Sedation

1. Sedation, Analgesia, and Sedation, Analgesia, and
Neuromuscular Blockade in the Neuromuscular Blockade in the
Adult ICU Adult ICU
Giuditta Angelini, MDGiuditta Angelini, MD
University of Wisconsin
Madison, WI
Gil Fraser, PharmD, FCCMGil Fraser, PharmD, FCCM
Maine Medical Center
Portland, ME
Doug Coursin, MD, FCCMDoug Coursin, MD, FCCM
University of Wisconsin
Madison, WI

2. ObjectivesObjectives
Participants should be able to:
Describe the SCCM guidelines for sedation, analgesia, and chemical
paralysis
Describe the benefits of daily awakening/lightening and sedation titration
programs
Devise a rational pharmacologic strategy based on treatment goals and
comorbidities Participants should be able to:
Describe the SCCM guidelines for sedation, analgesia, and chemical
paralysis
Describe the benefits of daily awakening/lightening and sedation titration
programs
Devise a rational pharmacologic strategy based on treatment goals and
comorbidities

3. What We Know About ICU What We Know About ICU
Agitation/DiscomfortAgitation/Discomfort
Prevalence
•50% incidence in those with length of stay > 24 hours
Primary causes: unrelieved pain, delirium, anxiety, sleep
deprivation, etc.
Immediate sequelae:
•Patient-ventilator dyssynchrony
•Increased oxygen consumption
•Self (and health care provider) injury
•Family anxiety
Long-term sequelae: chronic anxiety disorders and post-
traumatic stress disorder (PTSD)

4. Recall in the ICURecall in the ICU
Some degree of recall occurs in up to 70% of ICU
patients.
•Anxiety, fear, pain, panic, agony, or nightmares reported in 90% of
those who did have recall.
Potentially cruel:
•Up to 36% recalled some aspect of paralysis.
Associated with PTSD in ARDS?
•41% risk of recall of two or more traumatic experiences.
Associated with PTSD in cardiac surgery

5. Appropriate Recall May be ImportantAppropriate Recall May be Important
Factual memories (even unpleasant ones) help to put ICU
experience into perspective
Delusional memories risk panic attacks and PTSD
The optimal level of sedation for most patients is that
which offers comfort while allowing for interaction with the
environment.

6. Daily Goal is Arousable, Daily Goal is Arousable,
Comfortable SedationComfortable Sedation
Sedation needs to be protocolized and titrated to goal:
•Lighten sedation to appropriate wakefulness daily.
Effect of this strategy on outcomes:
•One- to seven-day reduction in length of sedation and mechanical
ventilation needs
•50% reduction in tracheostomies
•Three-fold reduction in the need for diagnostic evaluation of CNS

7. Protocols and Assessment ToolsProtocols and Assessment Tools
SCCM practice guidelines can be used as a template for
institution-specific protocols.
Titration of sedatives and analgesics guided by
assessment tools:
•Validated sedation assessment tools (Ramsay Sedation Scale [RSS],
Sedation-Agitation Scale [SAS], Richmond Sedation-agitation Scale
[RSAS], etc.)
-No evidence that one is preferred over another
•Pain assessment tools - none validated in ICU (numeric rating scale
[NRS], visual analogue scale [VAS], etc.)

8. Sedating/Analgesia OptionsSedating/Analgesia Options
Rule out reversible causes of discomfort/anxiety such as
hypoxemia, hypercarbia, and toxic/drug side effect.
Assess comorbidities and potential side effects of drugs
chosen.
Target irreversible etiologies of pain and agitation.

