ANALGESIA AND SEDATION UPDATE 2019

1. Analgesia and Sedation in
ICU
DR. ANWAR YUSR
Critical Care Medicine
2015
USTH

2. Predisposing and Causative Conditions
Anxiety Pain Delirium
Interventions
Management
of predisposing
& causative
conditions
Sedative,
analgesic,
antipsychotic,
medications
Calm Alert
Free of pain and anxiety
Lightly
sedated
Deeply
sedated
Unresponsive
Pain,
anxiety
Agitation, vent
dyssynchrony
Dangerous
agitation
Spectrum of Distress/Comfort/Sedation
ICU
Environmental
Influences
Hospital
Acquired
Illness
Medications
Invasive,
Medical, &
Nursing
Interventions
Underlying
Medical
Conditions
Acute Medical
or Surgical Illness
Mechanical
Ventilation
Agitation
Sessler CN, Varney K. Chest. 2008;133(2):552-565.

3.  Patient comfort.
 Control of pain.
 Anxiolytics and amnesia.
 Blunting adverse autonomic and
hemodynamic responses.
 Facilitate nursing management.
 Facilitate mechanical ventilation.
 Avoid self- extubation.
 Reduce oxygen consumption.
Goals of sedation in the ICU
 BETTER OUTCOME.

4. Levels of Sedation
MINIMAL
SEDATION
-anxiolysis
MODERATE
SEDATION
-conscious sedation
DEEP
SEDATION
GENERAL
ANESTHESIA

5. Sedation-Analgesia Policy Levels
of Sedation
Minimal
Sedation
(anxiolysis)
Moderate
Sedation/
Analgesia
Deep Sedation/
Analgesia
General
Anesthesia
Responsiveness Normal response
to speech
Purposeful response
to speech or touch
Purposeful response
to repeated or
painful stimulation
No response, even to
pain
Airway Unaffected Remains open May need help to
maintain airway
Often needs help to
maintain airway
Breathing Unaffected Adequate May not be adequate Often require
ventilatory support
Heart Function Unaffected Usually maintained Usually maintained May be impaired

6. Hello..hello ...
Who are you..?
 A trained anesthesiologist should provide anaesthesia in
remote locations within the hospital.
 However non anesthesiologists are allowed to
provide ‘conscious sedation'.
 It is mandatory that all providers should be
Adult Cardiac Life Support (ACLS) certified.

7. Preparations
 Expect and be prepared for the worse.
 You should have the skills to rescue from one level
higher than anticipate.
SOAPS
Suction
Oxygen
Airway equipment
BVM, blades, ETT
Pharmacy
Appropriate meds,
reversal agents,
emergency drugs
Special monitors
MSMAID
Monitor
CR monitor (EKG, HR, RR), BP,
continuous pulse oximetery,
capnography.
Suction.
Medicine / Machine.
Airway equipment.
IV access.
Drugs for rescue (includes O2).

8. Standards for Sedation
 Documentation of pre-procedure assessment.
 Informed consent obtained.
 Sedation options and risks must be discussed
with the patient and family prior to the
sedation/procedure.
 Continuous ECG and pulse oximetry monitoring.
 Vital Signs q 5 minutes during procedure.
 Supplemental O2, emergency equipment
available.
 Capnography (ET CO2) required for deep
sedation:
 etomidate, fentanyl, ketamine, propofol.

9. Nonpharmacologic Interventions
 Good nursing.
 Psychological:
- Explanation. - Reassurance.
 Physical:
 Touching & message.
 Prevent constipation.
 Tracheostomy.
 Proper position of the patient.
 Stabilization of fractures.
 Elimination of irritating stimulation.
 Proper positioning of the ventilator tubing to avoid
traction on endotracheal tube.
 Environment.
 Physiotherapy.

10. Set Treatment Goal
Sedation Analgesia
Amnesia AnxiolysisHypnosis
Patient Comfort

11. PAIN in ICU
At least 50% patients discharged from
ICU remember pain as worst
experience.
Can Anaesth Soc J 1979;26:173-80

12. Pain
Disease
Invasive
Devices
Immobility
Routine
Care
Complications
Chronic pain Stress
Sleep-loss
Hyper-
metabolism
Impaired
wound healing
Impaired
immune
function
Feelings of
Helplessness
Post-traumatic
stress disorder
“An unpleasant sensory and emotional experience
associated with actual or potential tissue damage.”
Barr, et al. Crit Care Med. 2013;41(1):263-306.

