Evidence-Based Guideline for Adult Sedation, Pain ...

Published 8 December 2020 Volume 2020:13 Pages 1445—1452 ... Sedation and analgesia for ICU patients should have a protocol to decrease interpersonal ... Journals WhyPublishWithUs? 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Weofferrealbenefitstoourauthors,includingfast-trackprocessingofpapers.Learnmore PromotionalArticleMonitoring RegisteryourspecificdetailsandspecificdrugsofinterestandwewillmatchtheinformationyouprovidetoarticlesfromourextensivedatabaseandemailPDFcopiestoyoupromptly.Learnmore SocialMedia       BacktoJournals»InternationalJournalofGeneralMedicine»Volume13 Review Evidence-BasedGuidelineforAdultSedation,PainAssessment,andAnalgesiainaLowResourceSettingIntensiveCareUnit:ReviewArticle            FulltextMetricsGetPermissionCitethisarticle AuthorsNemeD,AwekeZ ,MichoH,MolaS ,JemalB ,RegasaT Received29August2020 Acceptedforpublication3November2020 Published8December2020 Volume2020:13Pages1445—1452 DOIhttps://doi.org/10.2147/IJGM.S276878 CheckedforplagiarismYes ReviewbySingleanonymouspeerreview Peerreviewercomments2 Editorwhoapprovedpublication: DrScottFraser DownloadArticle[PDF]  DerartuNeme,1ZemeduAweke,1HaileleulMicho,2SimenehMola,1BedruJemal,1TeshomeRegasa11DepartmentofAnesthesiology,CollegeofMedicineandHealthScience,DillaUniversity,Dilla,Ethiopia;2DepartmentofBiochemistry,CollegeofMedicineandHealthScience,DillaUniversity,Dilla,EthiopiaCorrespondence:ZemeduAwekeDepartmentofAnesthesiology,CollegeofMedicineandHealthScienceDillaUniversity,P.O.0419,4620,Dilla,EthiopiaTel+251912406236Email[email protected]Background:AgitationandanxietyoccurfrequentlyinICUandaffectabout30–80%ofpatientsinICUpresentwithdeliriumworldwide,anditisassociatedwithadverseclinicaloutcomes.Thisreviewaimedtosystematicallyreviewarticlesandfinallydrawanevidence-basedguidelineforanareawithlimitedresources.Methods:Thereviewwasreportedbasedonpreferredreportingitemsforsystemicandmeta-analysis(PRISMA)protocol.WesearchedliteraturefromPubMed,GoogleScholar,andMedlinedatabaseusingkeywordslikethelevelofsedation,sedationscore,painassessmentinICU,andsedativedrugsinICUfromanarticlepublishedinEnglish.Afterextractionwithapatientpopulationandexclusion,fiverandomizedclinicaltrials,foursystemicreviewsandmeta-analysis,fourobservationcohortstudy,andtwopracticalguidelineswereusedforthereview.Conclusion:Inadditiontohighvalidityandreliability,RASShastheadvantageofeasinesstorememberfornursesmakingitapreferredsedationassessmenttoolinanadultICUsetting.Lightsedationwithdailyinterruptionwasrecommendedwithanaimofanawakeandalertpatientreadyfortheweaningtrial.Propofolwaspreferredwhensedationisforashortdurationandwhenintermittentawakeningisrequired.Ketamineisthepreferredinductionforasthmatichypotensiveandpatientrequiringprolongedcontinuoussedation.Withasimilartimeforsedation,diazepamshowsashortertimeforintubationcomparedtomidazolam.Besidesdiazepamhasshownacheapercostofsedationthanmidazolam.Thismakesitadrugofpreferenceinalowresourcesetting.Keywords:sedation,ICU,propofol,ketamine Introduction Sedationistheactofcalmingpatientsbytheadministrationofsedativemedications.SedativeandanalgesicdrugsarecommonlyadministeredforICUpatientsworldwidebecausetheexperienceofpainandanxietyoccursinthemajorityofcriticallyillpatientsduringICUstaytime.Upto50%ofsurgicalandmedicalICUpatientsexperiencepainatrestand80%duringproceduresornursingcare.Trachealsuctioning,removalofdrains,positioningofthepatientsarereportedasamongthemostpainfulproceduresinICU.1,2 AgitationandanxietyoccursfrequentlyinICUandalsoabout30%to80%ofpatientsinICUpresentwithdeliriumworld-wideanditisassociatedwithadverseclinicaloutcomessuchasdifficultyintrachealsuctioningandIVcannulation,increaseoxygenconsumption,andalsoitmayresultinaccidentalextubationformechanicallyventilatedpatients.3Earlydetectionandinterventionofthepossibleunderlyingcausesforagitationandanxietysuchaspain,delirium,hypoxemia,hypoglycemia,hypotension,orwithdrawalfromalcoholandotherdrugsareveryimportantbeforesedatingthepatient.4 