9. Overview of SCCM AlgorithmOverview of SCCM Algorithm
Yes
Reassess goal daily,
Titrate and taper therapy to maintain goal,
Consider daily wake-up,
Taper if > 1 week high-dose therapy & monitor
for withdrawal
No
Set Goal
for
Analgesia
Hemodynamically Unstable
Fentanyl 25 - 100 mcg IVP Q 5-15 min, or
Hydromorphone 0.25 - 0.75 mg IVP Q 5 - 15 min
Hemodynamically stable
Morphine 2 - 5 mg IVP Q 5 - 15 min
Repeat until pain controlled, then scheduled doses
+ prn
Set Goal
for
Sedation
Acute Agitation
#
Midazolam 2 - 5 mg IVP Q 5 - 15 min until
acute event controlled
Ongoing Sedation
#
Lorazepam 1 - 4 mg IVP Q 10-20 min until
at goal then Q 2 - 6 hr scheduled + prn, or
Propofol start 5 mcg/kg/min, titrate Q 5 min
until at goal
Set Goal
for Control
of Delirium
Haloperidol 2 - 10 mg IVP Q 20 - 30 min,
then 25% of loading dose Q 6hr x 2-3 days,
then taper
IVP Doses
more often than Q
2hr?
Consider continuous
infusion opiate or
sedative
> 3 Days Propofol?
(except neuro pt.)
Convert to
Lorazepam
Yes
Benzodiazepine or Opioid:
Taper Infusion Rate by
10-25% Per Day
Yes
Doses
approximate for
70kg adult
Rule out and Correct Reversible Causes
Use Non-pharmacologic Treament,
Optimize the Environment
ALGORITHM FOR SEDATION AND ANALGESIA OF MECHANICALLY VENTILATED PATIENTS
Use Pain Scale
*
to
Assess for Pain
Use Sedation Scale
**
to Assess for
Agitation/Anxiety
Use Delirium Scale
***
to
Assess for Delirium
Is the Patient Comfortable & at Goal?
Lorazepam via
infusion?
Use a low rate and IVP
loading doses

1
2
3
4
Jacobi J, Fraser GL, Coursin D, et al. Crit Care Med. 2002;30:119-141.

10. Address PainAddress Pain
Set Goal
for
Analgesia
Hemodynamically Unstable
Fentanyl 25 - 100 mcg IVP Q 5-15 min, or
Hydromorphone 0.25 - 0.75 mg IVP Q 5 - 15 min
Hemodynamically stable
Morphine 2 - 5 mg IVP Q 5 - 15 min
Repeat until pain controlled, then scheduled doses
+ prn
Use Pain Scale
*
to
Assess for Pain
Reassess goal daily,
Titrate and taper therapy to maintain goal,
Consider daily wake-up,
Taper if > 1 week high-dose therapy & monitor
for withdrawal
Is the Patient Comfortable & at Goal?

11. OpiatesOpiates
Benefits
•Relieve pain or the sensibility to noxious stimuli
•Sedation trending toward a change in sensorium, especially with more lipid
soluble forms including morphine and hydromorphone.
Risks
•Respiratory depression
•NO amnesia
•Pruritus
•Ileus
•Urinary retention
•Histamine release causing venodilation predominantly from morphine
•Morphine metabolites which accumulate in renal failure can be analgesic and
anti-analgesic.
•Meperidine should be avoided due to neurotoxic metabolites which
accumulate, especially in renal failure, but also produces more sensorium
changes and less analgesia than other opioids.

12. Opiate Analgesic Options: Fentanyl, Opiate Analgesic Options: Fentanyl,
Morphine, HydromorphoneMorphine, Hydromorphone
10 mg1.5 mg100 mcgEquivalent doses
XAvoid in hemodynamic
instability
XPreload reduction
X**Avoid in renal disease
X*Rapid offset
XRapid onset
MorphineHydromorphoneFentanyl
* Offset prolonged after long-term use
** Active metabolite accumulation causes excessive narcosis