13. Guidelines for PADIS 2018 SCCM
Ungraded statement:
Self-report scales:
A patient’s self-report of pain is the reference standard for pain assessment in
patients who can communicate reliably. Among critically ill adults who are able
to self-report pain, the 0–10 numeric rating scale administered either verbally or
visually is a valid and feasible pain scale.
 Behavioral pain assessment tools:
Among critically ill adults unable to self-report pain and in whom behaviors are
observable, the BPS and BPS-NI patients and the CPOT demonstrate the greatest
validity and reliability for monitoring pain.

14. Visual Pain Scales
NUMERICAL RATING SCALE (NRS)

16. Potential Benefits with Protocolized
ICU Pain Assessment
A higher degree of pain assessment with a validated tool
via protocol (and education) is associated with:
Improved pain scores.
Length of ventilation and ICU stay.
Mortality.
Consumption of sedatives.
Need for opioids in non communicative pts.
Use of non-opioid analgesics.
Opioid related adverse drug events (ORADE).
Gélinas C, et al. Int J Nurs Stud. 2011 Dec;48(12):1495-504.
Erdek M, et al.. Int J Qual Health Care. 2004 Feb;16(1):59-64.
van Gulik L, et al. Eur J Anaesthesiol. 2010 Oct;27(10):900-5.
Payen JF et al. Anesthesiology. 2009;111:1308-1316
Payen JF, et al. Anesthesiology. 2007;106:687-695.
Chanques G, et al. Crit Care Med. 2006;34(6):1691–9.

17. Guidelines for PADIS 2018 SCCM
Good Practice Statement.
Management of pain for adult ICU patients should be
guided by routine pain assessment and pain should be
treated before a sedative agent is considered.
Recommendation:
We suggest using an assessment-driven, protocol based,
stepwise approach for pain and sedation management in
critically ill adults. CONDITIONAL recommendation, MODERATE quality of evidence.

18. Options for Pain
• Acute painIV Opioids
• Neuropathic pain
Gabapentin
Carbamazepine
• Non-neuropathic pain
NSAIDS
Acetaminophen
Ketamine

19. FENTANYL
 Since fentanyl does not cause histamine release the
SCCM/ACCM recommend fentanyl for analgesia in the
haemodynamically unstable patient.
REMIFENTANIL
 The short duration of action is B/C it is broken down by
nonspecific esterases in plasma. So dose adjustments are
not necessary in renal or hepatic failure.
 Its unique characteristics make it suitable for patients in
whom pain is a limitation for weaning.
Recommendation:
We suggest using an opioid, at the lowest effective dose,
for procedural pain management in critically ill adults.
CONDITIONAL recommendation MODERATE quality of evidence.

20. Recommendation:
 We suggest using acetaminophen as an adjunct to an
opioid to decrease pain intensity and opioid
consumption for pain management in critically ill adults.
CONDITIONAL recommendation, VERY LOW quality of evidence.
 We suggest using low-dose ketamine (0.5 mg/kg IVP x 1
;1–2 μg/kg/hr) as an adjunct to opioid therapy when
seeking to reduce opioid consumption in post-surgical
adults admitted to the ICU. CONDITIONAL recommendation, VERY LOW
quality of evidence.

21. Recommendation:
 We recommend using a neuropathic pain medication
(e.g. gabapentin, carbamazepine, and pregabalin) with
opioids for neuropathic pain management in critically ill
adults. STRONG recommendation, MODERATE quality of evidence.
 We suggest using a neuropathic pain medication (e.g.,
gabapentin, carbamazepine, and pregabalin) with
opioids for pain management in ICU adults after
cardiovascular surgery. CONDITIONAL recommendation, LOW quality of
evidence.
Adjunctive Neuropathic
Pain Medications

22. Recommendation:
 We suggest not routinely using IV lidocaine as an
adjunct to opioid therapy for pain management in
critically ill adults. CONDITIONAL recommendation, LOW quality of evidence.
 We suggest not using either local analgesia or nitrous
oxide for pain management during chest tube removal in
critically ill adults. CONDITIONAL recommendation, LOW quality of evidence.
 We recommend not using inhaled volatile anesthetics
for procedural pain management in critically ill adults.
STRONG recommendation, VERY LOW quality of evidence.

