD): 95.6 ± 22.0 bpm; T1 (mean ± SD): 93.8 ± 22.0 bpm; p < 0.040) and body temperature (T0 (mean ± SD): 36.9 ± 1.1 °C; T1 (mean ± SD): 36.7 ± 1.2 °C; p < 0.002) with no change in other systemic hemodynamic variables. There was no significant correlation between PPV variation and HR (r = −0.010, p = 0.955), cardiac index (r = 0.218, p = 0.215) or mean arterial pressure (r = 0.276, p = 0.109) variation.

Conclusions

In patients with septic shock after the initial phase of hemodynamic resuscitation, passive exercise is not associated with relevant changes in sublingual microcirculation or systemic hemodynamics.

Electronic supplementary material

The online version of this article (doi:10.1186/s13613-017-0318-x) contains supplementary material, which is available to authorized users.

Sedation and neuromuscular blocking agents in acute respiratory distress syndrome

Mechanical ventilation (MV) is the cornerstone of acute respiratory distress syndrome (ARDS) management. The use of protective ventilation is a priority in this acute phase of lung inflammation. Neuromuscular blocking agents (NMBAs) induce reversible muscle paralysis. Their use in patients with ARDS remains controversial but occurs frequently. NMBAs are used in 25-45% of ARDS patients for a mean period of 1±2 days. The main indications of NMBAs are hypoxemia and facilitation of MV. For ethical reasons, NMBA use is inseparable from sedation in the management of early ARDS. During paralysis, sedation monitoring seems to be necessary to avoid awareness with recall. Three randomized controlled trials (RCTs) have demonstrated that the systematic use of NMBAs in the early management of ARDS patients improves oxygenation. Furthermore, the most recent trial reported a reduction of mortality at 90 days when NMBAs were infused over 48 hours. Spontaneous ventilation (SV) during MV at the acute phase of ARDS could improve oxygenation and alveolar recruitment, but it may not allow protective ventilation. The major risk is an increase in ventilator-induced lung injury. However, the adverse effects of NMBAs are widely discussed, particularly the occurrence of intensive care unit (ICU)-acquired weakness. This review analyses the recent findings in the literature concerning sedation and paralysis in managing ARDS.

[Special aspects of analgosedation in cardiogenic shock patients]

Patients with cardiogenic shock pose a challenge to physicians due to cardiorespiratory instability in addition to the underlying medical condition. If analgosedation and ventilation are indicated, commonly administered drugs themselves often influence hemodynamics and oxygenation. The present article provides an overview of the available substances with consideration of the patients' condition, then monitoring and optimization of analgosedation.

Mechanical ventilation during pregnancy: sedation, analgesia, and paralysis

Pregnant women occasionally require mechanical ventilation. Ventilated patients commonly need some form of analgesia and/or sedation with or without paralytics. The use of these agents is common in the intensive care unit setting, but most maternal-fetal medicine specialists are unfamiliar with their use. In the vast majority of cases, guidelines and recommendations regarding the use of these agents should be followed as recommended for nonpregnant individuals. This article discusses the most relevant issues of sedatives, analgesics, and neuromuscular blockers used in modern critical care practice.

The Sick and the Weak: Neuropathies/Myopathies in the Critically Ill

Critical illness polyneuropathies (CIP) and myopathies (CIM) are common complications of critical illness. Several weakness syndromes are summarized under the term intensive care unit-acquired weakness (ICUAW). We propose a classification of different ICUAW forms (CIM, CIP, sepsis-induced, steroid-denervation myopathy) and pathophysiological mechanisms from clinical and animal model data. Triggers include sepsis, mechanical ventilation, muscle unloading, steroid treatment, or denervation. Some ICUAW forms require stringent diagnostic features; CIM is marked by membrane hypoexcitability, severe atrophy, preferential myosin loss, ultrastructural alterations, and inadequate autophagy activation while myopathies in pure sepsis do not reproduce marked myosin loss. Reduced membrane excitability results from depolarization and ion channel dysfunction. Mitochondrial dysfunction contributes to energy-dependent processes. Ubiquitin proteasome and calpain activation trigger muscle proteolysis and atrophy while protein synthesis is impaired. Myosin loss is more pronounced than actin loss in CIM. Protein quality control is altered by inadequate autophagy. Ca(2+) dysregulation is present through altered Ca(2+) homeostasis. We highlight clinical hallmarks, trigger factors, and potential mechanisms from human studies and animal models that allow separation of risk factors that may trigger distinct mechanisms contributing to weakness. During critical illness, altered inflammatory (cytokines) and metabolic pathways deteriorate muscle function. ICUAW prevention/treatment is limited, e.g., tight glycemic control, delaying nutrition, and early mobilization. Future challenges include identification of primary/secondary events during the time course of critical illness, the interplay between membrane excitability, bioenergetic failure and differential proteolysis, and finding new therapeutic targets by help of tailored animal models.