13. Sample Analgesia ProtocolSample Analgesia Protocol
Numeric Rating Scale

14. Address SedationAddress Sedation
Set Goal
for
Sedation
Acute Agitation
#
Midazolam 2 - 5 mg IVP Q 5 - 15 min until
acute event controlled
Ongoing Sedation
#
Lorazepam 1 - 4 mg IVP Q 10-20 min until
at goal then Q 2 - 6 hr scheduled + prn, or
Propofol start 5 mcg/kg/min, titrate Q 5 min
until at goal
IVP Doses
more often than Q
2hr?
Consider continuous
infusion opiate or
sedative
> 3 Days Propofol?
(except neuro pt.)
Convert to
Lorazepam
Benzodiazepine or Opioid:
Taper Infusion Rate by
10-25% Per Day
Use Sedation Scale
**
to Assess for
Agitation/Anxiety
Lorazepam via
infusion?
Use a low rate and IVP
loading doses
Yes
Reassess goal daily,
Titrate and taper therapy to maintain goal,
Consider daily wake-up,
Taper if > 1 week high-dose therapy & monitor
for withdrawal
Is the Patient Comfortable & at Goal?

15. Sedation Options: Benzodiazepines Sedation Options: Benzodiazepines
(Midazolam and Lorazepam)(Midazolam and Lorazepam)
Pharmacokinetics/dynamics
•Lorazepam: onset 5 - 10 minutes, half-life 10 hours, glucuronidated
•Midazolam: onset 1 - 2 minutes, half-life 3 hours, metabolized by cytochrome
P450, active metabolite (1-OH) accumulates in renal disease
Benefits
•Anxiolytic
•Amnestic
•Sedating
Risks
•Delirium
•NO analgesia
•Excessive sedation: especially after long-term sustained use
•Propylene glycol toxicity (parenteral lorazepam): significance uncertain
-Evaluate when a patient has unexplained acidosis
-Particularly problematic in alcoholics (due to doses used) and renal failure
•Respiratory failure (especially with concurrent opiate use)
•Withdrawal

16. Sedation Options: PropofolSedation Options: Propofol
Pharmacology: GABA agonist
Pharmacokinetics/dynamics: onset 1 - 2 minutes, terminal half-
life 6 hours, duration 10 minutes, hepatic metabolism
Benefits
•Rapid onset and offset and easily titrated
•Hypnotic and antiemetic
•Can be used for intractable seizures and elevated intracranial pressure
Risks
•Not reliably amnestic, especially at low doses
•NO analgesia!
•Hypotension
•Hypertriglyceridemia; lipid source (1.1 kcal/ml)
•Respiratory depression
•Propofol Infusion Syndrome
-Cardiac failure, rhabdomyolysis, severe metabolic acidosis, and renal failure
-Caution should be exercised at doses > 80 mcg/kg/min for more than 48 hours
-Particularly problematic when used simultaneously in patient receiving
catecholamines and/or steroids

17. Sample Sedation ProtocolSample Sedation Protocol
Sedation-agitation Scale
Riker RR et al. Crit Care Med. 1999;27:1325.

18. Sedation Options: DexmedetomidineSedation Options: Dexmedetomidine
Alpha-2-adrenergic agonist like clonidine but with much less
imidazole activity
Has been shown to decrease the need for other sedation in
postoperative ICU patients
Potentially useful while decreasing other sedatives to prevent
withdrawal
Benefits
•Does not cause respiratory depression
•Short-acting
•Produces sympatholysis which may be advantageous in certain patients such as
postop cardiac surgery
Risks
•No amnesia
•Small number of patients reported distress upon recollection of ICU period despite
good sedation scores due to excessive awareness
•Bradycardia and hypotension can be excessive, necessitating drug cessation and
other intervention

19. Opiate and Benzodiazepine WithdrawalOpiate and Benzodiazepine Withdrawal
Frequency related to dose and duration
•32% if receiving high doses for longer than a week
Onset depends on the half-lives of the parent drug and its active
metabolites
Clinical signs and symptoms are common among agents
•CNS activation: seizures, hallucinations,
•GI disturbances: nausea, vomiting, diarrhea
•Sympathetic hyperactivity: tachycardia, hypertension, tachypnea, sweating,
fever
No prospectively evaluated weaning protocols available
•10 - 20% daily decrease in dose
•20 - 40% initial decrease in dose with additional daily reductions of 10 - 20%
Consider conversion to longer acting agent or transdermal delivery
form

