Abstract

In the critically ill patient, optimal pain and sedation management remains the cornerstone of achieving comfort, safety, and to facilitate complex life support interventions. Pain relief, using multimodal analgesia, is an integral component of any orchestrated approach to achieve clinically appropriate goals in critically ill patients. Sedative management, however, remains a significant challenge. Subsequent studies including most recent randomized trials have failed to provide strong evidence in favor of a sedative agent, a mode of sedation or ancillary protocols such as sedative interruption and sedative minimization. In addition, clinical practice guidelines, despite a comprehensive evaluation of relevant literature, have limitations when applied to individual patients. These limitations have been most apparent during the coronavirus disease 2019 pandemic. As such, there is a need for a mindset shift to a practical and achievable sedation strategy, driven by patients' characteristics and individual patient needs, rather than one cocktail for all patients. In this review, we present key principles to achieve patient-and symptom-oriented optimal analgesia and sedation in the critically ill patients. Sedative intensity should be proportionate to care complexity with due consideration to an individual patient's modifiers. The use of multimodal analgesics, sedatives, and antipsychotics agents—that are easily titratable—reduces the overall quantum of sedatives and opioids, and reduces the risk of adverse events while maximizing clinical benefits. In addition, critical considerations regarding the choice of sedative agents should be given to factors such as age, medical versus operative diagnosis, and cardiovascular status. Specific populations such as trauma, neurological injury, and pregnancy should also be taken into account to maximize efficacy and reduce adverse events.

Publication History

Publication Date:
21 September 2020 (online)

© 2020. Thieme. All rights reserved.

Thieme Medical Publishers
333 Seventh Avenue, New York, NY 10001, USA.

中文翻译：

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最佳镇静和镇痛管理：以患者和症状为导向的范例。

摘要

对于重症患者，最佳的疼痛和镇静管理仍然是获得舒适，安全并促进复杂的生命支持干预措施的基石。使用多模式镇痛的疼痛缓解是任何精心设计的方法中不可或缺的组成部分，可在危重患者中实现临床上适当的目标。但是，镇静剂管理仍然是一项重大挑战。随后的研究（包括最新的随机试验）未能提供强有力的证据来支持镇静剂，镇静方式或辅助方案，如镇静干扰和镇静作用最小化。此外，尽管对相关文献进行了综合评估，但临床实践指南在应用于个体患者时仍存在局限性。这些限制在2019年冠状病毒疾病大流行期间最为明显。因此，需要根据患者的特征和患者的个性化需求，而不是为所有患者提供一种鸡尾酒，将思维定势转向实用且可实现的镇静策略。在这篇综述中，我们提出了在重症患者中实现以患者和症状为导向的最佳镇痛和镇静作用的关键原则。镇静强度应与护理复杂程度成正比，并应适当考虑个别患者的修饰剂。易于滴定的多峰镇痛药，镇静剂和抗精神病药的使用减少了镇静剂和阿片类药物的总量，并减少了不良事件的风险，同时使临床获益最大化。此外，在选择镇静剂时，应考虑一些关键因素，例如年龄，医学诊断与手术诊断以及心血管状况。还应考虑特定人群，例如创伤，神经系统损伤和妊娠，以最大程度地发挥功效并减少不良事件。

出版历史

出版日期：
2020年9月21日（在线）

©2020年。Thieme。版权所有。

美国纽约第七大道333号Thieme Medical Publishers ，美国纽约。