Sedation and analgesia in the ICU

Analgesia, Amnesia, and NM blockade

Sedatives

• Fentanyl analgosedation (monotherapy) - estimated to be sufficient in 50% of ICU patients (source?)

• dexmetodomidine - less delirium

• propfol - fast on/off

• ketamine

Anelgesia

Analgesia first modality

Interventions

• ABCDEF bundle

Neuromuscular Blockade

Ciastricurium: degraded by Hoffman elimination = predictable even in hepatic and renal failure. Thus, preferred.

Monitoring

Train of 4 = measures neuromuscular blockade by summarizing how many receptors are blocked. Gives pulses through a nerve and 2 Hz and sees how many are conducted

• 4 twitches = 75% or less
• 3 twitches = 85% or less
• 2 twitches = 95% or less
• 1 twitch = 99% or less
• 0 twitch = 100% blocked.

BIS monitoring: uses machine learning algorithm to infer from EEG tracing what level of sedation the patient is at. Note: sedatives (e.g. opiates) will interfere with this.

• 100 = normal
• <60 = amnesia
• 0 = coma