Objective:To revise the “Clinical Practice Guidelines for the Sustained Use of Sedatives and Analgesics in the Critically Ill Adult” published in Critical Care Medicine in 2002.Methods:The American College of Critical Care Medicine assembled a 20-person, multidisciplinary, multi-institutional task f

/pdf/clinical-practice-guidelines-for-the-management-of-pain-4810wy3nml.pdf

Clinical Practice Guidelines for the Management of Pain, Agitation, and Delirium in Adult Patients in the Intensive Care Unit

Objective:To update and expand the 2013 Clinical Practice Guidelines for the Management of Pain, Agitation, and Delirium in Adult Patients in the ICU.Design:Thirty-two international experts, four methodologists, and four critical illness survivors met virtually at least monthly. All section groups g

/pdf/clinical-practice-guidelines-for-the-prevention-and-fvgclilv6m.pdf

Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU

https://redintensiva.cl/images/guias_sedacion_analgesia.pdf

Guía de práctica clínica basada en la evidencia para el manejo de la sedo-analgesia en el paciente adulto críticamente enfermo

"Introduccion: El optimo manejo de la sedacion, analgesia y delirium ofrece al paciente critico comodidad y seguridad, facilita el buen desarrollo de medidas de soporte y manejo integral y disminuye complicaciones, impactando en un mejor desenlace. Objetivo: Actualizar la Guia de practica clinica basada en la evidencia para el manejo de la sedoanalgesia en el paciente adulto criticamente enfermo publicada en Medicina Intensiva en el 2007 y dar recomendaciones para el manejo de la sedacion, analgesia y delirium. Metodologia: Se reunio un grupo de 21 intensivistas procedentes de 9 paises de la Federacion Panamericana e Iberica de Sociedades de Medicina Critica y Terapia Intensiva, 3 de ellos ademas especialistas en epidemiologia clinica y metodologia para elaboracion de guias. Se acogio la propuesta del Grading of Recommendations Assessment, Development and Evaluation Working Group para emitir el grado de recomendacion y evaluar la calidad de la evidencia. La fuerza de las recomendaciones fue calificada como 1 = fuerte, o 2 = debil, y la calidad de la evidencia como A = alta, B = moderada, o C = baja. Expertos en busqueda de literatura apoyaron con esta estrategia de busqueda: MEDLINE a traves de PUBMED, bases de datos de la biblioteca Cochrane a traves de The Cochrane Library y la base de datos Literatura Latinoamericana y del Caribe en Ciencias de la Salud. Los miembros asignados a las 11 secciones de la guia, basandose en la revision de la literatura, presentaron las recomendaciones, sustentadas y discutidas en sesiones plenarias, aprobando aquellas que superaron el 80% del consenso. La elaboracion de las guias conto con el soporte de la Asociacion Colombiana de Medicina Critica y Cuidado Intensivo. Resultados: Para la elaboracion de la guia fueron finalmente seleccionadas 467 referencias, observandose un importante aumento en el numero y calidad de los estudios, permitiendo realizar 64 fuertes recomendaciones con evidencia alta y moderada, contrastando con las 28 de la edicion anterior. Conclusiones: Esta guia contiene recomendaciones y sugerencias basadas en la mejor evidencia para el manejo de la sedacion, analgesia y delirium del paciente critico, incluyendo un paquete de medidas (bundle). Se destacan: evaluacion del dolor y la agitacion/sedacion mediante escalas; usar inicialmente opioides para el control de la analgesia, adicionando tecnicas multimodales para disminuir consumo de opioides; promover el menor nivel de sedacion necesario, evitando la sobresedacion; en caso de requerir medicamentos sedantes, escoger el mas apropiado, evitando el uso rutinario de benzodiazepinas; por ultimo, identificar factores de riesgo para delirium, prevenirlo, diagnosticarlo y manejarlo, con el medicamento mas conveniente, ya sea haloperidol, antipsicoticos atipicos o dexmedetomidina, evitando el uso de benzodiazepinas y disminuyendo el uso de opioides. © 2013 Elsevier Espana, S.L. y SEMICYUC. Todos los derechos reservados"

/pdf/guias-de-practica-clinica-basadas-en-la-evidencia-para-el-mu2p41imfz.pdf

Guías de práctica clínica basadas en la evidencia para el manejo de la sedoanalgesia y delirium en el paciente adulto críticamente enfermo