The acute respiratory distress syndrome

The acute respiratory distress syndrome (ARDS) is a major cause of acute respiratory failure. Its development leads to high rates of mortality, as well as short- and long-term complications, such as physical and cognitive impairment. Therefore, early recognition of this syndrome and application of demonstrated therapeutic interventions are essential to change the natural course of this devastating entity. In this review article, we describe updated concepts in ARDS. Specifically, we discuss the new definition of ARDS, its risk factors and pathophysiology, and current evidence regarding ventilation management, adjunctive therapies, and intervention required in refractory hypoxemia.

The use of paralytics in patients with acute respiratory distress syndrome

Interest in the role of neuromuscular blocking agents (NMBAs) in the treatment of acute respiratory distress syndrome (ARDS) has been renewed since a recent randomized clinical trial showed a reduction in mortality associated with the use of NMBAs. However, the role of paralytics in a protective mechanical ventilation strategy should be detailed. This review summarizes data in the literature concerning the clinical effects of NMBAs on the outcome of patients with ARDS, in an attempt to explain some pathophysiologic hypotheses concerning their action and to integrate them into the overall management strategy for the mechanical ventilation of ARDS patients.

The effect of modified ultrafiltration duration on pulmonary functions and hemodynamics in newborns and infants following arterial switch operation*

OBJECTIVES

Modified ultrafiltration is used to ameliorate the deleterious effects of cardiopulmonary bypass in pediatric cardiac surgery patients. The ideal duration of modified ultrafiltration has not been established yet. We investigated the effects of extended duration of modified ultrafiltration on pulmonary functions and hemodynamics in the early postoperative period in newborns and infants who had transposition of great arteries operations.

DESIGN

Single-center prospective randomized study.

SETTING

Pediatric cardiac surgery operating room and ICU.

PATIENTS

Sixty newborns and infants who had been scheduled to undergo transposition of great arteries operation.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Modified ultrafiltration was applied to all patients following the termination of cardiopulmonary bypass (for 10, 15, and 20 min in groups 1, 2, and 3, respectively). Pulmonary compliance, gas exchange capacity, hemodynamic measurements, inotropic support, blood loss, transfusion requirements, hematocrit level, and duration of ventilatory support were measured after intubation, at termination of cardiopulmonary bypass, at the end of modified ultrafiltration, and in the 1st, 6th, 12th, and 24th hours after admission to ICU. The amount of fluid removed by modified ultrafiltration in groups 2 and 3 was larger than that of group 1 (p < 0.01). Systolic blood pressure was significantly increased at the end of modified ultrafiltration in group 3 compared to groups 1 and 2 (p < 0.05). Hematocrit levels were significantly increased at the end of modified ultrafiltration in groups 2 and 3 compared to group 1 (p < 0.01). Therefore, RBCs were transfused less after modified ultrafiltration in groups 2 and 3 compared to group 1 (p < 0.05). Static and dynamic compliance, oxygen index, and ventilation index had improved similarly in all three groups at the end of modified ultrafiltration (p > 0.05) CONCLUSIONS:: Modified ultrafiltration acutely improved pulmonary compliance and gas exchange in all groups. Increased hematocrit and blood pressure levels were also observed in the longer modified ultrafiltration group. However, extended duration of modified ultrafiltration did not have a significant impact on duration of intubation or the stay in ICU.

