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Sedation and analgesia in the critically ill 

Sedation and analgesia in the critically ill

Chapter:
Sedation and analgesia in the critically ill
Author(s):

Gilbert Park

and Maire P. Shelly

DOI:
10.1093/med/9780199204854.003.1707
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date: 30 March 2017

Nearly all critically ill patients need analgesia, anxiolysis, hypnosis, or measures to help them tolerate their tracheal tube. Although making the patient unconscious may appear the easiest way to achieve this, it is fraught with hazards.

Pain relief and tube tolerance—these are the first priority, and usually involves giving opioids. Morphine, which has both analgesic and sedative effects, is the opioid against which others are judged. Remifentanil is a relatively new agent that has properties useful in critically ill patients: fast onset of action, a predictable short half-life (10–21 min), and it is broken down by a nonspecific enzyme system present in plasma such that accumulation does not occur, and the drug wears off rapidly, even after prolonged infusions and in renal or hepatic failure.

Hypnosis—the agents most commonly used are (1) the benzodiazepine midazolam, which accumulates in liver failure, and in renal failure the accumulation of a metabolic product can cause prolonged sedation or coma; and (2) the anaesthetic agent propofol, which does not accumulate to a significant extent in hepatic or renal failure.

Agitation, delirium, and confusion—these are some of the most difficult problems to deal with in the critically ill patient and may need to be controlled with drugs such as clonidine, or haloperidol. In addition to pharmacological restraint there is increasing interest in the use of physical restraint.

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