InICUpatients,monitoringofsedationandanalgesiahasmanychallengessincetheyarecriticallyillpatientsmostofthemevenmaynotcommunicateandcannotreporttheirpainverballyorwithothersignsduetoadiminishedlevelofconsciousness,beingonmechanicalventilatorsupport,orreceivedahighdoseofsedativeorneuromuscularblockingdrugs.5 MainlythecliniciansinvolvedinICUpatientmanagementarephysicians,anesthetists,andnurses.Sincetherearedifferenthealthpersonneltheyaredoingindifferentways.SothisisoneofthechallengesfacedinmanagingICUpatients.SedationandanalgesiaforICUpatientsshouldhaveaprotocoltodecreaseinterpersonaldifferencesinmanagingcriticalpatients.4 AdultICUpatientsarecriticallyillpatientswhoneedspecialcareandstrictlyfollowupthatneedsstandardprotocolineveryaspectofmanagement.OneoftheimportantmanagementforadultICUpatentissedationandanalgesia.SinceinmostICUpatientsanxietyandpainiscommon,theyneedbothsedationandanalgesicsdependingontheirlevelofanxiety/agitationandseverityofpain.ThereareinternationallyacceptedsedationandanalgesiaguidelinesforadultICUpatients.Lackofresourcesinalowresourcesettingwasamongchallengesinthefieldofcriticalcare.SomeofthemedicationswerenotavailableduringICUcare.Thus,findingalternativeguidesthroughasystemicreviewofliteratureisthemainaimofthisstudy.AmongseveralissuesinICUcare,monitoringsedation,levelofsedation,pharmacologyofsedatives,painassessmentandpainmanagementwillbediscussedsystematically. Methodology Thereviewwasreportedbasedonpreferredreportingitemsforsystemicandmeta-analysis(PRISMA)protocol.WesearchedarticlespublishedinEnglishfromPubMed,GoogleScholar,andMedlinedatabasetoidentifystudiesforourreviewusingthekeywords;thelevelofsedation,sedationscore,painassessmentinICU,andsedativedrugsinICU.Fromalotofjournalsobtainedfromasearchengine,filteringwasmadebasedontheintervention,outcome,dataonpopulation,andmethodologicalquality.Besides,articleswithapediatricpatientpopulationandsedationoutofICUwereexcludedfromthereview.Afterextractionwithapatientpopulationandexclusion,fiverandomizedclinicaltrials,foursystemicreviewsandmeta-analysis,fourobservationcohortstudyandtwopracticalguidelineswereusedforthereviewusingthekeywords(lightANDdeepsedation)midazolamANDdiazepam,midazolamANDPropofol,andketamineforICUsedation(seeFigure1).Articleswereindependentlyassessedanddeterminedtheireligibilitybasedonmethodologicalqualityoninclusionandexclusioncriteria,andoutcomevariablesbytwoevaluators.Anydiscrepancywascorrectedbythethirdevaluator.TheconclusionwasmadebasedonthelevelofevidencethatwasreferredfromtheOxfordCenterforevidence-basedmedicine(Table1). Table1LevelsofEvidencesandGradesofRecommendations Figure1PRISMAFlowchartforselectionofstudies.Notes:PRISMAfigureadaptedfromLiberatiA,AltmanD,TetzlaffJetal.ThePRISMAstatementforreportingsystematicreviewsandmeta-analysesofstudiesthatevaluatehealthcareinterventions:explanationandelaboration.JournalofClinicalEpidemiology.2009;62(10).CreativeCommons. DiscussionMonitoringSedation Tomonitorthelevelofsedationusesofastructuredtoolforassessmentofsedationandagitationisnecessary.Ithelpstominimizethedoseofsedativedrugsandtoavoidagitatedbehaviors.Eventhoughallsedationassessmenttoolshavetheirlimitationaclinicalguidelineforpain,agitation,anddeliriumofadultICUin2013showsthatRichmondagitationsedation(RASS)and(ASA)arethemostvalidandreliablesedationassessmentscalesformeasuringbothdepthsofsedationandqualityofsedationinadultICUpatients.6 InthestudythatcomparesthevalidityandreliabilityofRASSwiththeASAscale,itshowsthatRASSaslogical,easytoremember,andsimpleforadministrationfornursesandalsoRASShashighvalidityandreliabilityinsurgicalandmedicalICUpatientsregardlessofsedationstatusandtheneedofventilatorsupport.Besides,itdescribesthatRASShasanadvantageindecreasingthedoseofsedativemedicationandthelengthofmechanicalventilation.7,8Thistoolhadalsodemonstratedexcellentinterraterreliabilityandcriterion,construct,andfacereliabilityandvalidity.9 