The role of neuromuscular blockers in ARDS: benefits and risks

PURPOSE OF REVIEW

Neuromuscular blocking agents (NMBAs) are part of the pharmaceutical arsenal employed to treat acute respiratory distress syndrome (ARDS). However, their use remains controversial because the potential benefits of these agents are counterbalanced by possible adverse effects. This review summarizes advantages and risks of NMBAs based on the most recent literature.

RECENT FINDINGS

NMBAs have been shown to improve oxygenation during severe ARDS in three randomized controlled trials. The most recent results demonstrated that NMBAs decrease 90-day in-hospital mortality, particularly in the most hypoxaemic patients. NMBAs have not been shown to be an independent risk factor of neuromyopathy in most studies.

SUMMARY

NMBAs are commonly used in ARDS (25-55% of patients), but the benefits and the risks of using these agents are controversial. Recent data suggest that a continuous infusion of cisatracurium during the first 48  h of ARDS, particularly for patients with a P(a)O(2)/F(i)O(2) ratio less than 120, can decrease 90-day in-hospital mortality. NMBAs do not appear to be an independent risk factor for ICU-acquired weakness if they are not given with corticosteroids or in patients with hyperglycaemia.

The pharmacokinetics and pharmacodynamics of cisatracurium in critically ill patients with severe sepsis

AIM

To characterize the pharmacokinetics (PK) and pharmacodynamics (PD) of cisatracurium in critically ill patients with severe sepsis.

METHODS

Blood samples were collected before and over 8 h after a single bolus dose of cisatracurium 0.1 mg kg(-1) . Neuromuscular block was assessed by accelerometric peripheral nerve stimulation (TOF Watch). Plasma concentration and neuromuscular block data were fitted using population analysis.

RESULTS

Steady-state volume of distribution was determined to be 111 ± 71 ml kg(-1) and plasma clearance was 5.2 ± 1.8 ml min(-1) kg(-1) in these patients with greater inter-patient variability compared with other populations. The time to maximum block (8.3 ± 2.9 min) and delay time of transferring from central to effect compartment (17.2 min) was much longer, while the maximum block (95.0 ± 6.3%) was less compared with those in other patient populations. The effect compartment concentration resulting in 50% of maximum effect (128 ± 58 ng ml(-1)) was larger than previously described.

CONCLUSIONS

This study suggests that standard dosing of cisatracurium in patients with severe sepsis results in a slower patient response with a reduced effect. Use of a larger dose may overcome this reduced delayed response.

Current therapeutic uses, pharmacology, and clinical considerations of neuromuscular blocking agents for critically ill adults

OBJECTIVE

To summarize literature describing use of neuromuscular blocking agents (NMBAs) for common critical care indications and provide a review of NMBA pharmacology, pharmacokinetics, dosing, drug interactions, monitoring, complications, and reversal.

DATA SOURCES

Searches of MEDLINE (1975-May 2011), EMBASE (1980-May 2011), and Cumulative Index to Nursing and Allied Health Literature (1981-May 2011) were conducted to identify observational and interventional studies evaluating the efficacy or safety of NMBAs for management of acute lung injury (ALI)/acute respiratory distress syndrome (ARDS), status asthmaticus, elevated intracranial pressure (ICP), and therapeutic hypothermia.

STUDY SELECTION AND DATA EXTRACTION

We excluded case reports, animal- or laboratory-based studies, trials describing NMBA use during rapid sequence intubation or in the operating room, and studies published in languages other than English or French.

DATA SYNTHESIS

Clinical applications of NMBAs in intensive care include, but are not limited to, immobilizing patients for procedural interventions, decreasing oxygen consumption, facilitating mechanical ventilation, reducing intracranial pressure, preventing shivering, and management of tetanus. Recent data on ARDS demonstrated that early application of NMBAs improved adjusted 90-day survival for patients with severe lung injury. These results may lead to increased use of these drugs. While emerging data support the use of cisatracurium in select patients with ALI/ARDS, current literature does not support the use of one NMBA over another for other critical care indications. Cisatracurium may be kinetically preferred for patients with organ dysfunction. Close monitoring with peripheral nerve stimulation is recommended with sustained use of NMBAs to avoid drug accumulation and minimize the risk for adverse drug events. Reversal of paralysis is achieved by discontinuing therapy or, rarely, the use of anticholinesterases.

