Sedation assessment in critically ill adults.

OBJECTIVE: To review methods for assessing sedation in critically ill adults, discuss their impact on patient outcomes, and provide recommendations for implementing these methods into clinical practice in the intensive care unit (ICU). DATA SOURCES: A computerized search of MEDLINE from 1980 through June 2000 and a manual search of abstracts presented at recent critical care meetings were performed. STUDY SELECTION AND DATA EXTRACTION: Sedation assessment tools that have been used to titrate therapy in adult, critically ill patients were identified. Special emphasis was placed on sedation assessment instruments that have been prospectively validated. Objective methods that have been used to assess sedation therapy were also identified. DATA SYNTHESIS: Twenty-three adult sedation assessment instruments were identified. Few scales have been prospectively evaluated for validity (n = 6) or reliability (n = 7). Other methods of sedation assessment were identified (e.g., bispectral index monitor); however, most of these methods have only been studied in small subsets of critically ill patients. CONCLUSIONS: Incorporation of sedation assessment into ICU clinical practice may improve patient care. These sedation assessment instruments must be further evaluated to determine their impact on quality of care and ICU length of stay.     

Pain management

Postoperative pain management in the critically ill patient is a challenge for nurses. Knowing the basis of pain transmission and mechanisms of action of interventions can assist the critical care nurse in making clinical decisions regarding pain control for individual patients. There are a number of modalities available to treat postoperative pain including both pharmacologic and nonpharmacologic interventions. Techniques such as PCA not only can provide good analgesia, but allow the critically ill patient at least one aspect of control in the otherwise highly controlled environment of the critical care unit. Epidural or intrathecal analgesia, using either opioids or LAAs alone or in combination, provides excellent analgesic effect (with minimal side effects) and may improve patient outcomes. Nonpharmacologic techniques, unfortunately, are commonly overlooked as adjuncts to traditional analgesia routines because of the nature of the illness in the critically ill patient. Nonpharmacologic techniques of pain management have a place in the care of the critically ill when applied based on the assessment of an individual patient's needs and abilities to participate in his or her care. Ensuring optimal patient comfort can benefit critically ill patients and improve clinical outcomes.     

Critical care of the bariatric patient

OBJECTIVE: To synthesize the current literature on care of obese, critically ill, and bariatric surgical patients. DATA SOURCE: A MEDLINE/PubMed search from 1966 to August 2005 was conducted using the search terms obesity, bariatric surgery, and critical illness, and a search of the Cochrane Library was also conducted. DATA EXTRACTION AND SYNTHESIS: An increase in both the prevalence of obesity and the number of bariatric procedures performed has resulted in an increased number of obese and, specifically, bariatric surgical patients who require intensive care unit care. Obesity is a chronic inflammatory state with resultant effects on immune, metabolic, respiratory, cardiovascular, gastrointestinal, hematologic, and renal function. Principles of care of the critically ill obese patient are reviewed and then applied to critically ill bariatric surgical patients. Pharmacotherapy, vascular access, and the presentation and management of both pressure-induced rhabdomyolysis and anastomotic failure after bariatric surgery are also reviewed. CONCLUSIONS: Obesity causes a range of pathologic effects on all major organ systems. Knowledge of these effects and issues specific to the intensive care unit care of bariatric patients can help to predict and manage complications in this population.     