23. Recommendation:
 We suggest using an NSAID administered intravenously,
orally or rectally as an alternative to opioids for pain
management during discrete and infrequent procedures
in critically ill adults CONDITIONAL recommendation, LOW quality of evidence
 We suggest not using an NSAID topical gel for
procedural pain management in critically ill adults
CONDITIONAL recommendation, LOW quality of evidence).
NSAIDs
Only three drugs: acetaminophen, ketorolac, and
ibuprofen are used primarily for pain control in the
early postoperative period. combination with an
opioid analgesic for moderate-to-severe pain.

24. Recommendation:
 We suggest offering massage for pain management in
critically ill adults. CONDITIONAL recommendation, LOW quality of evidence.
 We suggest offering music therapy to relieve both
nonprocedural and procedural pain in critically ill adults.
CONDITIONAL recommendation, LOW quality of evidence.
 We suggest offering cold therapy for procedural pain
management in critically ill adults. CONDITIONAL recommendation,
LOW quality of evidence.
 Remarks: Cold ice packs were applied for 10 min, and wrapped in dressing
gauze, on the area around the chest tube before its removal.
 We suggest offering relaxation techniques for
procedural pain management in critically ill adults.
CONDITIONAL recommendation, VERY LOW quality of evidence.

25. Agitation
“A syndrome of excessive motor activity, usually non-
purposeful and associated with internal tension.”
 Observed in as many as 85% of patients in the ICU.
Reade, Crit Care. 1999;3(3):R35-R46.
Barr, et al. Crit Care Med. 2013;41(1):263-306.
Pain Hypoxia
Withdrawal Hypoglycemia
Delirium Hypotension
Photo: “Lumex Nightmare” by Ralph
Sirianni
Sources

26. Sedation
SedativesCauses for Agitation
Sedation is the process of relieving anxiety and
establishing a state of calm.

27. Respiratory Depression and
Oversedation
 30% respiratory depressions due to sedation:
 > 50% of GI suite cases.
 70% of radiology cases.
 Only 15% of these cases used capnography.
 92% of cases resulted in death or severe hypoxic
brain injury.
Metzner, Julia. Risks of Anesthesia in Remote Locations. ASA Newsletter. Volume 74, Number 2. February 2010
Metzner JL, Posner KL, Domino KB. The risk and safety of anesthesia at remote locations:
The US closed claims analysis. Curr Opin Anaesthesiology. 2009; 22:502‐508..

28. Assessment of Agitation
https://coreem.net, accessed May 19, 2017
Riker, et al. Crit Care Med 1999;27:1325-1329
28

29. Light Versus Deep Sedation
RAAS (-2 to +1)
Time to extubation Associated with shorter time.
 Tracheostomy rate Reduced.
 90 days mortality Not significant.
 Light sedation was not associated with reduction in:
 Delirium (2 RCTs, 140 patients), RR 0.96 (95% CI, 0.80 to 1.16).
 PTSD (2 RCTs, 62 patients), RR 0.67 (95% CI, 0.12 to 3.79).
 Depression (2 RCTs, 128 patients), RR 0.76 (95% CI, 0.10 to 5.58).
Recommendation:
We suggest using light vs. deep sedation in critically
ill, mechanically ventilated adults.
CONDITIONAL recommendation, LOW quality of evidence.

30. Daily Sedation Interruption Decreases Duration
of Mechanical Ventilation
 Hold sedation infusion until
patient awake and then
restart at 50% of the prior
dose.
 “Awake” defined as 3 of the
following 4:
1. Open eyes in response to
voice.
2. Use eyes to follow
investigator on request.
3. Squeeze hand on request.
4. Stick out tongue on request.
Kress JP, et al. N Engl J Med. 2000;342:1471-1477.
Effect of this strategy on outcomes:
 One- to seven-day reduction in length of sedation and MV need.
 50% reduction in tracheostomies.
 Three-fold reduction in the need for diagnostic evaluation of CNS.

31. Options for Sedation
Benzodiazepines
Propofol
Dexmedetomidine
31
Barr, et al. Crit Care Med. 2013;41(1):263-306.

32. Choose the Right Drug
Sedation
Amnesia
Benzodiazepines
Analgesia
AnxiolysisHypnosis
Diazpam, Midazolam and Lorazepam

33. Advantages:
 Benzodiazepines have a dose-dependent amnestic
effect (antegrade amnesia).
 Benzodiazepines have anticonvulsant effects.
 Benzodiazepines are the sedatives of choice for drug
withdrawal syndromes including alcohol, opiate, and
benzodiazepine withdrawal.
Disadvantages:
A. NO analgesia.
B. Drug accumulation with prolonged sedation.
C. The apparent tendency for BZD to promote delirium.
D. Dose dependent respiratory depression.
Benzodiazepines
Midazolam