Despiteitsinherentlimitations,sedationmonitoringtoolslikeFrontaliselectromyogram,Loweresophagealcontractility,Continuouselectroencephalography,Powerspectralanalysis,Sensoryandauditoryevokedpotentialsarenoteasilyavailableinalowresourcesetting.Inadditiontoscarceresources,theutilityandpracticeofthisdifferenttoolandtechniquesinthedailyICUsettingisunknown.10 ItishighlyrecommendedthatusingRASSisaneffectivesedationassessmenttoolforclinicaluseinadultICU. LevelofSedation ThepracticeoflightanddeepsedationhasanimpactoncognitiveandmentalhealthfunctioninICUpatientsbothmedicallyandpsychologically.Sedationcanbelightinwhichthepatientisinanarousalstateandcanpurposefullyrespondforsimpleinstructionsordeepinwhichthepatientisnotrespondingtopainfullstimuli.Ameta-analysisrevealedasignificantlyhigherincidenceofcognitivedysfunctionindeepsedationcomparedtoalightlevelofsedationandtheconclusionwasadeeplevelofsedationcanresultincognitiveimpairmentinadultICUpatients.8 Also,arandomizedcontrolledtrialwasdonein2012tosupportthelightlevelofsedationanddailyinterruptionofsedationtomaintainthepatient’sresponsiveness,improvecommunication,anditwasalsoencourageddailyinterruptionofsedation.11 Inthesameway,anotherrandomizedcontroltrialstudywhichcomparedlightversusdeepsedationrecommendedlightsedationbecauseitminimizesventilatorsupporttimebyone(1day)andICUstaytimebyoneandhalve(1½)daywithoutnegativelyaffectingpatientsmentalandphysicalhealth.Thestudyrevealsnosignificantchangesintheoccurrencesofanxiety,depression,mortality,andotheradverseevents.12 The2013Clinicalpracticeguidelinesforthemanagementofpain,agitationinICUpatientsalsosuggestlightsedationforcriticallyill,mechanicallyventilatedpatients.6Excessivesedationevenforlessthan48 hourscanincreasemorbidityandmortalityasshowninaprospectivecohortstudydoneoncriticallyillpatients.13 Itwasrecommendedthatlightsedationwithdailyinterruptionofsedativeinfusionortitrationofasedativedosewiththefinalgoalofhavingawakeandalertpatientswhocouldperformaweaningtrialunlessthereisacontraindication. PharmacologyofSedatives Anidealsedativeagentshouldhaveafastonset,ashortdurationofaction,alackofaccumulation,easeoftitration,andadministration,withoutcardiovascularandrespiratorydepression.14ButtheabsenceofthisidealsedativeresultinadifferentmethodofsedationinICUpatientswasthebasisforvariationsamongpublishedguidelinesandpracticalvariations.AmongagentscommonlyusedforICUsedationdiazepam,midazolam,Propofol,andketamineasaninductionagentwererevised. BenzodiazepinessuchasmidazolamandlorazepamareamongcommonlyusedsedativesinICU.Propofolhasbeenanotheralternativecommonlyusedtosedateadultcriticallyillpatientsinmostcases.Midazolamwasthemostpopularlyutilizeddrugforsedation(65–70%ofthetime),Propofolused20%ofthetime.Accordingto,open-labeltrial,comparedtomidazolamandfentanyl,PropofolandremifentanilhavebeenshowntofacilitateahigherturnoverofpatientsbyreducingthetimeofmechanicalventilationandalsoshorteningICUstaytime.ThetrialrevealedthehighercostofremifentanilhadbeencompensatedbyshorterICUstay.15 The2002guidelinesrecommendmidazolamshouldonlybeusedforshort-termsedation,whilelorazepamshouldbeconsideredonlyforlong-termsedation.Propofol,however,shallbeusedforpatientsrequiringintermittentawakenings.16 However,whenlong-termsedationisrequired,thetoxicaccumulationassociatedwithanagentlikePropofolhelpsinfindingalternativesedativeagents.Ketamine,anon-barbiturate,phencyclidinederivativecommonlyaccessedinalowresourcesettingcouldbeaviablealternativeforcontinuoussedation.17 PropofolvsMidazolam Asystemicreviewindicatesthatpropofolissimilarlyeffectiveasmidazolambutitprovidespredictableandfasterrecoveryevenafterprolongedinfusion(>72hours).Itwasalsoreportedthatcontrolofthedepthofsedationiseasilyachievedbypropofolsedation.Thereviewfinallyconcludesthatpropofolsedationeffectivesedationwithamorerapidandpredictableemergencetimethanmidazolaminavarietyofclinicalsettings.18 