20. Significance of ICU DeliriumSignificance of ICU Delirium
Seen in > 50% of ICU patients
Three times higher risk of death by six months
Five fewer ventilator free days (days alive and off vent.),
adjusted P = 0.03
Four times greater frequency of medical device removal
Nine times higher incidence of cognitive impairment at
hospital discharge

21. DeliriumDelirium
1.Acute onset of mental status changes or
a fluctuating course
&
2. Inattention
&
or
Courtesy of W Ely, MD
3. Disorganized
Thinking
4. Altered level of
consciousness

22. Risk Factors for DeliriumRisk Factors for Delirium
Primary CNS Dx
Infection
Metabolic derangement
Pain
Sleep deprivation
Age
Substances including tobacco (withdrawal as well as
direct effect)

23. Diagnostic Tools: ICUDiagnostic Tools: ICU
Routine monitoring
recommended by SCCM
•Only 6% of ICUs use
Confusion Assessment
Method (CAM-ICU) or
Delirium Screening
Checklist (DSC)
Requires Patient
Participation
•Cognitive Test for Delirium
•Abbreviated Cognitive Test
for Delirium
•CAM-ICU
Ely. JAMA. 2001;286: 2703-2710.

24. Delirium Screening ChecklistDelirium Screening Checklist
No Patient Participation
•Delirium Screening Checklist
Bergeron. Intensive Care Med. 2001;27:859.

25. Treatment of DeliriumTreatment of Delirium
Correct inciting factor, but as for pain…relief need not be
delayed while identifying causative factor
Control symptoms?
•No evidence that treatment reduces duration and severity of
symptoms
•Typical and atypical antipsychotic agents
•Sedatives?
-Particularly in combination with antipsychotic and for drug/alcohol withdrawal
delirium
No treatment FDA approved

26. HaloperidolHaloperidol
No prospective randomized controlled trials in ICU
delirium
> 700 published reports involving > 2,000 patients
The good:
•Hemodynamic neutrality
•No effect on respiratory drive
The bad:
•QTc prolongation and torsades de pointes
•Neuoroleptic malignant syndrome - only three cases with IV
haloperidol
•Extrapyramidal side effects - less common with IV than oral
haloperidol

27. Atypical Antipsychotics: Quetiapine, Atypical Antipsychotics: Quetiapine,
Olanzapine, Risperidone, ZiprasidoneOlanzapine, Risperidone, Ziprasidone
Mechanism of action unknown
Less movement disorders than haloperidol
Enhanced effects on both positive (agitation) and negative
(quiet) symptoms
Efficacy = haloperidol?
•One prospective randomized study showing equal efficacy of olanzapine
to haldol with less EPS
Issues
•Lack of available IV formulation
•Troublesome reports of CVAs, hyperglycemia, NMS
•Titratability hampered
-QTc prolongation with ziprasidone IM
-Hypotension with olanzapine IM

28. Neuromuscular Blockade (NMB) (Paralytics) Neuromuscular Blockade (NMB) (Paralytics)
in the Adult ICUin the Adult ICU
Used most often acutely (single dose) to facilitate
intubation or selected procedures
Issues
•NO ANALGESIC or SEDATIVE properties
•Concurrent sedation with amnestic effect is paramount analgesic as
needed
•Never use without the ability to establish and/or maintain a definitive
airway with ventilation
•If administering for prolonged period (> 6 - 12 hours), use an objective
monitor to assess degree of paralysis.