CONCLUSIONS

NMBAs are high-alert medications used to manage critically ill patients. New data are available regarding the use of these agents for treatment of ALI/ARDS and status asthmaticus, management of elevated ICP, and provision of therapeutic hypothermia after cardiac arrest. To improve outcomes and promote patient safety, intensive care unit team members should have a thorough knowledge of this class of medications.

Remifentanil, a different opioid: potential clinical applications and safety aspects

IMPORTANCE OF THE FIELD

Opioids play an important role in every aspect of modern anesthetic practice. Remifentanil is an ultra-short-acting opioid featuring a unique pharmacokinetic profile allowing clinical versatility and improved control of its action. In this review, we assess the pharmacology of remifentanil, its clinical uses as well as safety issues on its action on the major organ systems and in particular clinical settings.

AREAS COVERED IN THIS REVIEW

A synthesis of evidence from a MEDLINE search for articles from 1993 to 2009 for available up-to-date information on remifentanil and its current applications and safety profile.

WHAT THE READER WILL GAIN

A synopsis of the unique pharmacokinetic properties of remifentanil and its action on major organ systems will provide insight on the safe and effective use of the drug in a variety of clinical settings.

TAKE HOME MESSAGE

Remifentanil is a valuable opioid in the armamentarium of the clinician, providing great clinical flexibility and safety but vigilance is required to avoid pitfalls.

Neuromuscular blockers in early acute respiratory distress syndrome

BACKGROUND

In patients undergoing mechanical ventilation for the acute respiratory distress syndrome (ARDS), neuromuscular blocking agents may improve oxygenation and decrease ventilator-induced lung injury but may also cause muscle weakness. We evaluated clinical outcomes after 2 days of therapy with neuromuscular blocking agents in patients with early, severe ARDS.

METHODS

In this multicenter, double-blind trial, 340 patients presenting to the intensive care unit (ICU) with an onset of severe ARDS within the previous 48 hours were randomly assigned to receive, for 48 hours, either cisatracurium besylate (178 patients) or placebo (162 patients). Severe ARDS was defined as a ratio of the partial pressure of arterial oxygen (PaO2) to the fraction of inspired oxygen (FIO2) of less than 150, with a positive end-expiratory pressure of 5 cm or more of water and a tidal volume of 6 to 8 ml per kilogram of predicted body weight. The primary outcome was the proportion of patients who died either before hospital discharge or within 90 days after study enrollment (i.e., the 90-day in-hospital mortality rate), adjusted for predefined covariates and baseline differences between groups with the use of a Cox model.

RESULTS

The hazard ratio for death at 90 days in the cisatracurium group, as compared with the placebo group, was 0.68 (95% confidence interval [CI], 0.48 to 0.98; P=0.04), after adjustment for both the baseline PaO2:FIO2 and plateau pressure and the Simplified Acute Physiology II score. The crude 90-day mortality was 31.6% (95% CI, 25.2 to 38.8) in the cisatracurium group and 40.7% (95% CI, 33.5 to 48.4) in the placebo group (P=0.08). Mortality at 28 days was 23.7% (95% CI, 18.1 to 30.5) with cisatracurium and 33.3% (95% CI, 26.5 to 40.9) with placebo (P=0.05). The rate of ICU-acquired paresis did not differ significantly between the two groups.

CONCLUSIONS

In patients with severe ARDS, early administration of a neuromuscular blocking agent improved the adjusted 90-day survival and increased the time off the ventilator without increasing muscle weakness. (Funded by Assistance Publique-Hôpitaux de Marseille and the Programme Hospitalier de Recherche Clinique Régional 2004-26 of the French Ministry of Health; ClinicalTrials.gov number, NCT00299650.)

Paralytics in critical care: not always the bad guy

PURPOSE OF REVIEW

The use of neuromuscular blocking agents (NMBAs) in patients with acute respiratory distress syndrome (ARDS) and acute lung injury remains controversial, although frequent. This review analyzes the effects of NMBAs on thoracopulmonary mechanics, gas exchange, patient outcome and their potential adverse effects.

