PMID: 10628633

Issn Print: 0090-3493

Publication Date: 1999/12/01


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Practice in the new millennium: Standardization to improve outcome

William T. Peruzzi

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Sedation, although a common component of critical care treatment, is a complex aspect of care that has not been completely defined. As such, the term frequently means different things to different practitioners. The formal definition of "sedation" is "the act of calming, especially by the administration of a sedative drug; the state of being calm" (1). Such a state can be brought about in multiple ways with different drugs used either independently or concurrently. Some clinicians would include the use of analgesics as part of all sedation regimens whereas others would view pain management as a separate entity. Although the issue of what comprises "sedation" is important, acceptance of sedation as an integral component of critical care is even more important. Aside from simple humanitarian issues, appropriate sedation assures that very ill and unstable patients enjoy a level of comfort that may enhance their recovery. Inattention to ameliorating the stress of critical illness may prove a detriment as illustrated by reports of the posttraumatic stress syndrome following discharge from intensive care (2).
In this issue of Critical Care Medicine, Dr. Brook and colleagues (3) have demonstrated how a sedation protocol that considers pain management as the first step can improve patient care and outcome. The protocol required the exclusion of pain before the addition of other drugs to control agitation and reduce anxiety. Because inadequate pain control is a common reason for agitation and a significant cause of anxiety, the inclusion of drugs with analgesic properties as part of sedation regimens is not only appropriate, but essential (4). Appropriate attention to this aspect of the sedation regimen will often eliminate the need for more complex drug combinations. Despite the presence of adequate pain control and the euphoric effects of most narcotics, however, some patients continue to suffer agitation or delirium. Such symptoms may be manifestations of anxiety, depression, disturbed sleep patterns, or encephalopathy secondary to metabolic derangements or drug side effects. Control of such agitation or delirium often requires the administration of other agents (5). The adjunctive agent or agents to use in addition to analgesics is a very debatable issue. The considerations include the patient's clinical condition, drug metabolism in various disease states, and costs. The benzodiazepine class of drugs is the most commonly used adjunct to narcotics for intensive care unit (ICU) sedation because of the amnesia and anxiolysis that they provide and the calming effects that they carry (5, 6). Unfortunately, this class of drugs also carries a frequent occurrence of paradoxic excitatory effects and unpredictable hemodynamic effects in patients with the propensity for such instability (7). Additionally, these agents may accumulate when their pharmacokinetic profiles are altered by end organ dysfunction. Propofol has garnered significant popularity as an ICU sedation adjunct recently; however, the precise place for this drug is debatable. The advantages that it offers include a short duration of action because of rapid redistribution, a lack of prolonged sedating effects, and a metabolic profile that appears to be somewhat independent of hepatic function (8, 9). The benzodiazepines have a significant amnestic effect that may be less with propofol, but propofol has titratability that is not shared by the benzodiazepines (5). Haloperidol is another agent that is popular and effective for control of agitation in the ICU (5, 6). It carries few significant side effects, but has no amnestic effects. The optimal agent for ICU sedation should combine these various components: analgesia, amnesia, anxiolysis, and control of agitation. Currently, a class of drug with some potential to offer such a combination is the α2-agonists (10).
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