29. Neuromuscular Blockade in the ICUNeuromuscular Blockade in the ICU
Current use in ICU limited because of risk of prolonged
weakness and other complications
•Maximize sedative/analgesic infusions as much as possible prior to
adding neuromuscular blockade
Indications
•Facilitate mechanical ventilation, especially with abdominal
compartment syndrome, high airway pressures, and dyssynchrony
•Assist in control of elevated intracranial pressures
•Reduce oxygen consumption
•Prevent muscle spasm in neuroleptic malignant syndrome, tetanus, etc.
•Protect surgical wounds or medical device placement

30. Neuromuscular Blocking AgentsNeuromuscular Blocking Agents
Two classes of NMBS:
•Depolarizers
-Succhinylcholine is the only drug in this class
-Prolonged binding to acetylcholine receptor to produce depolarization
(fasciculations) and subsequent desensitization so that the motor endplate
cannot respond to further stimulation right away
•Nondepolarizers
-Blocks acetylcholine from postsynaptic receptor competitively
-Benzylisoquinoliniums
•Curare, atracurium, cisatracurium, mivacurium, doxacuronium
-Aminosteroids
•Pancuronium, vecuronium, rococuronium

31. Quick Onset Muscle Relaxants for Quick Onset Muscle Relaxants for
IntubationIntubation
Patients with aspiration risk need rapid onset paralysis for
intubation.
Not usually used for continuous maintenance infusions
Rocuronium
•Nondepolarizer with about an hour duration and 10% renal elimination
•Dose is 1.2 mg/kg to have intubating conditions in 45 seconds
Succinylcholine
•Depolarizer with a usual duration of 10 minutes
•All or none train of four after administration due to desensitization (can
be prolonged in patients with abnormal plasma cholinesterase)
•Dose is 1 - 2 mg/kg to have intubating conditions in 30 seconds

32. Potential Contraindications of Potential Contraindications of
SuccinylcholineSuccinylcholine
Increases serum potassium by 0.5 to 1 meq/liter in all
patients
Can cause bradycardia, anaphylaxis, and muscle pain
Potentially increases intragastric, intraocular, and
intracranial pressure
Severely elevates potassium due to proliferation of
extrajunctional receptors in patients with denervation
injury, stroke, trauma, or burns of more than 24 hours

33. Neuromuscular Blocking AgentsNeuromuscular Blocking Agents
Nondepolarizing muscle relaxants
•Pancuronium, vecuronium, cisatracurium
•All rapid onset (2 - 3 minutes)
•Differ in duration (pancuronium 1 - 2 hours, vecuronium 0.5 hours,
cisatracurium 0.5 hours)
•Differ in route of elimination (pancuronium = renal/liver, vecuronium =
renal/bile, cisatracurium = Hoffman degradation)

34. Neuromuscular Blocking AgentsNeuromuscular Blocking Agents
Infusion doses
•Pancuronium 0.05 - 0.1 mg/kg/h
•Vecuronium 0.05 - 0.1 mg/kg/h
•Cisatracurium 0.03 - 0.6 mg/kg/h
Other distinguishing features
•Pancuronium causes tachycardia
•Vecuronium has neutral effects on hemodynamics but has several
renally excreted active metabolites
•Elimination of cisatracurium is not affected by organ dysfunction, but it is
expensive

35. Monitoring NMBAsMonitoring NMBAs
Goal - To prevent prolonged weakness associated with
excessive NMBA administration
Methods:
•Perform NMBA dose reduction or cessation once daily if possible
•Clinical evaluation: Assess skeletal muscle movement and respiratory
effort
•Peripheral nerve stimulation
-Train of four response consists of four stimulae of 2 Hz, 0.2 msec in
duration, and 500 msec apart.
-Comparison of T4 (4
th
twitch) and T1 with a fade in strength means that 75%
of receptors are blocked.
-Only T1 or T1 and 2 is used for goal in ICU and indicates up to 90% of
receptors are blocked.

36. Monitoring Sedation During ParalysisMonitoring Sedation During Paralysis
Bispectral index is based on cumulative observation of a large
number of clinical cases correlating clinical signs with EEG
signals.
While used to titrate appropriate sedation (and amnesia) in
anesthetized patients to the least amount required, not proven to
achieve this goal.
Increased potential for baseline neurologic deficit and EEG
interference in ICU patients
No randomized controlled studies to support reliable use in ICU.
Other neuromonitoring (awareness) modalities are likely to be
developed.
Cessation of NMB as soon as safe in conjunction with other
patient parameters should be a daily consideration.