RECENT FINDINGS

NMBAs are used in 25-45% of acute lung injury/ARDS patients for a mean period of 12 days, especially in severe ARDS. Hypoxemia and facilitation of mechanical ventilation are the main indications of NMBAs. Two randomized controlled trials showed that the systematic early use of NMBAs is associated with a sustained improvement in oxygenation in ARDS patients. The most recent suggests a beneficial effect on proinflammatory response associated with ARDS and mechanical ventilation.

SUMMARY

The use of NMBAs in acute lung injury/ARDS patients is not marginal. Recent studies suggest a beneficial effect of early use of NMBAs on oxygenation and inflammation. The role of NMBAs in the occurrence of ICU-acquired neuromyopathies and lung atelectasis in ARDS patients remains largely questioned. The use of NMBAs in the early phase of ARDS could reinforce the beneficial effects of a lung-protective ventilation. In this context, the effect of NMBAs on the outcome of ARDS patients must be evaluated.

High-frequency oscillatory ventilation in adults: clinical considerations and management priorities

Recently, there has been renewed interest in high-frequency oscillatory ventilation (HFOV) as a lung-protective strategy in adults. It limits overdistension and prevents cyclic collapse by maintaining end-expiratory lung volume. Studies have shown that HFOV is safely tolerated in the adult population and may offer more benefit if applied early in the course of disease. These findings have implications for clinicians as the use of HFOV may increase in the coming decade. Gas transport mechanisms, ventilator settings, patient monitoring, and clinical considerations for HFOV are substantially different from conventional mechanical ventilation. This article reviews management strategies and monitoring priorities currently recommended for management of adults receiving HFOV.

The efficacy of the COMFORT scale in assessing optimal sedation in critically ill children requiring mechanical ventilation

Sedation is often necessary to optimize care for critically ill children requiring mechanical ventilation. If too light or too deep, however, sedation can cause significant adverse reactions, making it important to assess the degree of sedation and maintain its optimal level. We evaluated the efficacy of the COMFORT scale in assessing optimal sedation in critically ill children requiring mechanical ventilation. We compared 12 month data in 21 patients (intervention group), for whom we used the pediatric intensive care unit (PICU) sedation protocol of Asan Medical Center (Seoul, Korea) and the COMFORT scale to maintain optimal sedation, with the data in 20 patients (control group) assessed before using the sedation protocol and the COMPORT scale. Compared with the control group, the intervention group showed significant decreases in the total usage of sedatives and analgesics, the duration of mechanical ventilation (11.0 days vs. 12.5 days) and PICU stay (15.0 days vs. 19.5 days), and the development of withdrawal symptoms (1 case vs. 7 cases). The total duration of sedation (8.0 days vs. 11.5 days) also tended to decrease. These findings suggest that application of protocol-based sedation with the COMPORT scale may benefit children requiring mechanical ventilation.

Sepsis in critical care

Sepsis is a syndrome produced by the accelerated activity of the inflammatory immune response, the clotting cascade, and endothelial damage. It is a systematic process that can progress easily into septic shock and MODS. The chemical mediators or cytokines produce a complex self-perpetuating process that impacts all body systems. It is critical for the nurse first to identify patients at risk for developing sepsis and to assess patients who have SIRS and sepsis continually for signs and symptoms of organ involvement and organ dysfunction. Once sepsis has been diagnosed, evidence-based practice indicates initiation of fluid resuscitation. Vasopressor therapy, positive inotropic support, and appropriate antibiotic therapy should be started within the first hour. Within a 6-hour timeframe the goal is stabilization of the CVP, MAP, and UOP to prevent further organ damage. The challenge for nurses caring for septic patients is to support the treatment goals, to prevent added complications including stress ulcers, DVTs, aspiration pneumonia, and the progression to MODS, and to address the patient's and the family's psychosocial needs. As complex as the pathophysiology of sepsis is, the nursing care is equally complex but also rewarding. Patients who previously might have died now recover as vigilant nursing care combines forces with new drug therapies and evidence-based practice guidelines.

