Hostname: page-component-8448b6f56d-cfpbc Total loading time: 0 Render date: 2024-04-18T04:39:47.065Z Has data issue: false hasContentIssue false
  • English
  • Français

A Critical Appraisal of Sedation, Analgesia and Delirium in Neurocritical Care

Published online by Cambridge University Press:  02 December 2014

Jeanne S. Teitelbaum ,
Omar Ayoub  and
Yoanna Skrobik
Jeanne S. Teitelbaum*
Affiliation:
Department of Neurology and Neurosurgery, Montreal Neurological Institute, McGill University
Omar Ayoub
Affiliation:
Department of Neurology and Neurosurgery, Montreal Neurological Institute, McGill University Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
Yoanna Skrobik
Affiliation:
Department of Medicine, Hôpital maisonneuve-Rosemont, Université de Montréal, Montréal, Québec, Canada
*
Department of Neurology and Neurosurgery, Montreal Neurological Institute, McGill University, 3801 University Ave, Montreal, Quebec, H3A 2B4, Canada.
Rights & Permissions [Opens in a new window]

Abstract

Core share and HTML view are not available for this content. However, as you have access to this content, a full PDF is available via the ‘Save PDF’ action button.

Administering analgesics, sedatives and antipsychotics is challenging in the Neurological Intensive Care Unit (NICU). We reviewed this literature and our current practice to better inform the critical care practitioner and to identify gaps for future research. We electronically searched observational, intervention and outcome studies addressing sedation, analgesia and delirium in the NICU, and their bibliographies. Practice patterns were assessed in three critical care units with specialized neurological care in Montreal. Bedside pain assessment tools are psychometrically validated in the neuro-critically ill but sedation and delirium tools are not. Rigorous pain and sedation assessments appear feasible; delirium screening has not been tested. Publications addressing outcomes and responses to pharmacologic treatment lack consistency, rigor or both. In daily practice, pharmacologic management varies greatly. Clearly, little information exists on analgesia, sedation and delirium in the NICU. Systematic evaluation of pain improves outcome. No evidence-based therapeutic recommendations can be proffered.

Type
Review Article
Information
Canadian Journal of Neurological Sciences , Volume 38 , Issue 6 , November 2011 , pp. 815 - 825
Copyright
Copyright © The Canadian Journal of Neurological 2011