As most critically ill or injured patients will require some degree of sedation, the goal of this paper was to comprehensively review the literature associated with use of sedative agents in the intensive care unit (ICU). The first and selected latter portions of this article present a narrative overview of the shifting paradigm in ICU sedation practices, indications for uninterrupted or prolonged ICU sedation, and the pharmacology of sedative agents. In the second portion, we conducted a structured, although not entirely systematic, review of the available evidence associated with use of alternative sedative agents in critically ill or injured adults. Data sources for this review were derived by searching OVID MEDLINE and PubMed from their first available date until May 2012 for relevant randomized controlled trials (RCTs), systematic reviews and/or meta-analyses and economic evaluations. Advances in the technology of mechanical ventilation have permitted clinicians to limit the use of sedation among the critically ill through daily sedative interruptions or other means. These practices have been reported to result in improved mortality, a decreased length of ICU and hospital stay and a lower risk of drug-associated delirium. However, in some cases, prolonged or uninterrupted sedation may still be indicated, such as when patients develop intracranial hypertension following traumatic brain injury. The pharmacokinetics of sedative agents have clinical importance and may be altered by critical illness or injury, co-morbid conditions and/or drug-drug interactions. Although use of validated sedation scales to monitor depth of sedation is likely to reduce adverse events, they have no utility for patients receiving neuromuscular receptor blocking agents. Depth of sedation monitoring devices such as the Bispectral Index (BIS©) also have limitations. Among existing RCTs, no sedative agent has been reported to improve the risk of mortality among the critically ill or injured. Moreover, although propofol may be associated with a shorter time to tracheal extubation and recovery from sedation than midazolam, the risk of hypertriglyceridaemia and hypotension is higher with propofol. Despite dexmedetomidine being linked with a lower risk of drug-associated delirium than alternative sedative agents, this drug increases risk of bradycardia and hypotension. Among adults with severe traumatic brain injury, there are insufficient data to suggest that any single sedative agent decreases the risk of subsequent poor neurological outcomes or mortality. The lack of examination of confounders, including the type of healthcare system in which the investigation was conducted, is a major limitation of existing pharmacoeconomic analyses, which likely limits generalizability of their results.

/pdf/sedation-for-critically-ill-or-injured-adults-in-the-4vgxzykw0r.pdf

Sedation for critically ill or injured adults in the intensive care unit: a shifting paradigm

Aim. The aim of this study was to compare the effect of protocol-directed sedation propofol vs. midazolam by nurses in intensive care on efficacy, haemodynamic stability and patient satisfaction.



Background.  Protocols represent one method potentially to reduce treatment delays and ensure that medical care is administered in a standardised manner. Propofol and midazolam are often used for sedation in intensive care units.



Method.  A randomised, prospective cohort study and data were collected in 2003. The subjects were randomised either into propofol (n = 32) or into midazolam (n = 28) group. Efficacy of sedation, haemodynamic stability, pulse oximetry saturation, Acute Physiology and Chronic Health Evaluation II (APACHE II score), weaning time from mechanical ventilation, duration of mechanical ventilation, length of stay at intensive care unit, sedative drugs cost and patient satisfaction were measured.



Results.  The nursing staff were able to maintain patients at Ramsay sedation scale (RSS) 3–4 during the sedative period. The efficacy of sedation was 74·2% and 66·9% of time in propofol and midazolam group respectively. Both sedatives reduced the arterial blood pressure and heart rate, but did not alter haemodynamic stability. The mean score of satisfactory sedation was not significantly different between the two groups (propofol: 11·4 SEM 0·2 vs. midazolam: 11·5 SEM 0·7).



Conclusion.  Protocol-directed sedation with propofol vs. midazolam by nurses were similar in quality during the sedative period.



Relevance to clinical practice.  This sedation practice for titration of propofol and midazolam by nurses was of similar quality and able to achieve an appropriate depth of sedation during the sedative period. Furthermore, they should provide care for patients’ needs during the sedative period.

Comparison of the effect of protocol-directed sedation with propofol vs. midazolam by nurses in intensive care: Efficacy, haemodynamic stability and patient satisfaction

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Comparison of the effect of protocol-directed sedation with propofol vs. midazolam by nurses in intensive care: Efficacy, haemodynamic stability and patient satisfaction