Adjunctive Dexmedetomidine Therapy in the Intensive Care Unit: A Retrospective Assessment of Impact on Sedative and Analgesic Requirements, Levels of Sedation and Analgesia, and Ventilatory and Hemodynamic Parameters

STUDY OBJECTIVE

To determine if adjunctive dexmedetomidine therapy in intensive care patients alters requirements for and levels of sedation and analgesia, and to describe hemodynamic and ventilatory parameters.

DESIGN

Retrospective, noncontrolled, descriptive study of clinical practice.

SETTING

Four intensive care units (ICUs; medical, surgical, neurosurgical, or burn) in a university-affiliated medical center.

PATIENTS

Forty patients who were already receiving sustained use of propofol, lorazepam, or fentanyl when dexmedetomidine was started.

MEASUREMENTS AND MAIN RESULTS

Medical records were identified by searching the pharmacy database for patients who had received continuous-infusion dexmedetomidine from January 2000-January 2003 while in one of the four ICUs. Primary end points were discontinuation or dosage reduction of other sedatives or fentanyl from the hour before to 6 hours after starting dexmedetomidine. Other outcomes included levels of sedation and analgesia before and after dexmedetomidine and description of ventilatory and hemodynamic parameters. The initial dexmedetomidine rate of 0.4 +/- 0.25 microg/kg/hour changed minimally through 47.4 +/- 61.1 infusion hours. At 6 hours, 11 of 13 patients receiving propofol, 14 of 23 receiving lorazepam, and 4 of 30 receiving fentanyl had the respective agent discontinued. With dexmedetomidine, the hourly rates and cumulative daily doses were reduced only for propofol. Adequate sedation occurred at rates of 64.6% and 47.9% during the 24-hour periods before and after dexmedetomidine was started, respectively (p=0.001). Four and 12 patients had severe agitation before and after, respectively (p=0.05). One and 12 patients had severe pain before and after, respectively (p=0.02). Nine patients experienced hypotension or bradycardia. Twenty-two patients were successfully extubated within 24 hours of starting dexmedetomidine.

CONCLUSIONS

Adjunctive dexmedetomidine reduces sedative requirements but does not alter analgesic requirements. However, dexmedetomidine was associated with enhanced agitation, severe pain, and hemodynamic compromise. Transitioning to dexmedetomidine from other sedatives and analgesics may not provide optimal sedation and analgesia. Future studies are needed to evaluate dexmedetomidine as a bridge to extubation.

Management of Severe Sepsis in the Surgical Patient

Sepsis and septic shock are not uncommon conditions in the surgical intensive care unit. Sepsis is a generalized activation of the immune system in the presence of clinically suspected or culture-proven infection. Severe sepsis is sepsis with organ system dysfunction. Septic shock is sepsis with hypotension (systolic blood pressure <90 mm Hg) without other causes. Although the incidence of sepsis is increasing, the case fatality rate is falling. This improvement in outcome is in part due to bold initiatives like the Surviving Sepsis Campaign from the Institute for Health Care Improvement. In this article the authors present the epidemiology of severe sepsis and evidence-based campaigns for its treatment, with a focus on the surgical patient.

Economic evaluation of sustained sedation/analgesia in the intensive care unit

Lorazepam, midazolam, propofol and opioids are the primary agents that are used for sustained sedation and analgesia of critically ill patients. The choice of agent depends on safety profiles, expected outcomes, cost, patient characteristics and clinical experience. Few studies have comparatively evaluated the sedatives in terms of cost. Many factors, aside from drug costs, influence the total cost of sedation in the intensive care unit. This article reviews the cost parameters of intensive care unit sedation that are specific to the characteristics of commonly used sedatives and analgesics, evaluates economic studies and cost models, summarises alternative methods of sedation and analgesia, and provides practical recommendations for methods of cost containment, including daily sedation interruption, sedation monitoring and protocol implementation.

Sedation in the intensive care unit with remifentanil/propofol versus midazolam/fentanyl: a randomised, open-label, pharmacoeconomic trial

Introduction

Remifentanil is an opioid with a unique pharmacokinetic profile. Its organ-independent elimination and short context-sensitive half time of 3 to 4 minutes lead to a highly predictable offset of action. We tested the hypothesis that with an analgesia-based sedation regimen with remifentanil and propofol, patients after cardiac surgery reach predefined criteria for discharge from the intensive care unit (ICU) sooner, resulting in shorter duration of time spent in the ICU, compared to a conventional regimen consisting of midazolam and fentanyl. In addition, the two regimens were compared regarding their costs.