34. Choose the Right Drug
Sedation Analgesia
Amnesia AnxiolysisHypnosis
Propofol

35. Clinical Effects: Adverse Effects:
Propofol
Sedation.
Hypnosis.
Anxiolysis
Muscle relaxation.
Mild bronchodilation.
Decreased ICP.
Decreased cerebral
metabolic rate.
Antiemetic.
Pain on injection.
 Respiratory depression.
Hypotension.
 Decreased myocardial
contractility.
 Increased serum triglycerides
 Tolerance.
Propofol infusion syndrome.
 Prolonged effect with high
adiposity.
Not analgesia!
 Can be used for intractable seizures and elevated ICP.
Don’t give Propofol >4mg/kg/h for >7 days.

36. Ketamine
 Acts by stimulation of NMDA receptors.
 Provides analgesia + amnestic + sedative effects.
 Preserves respiratory drive - "awake" intubation.
 Bronchodilator – used to treat severe acute asthma.
 Beneficial effects on stunned myocardium.
 Ketamine 0.5 – 1 mg / kg / hour in Refractory S E.
 Generally not used because Releases catecholamine's –
Positive inotropic, Induce VC, Inhibits end NO
myocardial O2 demand and intracranial pressure (ICP).
 Produces nightmares so combine with benzodiazepines.
 INDICATION: Intubation in SHOCK and ASTHAMA.

37. Dexmedetomidine
 Has been shown to decrease the need for other sedation in
postoperative ICU patients.
 Benefits:
 Does not cause respiratory depression.
 Short- acting Sedation, Analgesia and Anxiolysis.
 Produces sympatholysis which may be advantagous
in certain patients such as postoperative 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.
 Can be used for sedation in both spontaneous
and mechanically ventilated patients.

38. Propofol
Hypertriglyceridemia
CVS depression
Hypotension
2-agonists
 Hypotension
 Bradycardia
 Hypertension
 Secretions
 Dysphoria
 Over sedation
 Delayed awakening/
extubation.
Benzodiazepines
 Hypotension
 Respiratory depression
 Agitation/Confusion
Ketamine
General

39. Cardiac surgery
Choice of Sedative
© Society of Critical Care Medicine.
All rights reserved.
Recommendation:
We suggest using propofol over a benzodiazepine for
sedation in mechanically ventilated adults after cardiac
surgery. CONDITIONAL recommendation, LOW quality of evidence.
Non-cardiac Surgery
Recommendation:
We suggest using either propofol or dexmedetomidine over
benzodiazepines for sedation in critically ill mechanically
ventilated adults. CONDITIONAL recommendation, LOW quality of evidence

40. Choose the Right Drug
Sedation Analgesia
Amnesia AnxiolysisHypnosis
-2 agonistsPrimary
Adjunct
sedation Propofol

41. Choose the Right Drug
Sedation Analgesia
Amnesia AnxiolysisHypnosis
-2 agonistsPrimary
Adjunct
sedation Midazolam

42. Choose the Right Drug
Sedation Analgesia
Amnesia AnxiolysisHypnosis
-2 agonistsPrimary
Adjunct
analgesia Fentanyl

43. Choose the Right Drug
Sedation Analgesia
Amnesia AnxiolysisHypnosis
-2 agonistsPrimary
Adjunct
analgesia
Morphine

44. TAKE HOME MESSAGE

45. 1) Sedation, Analgesia & Paralytics are not a
treatment.
Its just an adjunctive therapy.
3) Use right medications, right dose according to
condition of patients.
It should be confirm by prescribing doctor.
2) Never use Paralytics without sedation &
Analgesia.
Same way never use sedation without analgesia.

46. 4) Dex + Propofol + Cis-Atra ideal combination
but with limitations.
Increase use of Dex & Cis-Atra
Avoid Midazolam as much as possible.
5) Label over infusion pump about medicine,
dosage and preparations.

47. Summary
 Patients must be assessed before moderate sedation.
 Sedation options and risks must be discussed with the
patient and family prior to the procedure.
 Moderate sedation must be given by a qualified
provider.
 Patients must be monitored during sedation.
 Protocol for Pain, Agitation & Delirium Scoring
systems.
 Adequate analgesia for procedures.
 Light sedation is ass with improved clinical outcomes.
 Daily sedation interruption.
 Use non-benzodiazepine sedative.

48. Thank you