References

1.Karabinis, A, Mandragos, K, Stergiopoulos, S, et al.Safety and efficacy of analgesia-based sedation with remifentanil versus standard hypnotic-based regimens in intensive care unit patients with brain injuries: a randomised, controlled trial. Crit Care. 2004; 8(4):R268–80.Google Scholar
2.Thomason, J, Shintani, A, Peterson, E, Pun, B, Jackson, J, Ely, E.Intensive care unit delirium is an independent predictor of longer hospital stay: a prospective analysis of 261 non-ventilated patients. Crit Care. 2005;9(4):R375–81.Google Scholar
3.Lewis, KS, Whipple, JK, Michael, KA, Kebbeman, EJ.Effect of analgesic treatment on the physiological consequences of acute pain. Am J Hosp Pharm. 1994; 51:1539.-54.Google ScholarPubMed
4.Desbiens, NA, Wu, AW, Broste, SK, et al.Pain and satisfaction with pain control in seriously ill hospitalized adults: Findings from the SUPPORT research investigations. For the SUPPORT investigators, Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment. Crit Care Med. 1996; 24:1953–61.CrossRefGoogle Scholar
5.Marshall, J, Finn, CA, Theodore, AC.Impact of a clinical pharmacist enforced intensive care unit sedation protocol on duration of mechanical ventilation and hospital stay. Crit Care Med. 2008; 36:427–33.Google Scholar
6.Ouimet, S, Kavanagh, BP, Gottfried, SB, Skrobik, Y.Incidence, risk factors and consequences of ICU delirium. Intensive Care Med. 2007;33(8):66–73.CrossRefGoogle ScholarPubMed
7.Ouimet, S, Riker, R, Bergeron, N, Cossette, M, Kavanagh, B, Skrobik, Y.Subsyndromal delirium in the ICU: evidence for a disease spectrum. Intensive Care Med. 2007;33(6):1007–13.Google Scholar
8.Schnakers, C, Chatelle, C, Vanhaudenhuyse, A, et al.The nociception coma scale: a new tool to assess nociception in disorders of consciousness. Pain. 2010; 148(2):215–19.Google Scholar
9.Boly, M, Faymonville, ME, Schnakers, C.Perception of pain in the minimally conscious state with PET activation: an observational study. Lancet Neurol. 2008; 7(11):1013–20.CrossRefGoogle ScholarPubMed
10.Egerod, I, Jensen, MB, Herling, SF, Welling, KL.Effect of an analgosedation protocol for neurointensive patients: a two-phase interventional non-randomized pilot study. Crit Care. 2010; 14(2):R71.Google Scholar
11.Gélinas, C, Arbour, C.Behavioral and physiologic indicators during a nociceptive procedure in conscious and unconscious mechanically ventilated adults: similar or different? J Crit Care. 2009; 24(4):628.e7–17.CrossRefGoogle ScholarPubMed
12.Gélinas, C, Johnston, C.Pain assessment in the critically ill ventilated adult: validation of the Critical-Care Pain Observation Tool and physiologic indicators. Clin J Pain. 2007; 23(6): 497–505.Google Scholar
13.Riker, RR, Picard, JT, Fraser, GL.Prospective evaluation of the sedation-agitation scale for adult critically ill patients. Crit. Care Med. 1999; 27(7):1325–9.CrossRefGoogle ScholarPubMed
14.Topolovec-Vranic, J, Canzian, S, Innis, J, Pollmann-Mudryj, MA, McFarlan, AW, Baker, AJ.Patient satisfaction and documentation of pain assessments and management after implementing the adult nonverbal pain scale. Am J Crit Care. 2010; 19(4):345–54.CrossRefGoogle ScholarPubMed
15.Skrobik, Y, Ahern, S, Leblanc, M, Marquis, F, Awissi, DK, Kavanagh, BP.Protocolized intensive care unit management of analgesia, sedation, and delirium improves analgesia and subsyndromal delirium rates. Anesth Analg. 2010; 111(2): 451–63.CrossRefGoogle ScholarPubMed
16.Chanques, G, Viel, E, Constantin, JM, et al.The measurement of pain in intensive care unit: Comparison of 5 self-report intensity scales. Pain. 2010; 151(3):711–21.Google Scholar
17.Puntillo, KA, Miaskowski, C, Kehrle, K, Stannard, D, Gleeson, S, Nye, P.Relationship between behavioral and physiological indicators of pain, critical care patients’ self-reports of pain, and opioid administration. Crit Care Med. 1997; 25(7):1159–66.Google Scholar