Sedation in the intensive care unit

OBJECTIVE: To describe the goals of sedative use in the intensive care unit and review the pharmacology of commonly used sedative drugs as well as to review pertinent publications in the literature concerning the comparative pharmacology of these drugs, with emphasis on outcomes related to sedation and comparative pharmacoeconomics. DATA SOURCES: Publications in the scientific literature. DATA EXTRACTION: Computer search of the literature with selection of representative articles. SYNTHESIS: Proper choice and use of sedative drugs is based on knowledge of the pharmacology of commonly used agents and is an essential component of caring for patients in the intensive care unit. The large variability in pharmacokinetics and pharmacodynamics in the critically ill make it difficult to directly compare agents. Midazolam provides rapid and reliable amnesia, even when administered for low levels of sedation. Propofol may be useful when deeper levels of sedation and more rapid awakening are required. Lorazepam can be used for long-term sedation in more stable patients if rapidity of effect is not required. Further investigation in assessment of depth of sedation in the critically ill is needed. Continued study of costs, side effects, and appropriate dosing strategies of all sedative agents is needed to answer questions not sufficiently addressed in the current literature. Conclusion: An individualized approach to sedation based on knowledge of drug pharmacology is needed because of confounding variables including concurrent patient illness, depth of sedation, and concomitant use of analgesic agents. (Crit Care Med 2000; 28:854-866) KEY WORDS: sedation; anxiolysis; critical care; midazolam; lorazepam; propofol; benzodiazepines; intensive care unit; pharmacoeconomics; critical illness     

Proton-pump inhibitors for stress ulcer prophylaxis in critically ill patients

OBJECTIVE: To evaluate the use of proton-pump inhibitors (PPIs) for stress ulcer prophylaxis in critically ill adults. DATA SOURCES: Computerized biomedical literature search of MEDLINE (1966-June 2002) was conducted using the MeSH headings proton-pump inhibitor, ulcer, critical care, and acid. References of selected articles were reviewed. A manual search of critical care, surgery, trauma, gastrointestinal, and pharmacy journals was conducted to identify relevant abstracts. DATA SYNTHESIS: Traditional medications used for stress ulcer prophylaxis include antacids, histamine(2) receptor antagonists (H(2)RAs), and sucralfate. Few studies have evaluated PPIs for stress ulcer prophylaxis. The majority of studies have demonstrated that enteral or intravenous administration of PPIs to critically ill patients elevates intragastric pH and consistently maintains pH > or =4.0. PPIs are safe and seem to be as efficacious as H(2)RAs or sucralfate for prevention of bleeding from stress-related mucosal damage (SRMD) and they may provide cost minimization. The small patient populations limit the results of comparative studies. CONCLUSIONS: Available data indicate that PPIs are safe and efficacious for elevating intragastric pH in critically ill patients. PPIs should be used only as an alternative to H(2)RAs or sucralfate since the superiority of PPIs over these agents for preventing SRMD-associated gastrointestinal bleeding has not been established. Additional comparative studies with adequate patient numbers and pharmacoeconomic analyses are needed before PPIs are considered the agents of choice for stress ulcer prophylaxis.     

Sedation assessment in critically ill adults: 2001-2004 update

OBJECTIVE: To review recently published literature on the validity and reliability of sedation assessment tools in critically ill adults and evaluate the potential advantages and disadvantages of each. DATA SOURCES: A computerized search of MEDLINE and PubMed (2001-May 2004) was conducted. STUDY SELECTION AND DATA EXTRACTION: Sedation assessment tools used in adult intensive care units (ICUs) were identified. DATA SYNTHESIS: Six subjective and 3 objective assessment tools were identified. Four subjective assessment tools have reliability and 4 have validity data published that were not previously available. There are reliability data to further support the use of the previously published Motor Activity Assessment Scale. Additional reliability data exist for the Ramsay Scale and Glasgow Coma Scale. Conflicting evidence is available with the use of the Bispectral Index monitor in the ICU. Recently, the Patient State Index and Auditory Evoked Potentials were introduced for objective monitoring in critically ill patients. CONCLUSIONS: Increasing data on sedation assessment were published over the last few years, probably in response to supporting evidence that goal-driven sedation therapy improves patient outcomes. Reliability and/or validity testing exists for many of these scales. Several useful tools are available to guide sedation therapy in critically ill patients.     