Inthesameway,anotherstudyreportedthatPropofolandmidazolamaresimilarlyeffectiveinprovidingtherequiredlevelofsedation.However,afterthedecisionofweaningmade,Propofolminimizesthetimetoextubationregardlessofthedurationofsedation.14 Ameta-analysisshowsnosignificantdifferenceinmortalitybetweensedationwithPropofolandotherdifferentsedativeagentswithoddsratio[OR]1.05,95%confidenceinterval[CI]0.80–1.38,P=0.74;I(2)=(0%).ItshowsUsingmediumandlong-termsedationwithpropofolwasassociatedwithasignificantreductioninlengthofICUstaywithoverallweighted-mean-difference[WMD]indays−0.99,95%CI−1.51to−0.47,P=0.0002;I(2)=(82.26%)whencomparedtodifferentsedativeagentsbutitisinsignificantwhencomparedwithmidazolam.19 Propofolisrecommendedforshort-termsedationandpreferabletomidazolamandothersedativedrugs.Alsoformedium-andlong-termsedation,itisassafeasmidazolamevenformorethan72hrs.SowecanusePropofolbothforshort-termandlong-termsedationsafely. KetamineforICUSedation SystemicreviewshowsthatketaminecanbeusedasanalternativeforsedationinadultICUpatientsandithasanadvantageforhypotensivepatientsandalsoforpatientsrequiringahighdoseofvasopressors.Thestudyshowsthatitisaneffectivesedativeagentasfentanylwasforheadinjurypatient.Ketaminecanbeusedasanalternativesedativeagentincaseoflong-termsedationwheremidazolamandPropofolmayresultintoxicaccumulationorPropofolinfusionsyndrome.17 Ketamineisalsorecognizedbybeneficialrespiratoryandcardiovasculareffectswhenadministeredasmaintenancesedationviacontinuousinfusion.TheeffectofketamineisonFunctionalresidualcapacity,minuteventilation,tidalvolumeisveryminimalcomparedtoothersedatives.Furthermore,itwasshowntodecreaseairwayresistanceandpreserveprotectivepharyngealandlaryngealreflexesinanasthmaticpatientwithrefractorybronchospasm.Administrationofketaminebycontinuousinfusionhasbeenreportedtodecreaseaudiblewheezing,carbondioxidelevel,broncodilatorrequirements,andimproverespiratoryrateandoxygenation.20Itisalsorecommendedtouseketamineasanalternativewhencontinuoussedationforalongtimeisrequiredtodecreasethesideeffectofothers.17 ItisrecommendedtouseketamineasanalternativesedativeagentinadultICUespeciallyforpatientswithasthmaandhypotensivepatients.Itisalsorecommendedforlongercontinuoussedation. RegardingtoDiazepamorMidazolam Arandomizedcontrolledtrialstudythatcomparedclinicallyandcost-effectivenessbetweendiazepamandmidazolamforurgentintubationinICUindicatesthattimeforadequatesedationwasshorterwith132±87secfordiazepamvs.224±117sec,p=0.016formidazolam.Butthedurationofsedationwassimilarto86±67minvs.88±50min,p=0.936fordiazepamwhencomparedtomidazolam.Thetotaldoseofdrugstoreachadequatesedationissimilarforbothdrugs(10–12mgvs.10–17mg,p=0.248).Costofsedationwaslowerfordiazepamcomparedtomidazolam(1.4–1.8vs.9.4–16.2,p<0.001).21ItisrecommendedtousediazepaminadultICUforthepatientwhoneedsurgentintubation. PainAssessmentinICU Painisaprotectivemechanismforacertainpathophysiologicconditionthatneedstobecorrectedbutalsoacauseforunwantedstressorofthosepathophysiologicproblems.Paininadditiontonegativeeffectsonnormalphysiologycancauseanxietyincriticallyillpatients.MeasurementofpaininICUespeciallyunconsciouspatientscanbechallenging.Soseveraltoolsformeasuringthepainforcriticallyillpatientsalreadydevelopedandvalidated.Aprospectiveobservationalstudyshowsthatfornon-communicatingpatientsthecommonpainassessmenttoolusedisBPS(BehaviourPainScale)andCPOT(Critically-illPainObservationTool).BPShasthreeparametersthatarefacialexpression,upperlimbmovement,andcompliancewithventilator,whileCPOTusesfourparametersthatarefacialexpression,musculartone(passivemovement),upperextremitymovement(active),andcompliancewiththeventilator.ItwasindicatedinthestudythatCPOTandBPSwereagoodcriterionanddiscriminantvalidity(p