18.Deogaonkar, A, Gupta, R, DeGeorgia, M, et al.Bispectral Index monitoring correlates with sedation scales in brain-injured patients. Crit Care Med. 2004; 32(12):2403–6.Google Scholar
19.Glass, P, Bloom, M, Kearse, L, Rosow, C, Sebel, P, Manberg, P.The sedation level and effects on memory of propofol, midazolam, isoflurane, and alfentanil in healthy volunteers. Anesthesiology. 1997; 86(4):836–47.Google Scholar
20.Sessler, CN, Gosnell, M, Grap, MJ, et al.The Richmond agitation-sedation scale: validity and reliability in adult intensive care patients. Am J Respir Crit Care Med. 2002; 166(10):1338–44.CrossRefGoogle Scholar
21.Teasdale, G, Jennett, B.Assessment and prognosis of coma after head injury. Acta Neurochirgica (Wien). 1976; 34(1-4):45–55.Google Scholar
22.Olson, DM, Thoyre, SM, Peterson, ED, Graffagnino, C.A randomized evaluation of bispectral index-augmented sedation assessment in neurological patients. Neurocrit Care. 2009; 11(1):20–7.Google Scholar
23.Hansen-Flaschen, J, Cowen, J, Polomano, RC.Beyond the Ramsay scale: need for a validated measure of sedating drug efficacy in the intensive care unit. Crit Care Med. 1994; 22(5):732–3.Google Scholar
24.Ramsay, MA, Savege, TM, Simpson, BR, Goodwin, R.Controlled sedation with alphaxalone-alphadolone. Br Med J. 1974; 22;2(5920):656–9.Google Scholar
25.Bergeron, N, Dubois, MJ, Dumont, M, Dial, S, Skrobik, Y.Intensive Care Delirium Screening Checklist: evaluation of a new screening tool. Intensive Care Med. 2001; 27(5):859–64.CrossRefGoogle ScholarPubMed
26.Van Rompaey, B, Elseviers, MM, Schuurmans, MJ, Shortridge-Baggett, LM, Truijen, S, Bossaert, L.Risk factors for delirium in intensive care patients: a prospective cohort study. Crit Care. 2009; 13(3):R77.Google Scholar
27.Ouimet, S, Kavanagh, BP, Gottfried, SB, Skrobik, Y.Incidence, risk factors and consequences of ICU delirium. Intensive Care Med. 2007; 33(1):66–73.Google Scholar
28.Guyatt, GH, Oxman, AD, Vist, GE, et al.GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. BMJ. 2008; 26;336(7650):924–6.Google Scholar
29.Ouimet, S, Riker, R, Bergeron, N, Cossette, M, Kavanagh, B, Skrobik, Y.Subsyndromal delirium in the ICU: evidence for a disease spectrum. Intensive Care Med. 2007; 33(6):1007–13.Google Scholar
30.Pandharipande, P, Shintani, A, Peterson, J, et al.Lorazepam is an independent risk factor for transitioning to delirium in intensive care unit patients. Anesthesiology. 2006; 104(1):21–6.Google Scholar
31.Cochen, V, Arnulf, I, Demeret, S, et al.Vivid dreams, hallucinations, psychosis and REM sleep in Guillain-Barré syndrome. Brain. 2005; 128(11):2535–45.Google Scholar
32.Caeiro, L, Menger, C, Ferro, JM, Albuquerque, R, Figueira, ML.Delirium in acute subarachnoid haemorrhage. Cerebrovasc Dis. 2005; 19(1):31–8.Google Scholar
33.Reijneveld, JC, Wermer, M, Boonman, Z, van Gijn, J, Rinkel, GJE.Acute confusional state as presenting feature in aneurysmal subarachnoid haemorrhage: Frequency and characteristics. J Neurol. 2000; 247(2):112–16.Google Scholar
34.Gustafson, Y, Olsson, T, Erikkson, S, Bucht, G.Acute confusional state (delirium) in stroke patients. Cerebrovasc Dis. 1991; 1: 257–64.Google Scholar
35.Hénon, H, Lebert, F, Durieu, I, et al.Confusional state in stroke: relation to preexisting dementia, patient characteristics, and outcome. Stroke. 1999; 30(4):773–9.Google Scholar
36.Caeiro, L, Ferro, JM, Albuquerque, R, Figueira ML: Delirium in the first days of acute stroke. J Neurol. 2004; 251(2):171–8.Google Scholar
37.Ramirez-Bermudez, J, Lopez-Gómez, M, Sosa Ana, L, Aceves, S, Nader-Kawachi, J, Nicolini, H.Frequency of delirium in a neurological emergency room. J Neuropsychiatry Clin Neurosci. 2006; 18(1):108–12.Google Scholar