Methods

In this prospective, open-label, randomised, single-centre study, a total of 80 patients (18 to 75 years old), who had undergone cardiac surgery, were postoperatively assigned to one of two treatment regimens for sedation in the ICU for 12 to 72 hours. Patients in the remifentanil/propofol group received remifentanil (6- max. 60 μg kg^-1 h^-1; dose exceeds recommended labelling). Propofol (0.5 to 4.0 mg kg^-1 h^-1) was supplemented only in the case of insufficient sedation at maximal remifentanil dose. Patients in the midazolam/fentanyl group received midazolam (0.02 to 0.2 mg kg^-1 h^-1) and fentanyl (1.0 to 7.0 μg kg^-1 h^-1). For treatment of pain after extubation, both groups received morphine and/or non-opioid analgesics.

Results

The time intervals (mean values ± standard deviation) from arrival at the ICU until extubation (20.7 ± 5.2 hours versus 24.2 h ± 7.0 hours) and from arrival until eligible discharge from the ICU (46.1 ± 22.0 hours versus 62.4 ± 27.2 hours) were significantly (p < 0.05) shorter in the remifentanil/propofol group. Overall costs of the ICU stay per patient were equal (approximately €1,700 on average).

Conclusion

Compared with midazolam/fentanyl, a remifentanil-based regimen for analgesia and sedation supplemented with propofol significantly reduced the time on mechanical ventilation and allowed earlier discharge from the ICU, at equal overall costs.

Acute Lung Injury and Acute Respiratory Distress Syndrome in The Pediatric Patient

When the lung becomes injured by direct or indirect assault, the body unleashes a massive immune-modulated initiative. The pediatric patient who experiences acute lung injury is at considerable risk for developing life-threatening respiratory compromise. By understanding the mechanisms of illness in these complex patients, the critical care nurse can connect the science of therapy with the art of providing care that minimizes oxygen expenditure and maximizes oxygen delivery.

Sedation, analgesia, and neuromuscular blockade for high-frequency oscillatory ventilation

OBJECTIVE

To provide a comprehensive review of the issue related to the administration of sedative, analgesic, and neuromuscular blocking agents (NMBA) to patients who are receiving ventilatory support for acute respiratory distress syndrome (ARDS) with high-frequency oscillatory ventilation.

RESULTS

Sedative, analgesic, and NMBA are used with great frequency in patients with severe ARDS who are undergoing high-frequency oscillatory ventilation. In particular, the use of NMBA has been higher than for other ARDS populations. Important considerations for effective treatment include careful patient evaluation, patient-based medication selection, identification of treatment goals with periodic re-assessment, titration of medications to objective parameters such as sedation scales and peripheral nerve stimulation, use of intermittent therapy when feasible, implementation of drug interruption strategies, and discontinuation of medications at the earliest possible time. It is important to recognize that patients evolve from severe ARDS through phases of recovery to the resolution of respiratory failure and that ventilatory management, as well as sedative and related medication requirements, will vary markedly over the course of this process.

CONCLUSIONS

A multidisciplinary, structured approach that is based on the considerations described should help achieve optimal results in this challenging patient population.

Pilzsepsis - Therapeutische Strategie. Fungal sepsis - therapeutical strategy

The incidence of fungal infection as well as fungal sepsis has increased dramatically during the last decade. Changes of local microbial flora after broad-spectrum antibiotic therapy allow overgrowth of Candida species. Prophylactic strategies to lower fungal infection and sepsis include adequate and restrictive antibiotic therapy. Concerning the treatment of the septic syndrome, supportive as well as adjunctive strategies like early-goal-directed cardiovascular therapy, hydrocortisone replacement therapy, intense insulin application to achieve normoglycemia as well as the application of activated Protein C besides a consequent source control regimen and standard intensive care therapy, are able to improve significantly the outcome of septic patients.