Intensive insulin therapy for critically ill patients

OBJECTIVE: To evaluate the clinical outcomes of glycemic control of intensive insulin therapy and recommend its place in the management of critically ill patients. DATA SOURCES: Searches of MEDLINE (1966-March 2004) and Cochrane Library, as well as an extensive manual review of abstracts were performed using the key search terms hyperglycemia, insulin, intensive care unit, critically ill, outcomes, and guidelines and algorithms. STUDY SELECTION AND DATA EXTRACTION: All articles identified from the data sources were evaluated and deemed relevant if they included and assessed clinical outcomes. DATA SYNTHESIS: Mortality among patients with prolonged critical illness exceeds 20%, and most deaths are attributable to sepsis and multisystem organ failure. Hyperglycemia is common in critically ill patients, even in those with no history of diabetes mellitus. Maintaining normoglycemia with insulin in critically ill patients has been shown to improve neurologic, cardiovascular, and infectious outcomes. Most importantly, morbidity and mortality are reduced with aggressive insulin therapy. This information can be implemented into protocols to maintain strict control of glucose. CONCLUSIONS: Use of insulin protocols in critically ill patients improves blood glucose control and reduces morbidity and mortality in critically ill populations. Glucose levels in critically ill patients should be controlled through implementation of insulin protocols with the goal to achieve normoglycemia, regardless of a history of diabetes. Frequent monitoring is imperative to avoid hypoglycemia.     

Pain: advances and issues in critical care

The milieu of the critical care unit is stressful for both the patient and health care professionals. As such, it has the potential to increase pain perception in patients, and decrease the nurse's awareness of pain relief needs of the patient. Several physical and pharmacologic methods of pain relief were discussed in this article. Nontechnologic analgesia such as hypnosis and relaxation were introduced as adjuncts or alternatives to more familiar methods of pain relief. Although critically ill patients are not always able to express their discomfort, it is the responsibility of the nurse to recognize the potential for pain, and plan treatment accordingly. This article suggests several strategies for dealing with pain in critically ill patients.     

Clinical uses and controversies of neuromuscular blocking agents in infants and children.

OBJECTIVE: To review the pharmacology of neuromuscular blocking drugs (NMBDs), their use in critically ill or injured infants and children, and the relevance of developmental changes in neuromuscular transmission. DATA SOURCES: Computerized search of the medical literature. STUDY SELECTION: Studies specifically examining the following were reviewed: a) the developmental changes in neuromuscular transmission; b) the pharmacokinetics and pharmacodynamics of all clinically available NMBDs in neonates, infants, children, and adults; and c) clinical experience with NMBDs in the critical care setting. Particular attention was directed toward studies in the pediatric population. DATA SYNTHESIS: Neuromuscular transmission undergoes maturational changes during the first 2 months of life. Alterations in body composition and organ function affect the pharmacokinetics and pharmacodynamics of the NMBDs throughout active growth and development. Numerous NMBDs have been developed during the last two decades with unique pharmacologic profiles and potential clinical advantages. The NMBDs are routinely used in critically ill or injured patients of all ages. This widespread use is associated with rare but significant clinical complications, such as prolonged weakness. CONCLUSIONS: Significant gaps in our knowledge of the pharmacokinetics and pharmacodynamics of NMBDs in infants and children continue to exist. Alterations in electrolyte balance and organ-specific drug metabolism may contribute to complications with the use of NMBDs in the critical care arena.     

A review and analysis of intensive care medicine in the least developed countries