38.Engelhard, K, Reeker, W, Kochs, E, Werner, C.Effect of remifentanil on intracranial pressure and cerebral blood flow velocity in patients with head trauma. Acta Anaesthesiol Scand. 2004; 48(4):396–9.CrossRefGoogle ScholarPubMed
39.Albanese, J, Durbec, O, Viviand, X, Potie, F, Alliez, B, Martin, C.Sufentanil increases intracranial pressure in patients with head trauma. Anesthesiology. 1993; 79(3):493–7.CrossRefGoogle ScholarPubMed
40.Albanèse, J, Viviand, X, Potie, F, Rey, M, Alliez, B, Martin, C.Sufentanil, fentanyl, and alfentanil in head trauma patients: a study on cerebral hemodynamics. Crit Care Med. 1999;27(2): 407–11.CrossRefGoogle Scholar
41.Albanèse, J, Arnaud, S, Rey, M, Thomachot, L, Alliez, B, Martin, C.Ketamine decreases intracranial pressure and electroencephalographic activity in traumatic brain injury patients during propofol sedation. Anesthesiology. 1997; 87(6):1328–34.CrossRefGoogle ScholarPubMed
42.Kolenda, H, Gremmelt, A, Rading, S, Braun, U, Markakis, E.Ketamine for analgosedative therapy in intensive care treatment of head-injured patients. Acta Neurochir (Wien). 1996; 138(10): 1193–9.CrossRefGoogle ScholarPubMed
43.Bourgoin, A, Albanèse, J, Léone, M, Sampol-Manos, E, Viviand, X, Martin, C.Effects of sufentanil or ketamine administered in target-controlled infusion on the cerebral hemodynamics of severely brain-injured patients. Crit Care Med. 2005; 33(5): 1109–13.Google Scholar
44.Watling, SM, Dasta, JF, Seidl, EC.Sedatives, analgesics, and paralytics in the ICU. Ann Pharmacother. 1997; 31(2):148–53.Google Scholar
45.Rapanos, T, Murphy, P, Szalai, JP, Burlacoff, L, Lam-McCulloch, J, Kay, J.Rectal indomethacin reduces postoperative pain and morphine use after cardiac surgery. Can J Anaesth. 1999; 46(8): 725–30.Google Scholar
46.Hynninen, MS, Cheng, DC, Hossain, I, et al.Non-steroidal anti-inflammatory drugs in treatment of postoperative pain after cardiac surgery. Can J Anaesth. 2000; 47(12):1182–7.Google Scholar
47.Marinella, MA.Propofol for sedation in the intensive care unit: essentials for the clinician. Respir Med. 1997; 91(9): 505–10.Google Scholar
48.Farling, PA, Johnston, JR, Coppel, DL.Propofol infusion for sedation of patients with head injury in intensive care. A preliminary report. Anaesthesia. 1989; 44(3):222–6.Google Scholar
49.Johnston, AJ, Steiner, LA, Chatfield, DA, et al.Effects of propofol on cerebral oxygenation and metabolism after head injury. Br J Anaesth. 2003; 91(6):781–6.Google Scholar
50.Aryan, HE, Box, KW, Ibrahim, D, Desiraju, U, Ames, CP.Safety and efficacy of dexmedetomidine in neurosurgical patients. Brain Inj. 2006; 20(8):791–8.Google Scholar
51.Grof, TM, Bledsoe, KA.Evaluating the use of dexmedetomidine in neurocritical care patients. Neurocrit Care. 2010; 12(3):356–61.Google Scholar
52.Mirski, MA, Lewin, JJ 3rd, Ledroux, S, et al.Cognitive improvement during continuous sedation in critically ill, awake and responsive patients: the acute neurological ICU sedation trial (ANIST)… Neurocrit Care. 2010; 12(3):356–61.Google Scholar
53.Chanques, G, Viel, E, Constantin, JM, et al.The measurement of pain in intensive care unit: comparison of 5 self-report intensity scales. Pain. 2010; 151(3):711–21.CrossRefGoogle ScholarPubMed
54.Devlin, JW, Roberts, RJ, Fong, JJ, et al.Efficacy and safety of quetiapine in critically ill patients with delirium: a prospective, multicenter, randomized, double-blind, placebo-controlled pilot study. Crit Care Med. 2010; 38(2):419–27.Google Scholar
55.Savard, M, Al Thenayan, E, Norton, L, Sharpe, MD, Young, GB.Continuous EEG monitoring in severe Guillain-Barré syndrome patients J Clin Neurophysiol. 2009; 26(1):21–3.CrossRefGoogle ScholarPubMed