37. Complications of Neuromuscular Blocking Complications of Neuromuscular Blocking
AgentsAgents
Associated with inactivity:
•Muscle wasting, deconditioning, decubitus ulcers, corneal drying
Associated with inability to assess patient:
•Recall, unrelieved pain, acute neurologic event, anxiety
Associated with loss of respiratory function:
•Asphyxiation from ventilator malfunction or accidental extubation,
atelectasis, pneumonia
Other:
•Prolonged paralysis or acute NMBA related myopathy
-Related to decreased membrane excitability or even muscle necrosis
-Risk can be compounded by concurrent use of steroids.

38. Sample NMBA ProtocolSample NMBA Protocol

39. ReferencesReferences
Jacobi J, et al. Crit Care Med. 2002;30:119-141.
Jones, et al. Crit Care Med. 2001;29:573-580.
Cammarano, et al. Crit Care Med. 1998;26:676.
Ely, et al. JAMA. 2004;292:168.

40. Case Scenario #1Case Scenario #1
22-year-old male with isolated closed head injury who was
intubated for GCS of 7
He received 5 mg of morphine, 40 mg of etomidate, and 100
mg of succinylcholine for his intubation.
He is covered in blood spurting from an arterial catheter that
was just removed, and he appears to be reaching for his
endotracheal tube.
What sedative would you use and why?
What are the particular advantages in this situation?
How could you avoid the disadvantages of this drug?

41. Case Scenario #1 - AnswerCase Scenario #1 - Answer
Propofol will rapidly calm a patient who is displaying dangerous
behavior without need for paralysis.
Titratable and can be weaned quickly to allow for neurologic
exam
Can treat seizures and elevated ICP which may be present in a
head trauma with GCS of eight or less
Minimizing dose and duration will avoid side effects.

42. Case Scenario #2Case Scenario #2
54-year-old alcoholic who has been admitted for Staph sepsis
Intubated in the ICU for seven days and is currently on
midazolam at 10 mg/hour
His nurse was told in report that he was a “madman” on the
evening shift.
Currently, he opens his eyes occasionally to voice but does not
follow commands nor does he move his extremities to deep
painful stimulation.
Is this appropriate sedation?
What would you like to do?
How would you institute your plan of action?

43. Case Scenario #2 - AnswerCase Scenario #2 - Answer
This patient is oversedated. Not only can a neurologic exam
not be performed, but it would be unlikely to be able to perform
a wakeup test within one 24-hour period.
Given the need to examine the patient, midazolam should be
stopped immediately.
Rescue sedatives including midazolam should be available if
agitation develops.
Flumazenil should be avoided.

44. Case Scenario #3Case Scenario #3
62-year-old, 65-kg woman with ARDS from aspiration pneumonia
Her ventilator settings are PRVC 400, RR 18, PEEP 8, and FIO
2
100%. She is dyssynchronous with the ventilator and her
plateau pressure is 37 mm Hg.
She is on propofol at 50 mcg/kg/min, which has been ongoing
since admit four days ago.
She is also on norepinephrine 0.1 mcg/kg/min and she was just
started on steroids.
What do you want to do next?
Do you want to continue the propofol?
Why or why not?
What two iatrogenic problems is she likely at risk for?

45. Case Scenario #3 - AnswerCase Scenario #3 - Answer
This patient needs optimization of her sedatives, and
potentially chemical paralysis to avoid complications of
ventilator dyssynchrony and high airway pressures.
If you continue to use propofol, higher doses are required and
the patient is already on norepinephrine. In addition, if
paralysis is used, you do not have reliable amnesia.
She is at risk for propofol infusion syndrome and critical illness
polyneuropathy.