1. Sedation and Anagesia in Critical Care
John Dade
Pharmacist SJUH

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

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

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

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

7. 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

8. 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

9. Propofol GABA anaesthetic agent Short duration of action
Low risk of accumulation
Start at 5-10 ml/hr ( mg/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

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

11. 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

12. 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

13. 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

14. 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