OBJECTIVE: To give critical care clinicians in Western nations a general overview of intensive care medicine in less developed countries and to stimulate institutional or personal initiatives to improve critical care services in the least developed countries. DATA SOURCE: In-depth PubMed search and personal experience of the authors. DATA SYNTHESIS: In view of the eminent burden of disease, prevalence of critically ill patients in the least developed countries is disproportionately high. Despite fundamental logistic (water, electricity, oxygen supply, medical technical equipment, drugs) and financial limitations, intensive care medicine has become a discipline of its own in most nations. Today, many district and regional hospitals have units where severely ill patients are separately cared for, although major intensive care units are only found in large hospitals of urban or metropolitan areas. High workload, low wages, and a high risk of occupational infections with either the human immunodeficiency virus or a hepatitis virus explain burnout syndromes and low motivation in some health care workers. The four most common admission criteria to intensive care units in least developed countries are postsurgical treatment, infectious diseases, trauma, and peripartum maternal or neonatal complications. Logistic and financial limitations, as well as insufficiencies of supporting disciplines (e.g., laboratories, radiology, surgery), poor general health status of patients, and in many cases delayed presentation of severely sick patients to the intensive care unit, contribute to comparably high mortality rates. CONCLUSION: More studies on the current state of intensive care medicine in least developed countries are needed to provide reasonable aid to improve care of the most severely ill patients in the poorest countries of the world.     

Guidelines on critical care services and personnel: Recommendations based on a system of categorization of three levels of care

OBJECTIVES: To describe three levels of hospital-based critical care centers to optimally match services and personnel with community needs, and to recommend essential intensive care unit services and personnel for each critical care level. PARTICIPANTS: A multidisciplinary writing panel of professionals with expertise in the clinical practice of critical care medicine working under the direction of the American College of Critical Care Medicine (ACCM). DATA SOURCES AND SYNTHESIS: Relevant medical literature was accessed through a systematic Medline search and synthesized by the ACCM writing panel, a multidisciplinary group of critical care experts. Consensus for the final written document was reached through collaboration in meetings and through electronic communication modalities. Literature cited included previously written guidelines from the ACCM, published expert opinion and statements from official organizations, published review articles, and nonrandomized, historical cohort investigations. With this background, the ACCM writing panel described a three-tiered system of intensive care units determined by service-based criteria. CONCLUSIONS: Guidelines for optimal intensive care unit services and personnel for hospitals with varying resources will facilitate both local and regional delivery of consistent and excellent care to critically ill patients.     

A review of objective pain measures for use with critical care adult patients unable to self-report.

Critically ill patients experience significant levels of pain and discomfort from multiple intrinsic and extrinsic sources while in the intensive care unit (ICU). The use of objective pain measures in nonverbal patients is an essential alternative approach for pain assessment when self-reports are unavailable. This paper provides a critical review of the psychometric properties of 6 objective pain measures that were developed to assess pain in nonverbal adult patients in the ICU. The strengths and weaknesses of these objective measures are evaluated, as well as their applicability for use with this patient population. Although 2 of the 6 objective pain measures showed good evidence of validity and reliability, none has undergone vigorous validation or has been accepted as a standardized measure. Findings from the available studies of objective pain measures provide useful information to direct future research to develop and validate clinically useful pain measures for use with critically ill patients unable to self-report. PERSPECTIVE: This review provides clinicians with a summary of the psychometric properties of 6 objective pain measures and discusses their applicability for use to assess pain in critically ill adult patients unable to self-report.     

Use of epoetin alfa in critically ill patients

OBJECTIVE: To discuss the controversies regarding the use of epoetin alfa (EPO) for reducing red blood cell (RBC) transfusions in critically ill patients with anemia. DATA SOURCES: A MEDLINE search (1966-July 2003) was conducted using the search terms anemia; critical illness; erythropoietin; epoetin alfa; and erythropoietin, recombinant. References of selected articles were reviewed for studies that may have been missed by the computerized search. STUDY SELECTION AND DATA EXTRACTION: Studies pertaining to the use of EPO for anemia of critical illness with an emphasis on data obtained from controlled trials. DATA SYNTHESIS: Anemia is a common complication in patients admitted to the intensive care unit (ICU). Two prospective, randomized studies have demonstrated decreased transfusion requirements associated with EPO administration in medical/surgical patients who were in the ICU for at least 3 days and had hematocrit concentrations <38%. No differences were found in length of stay or mortality. A multicenter trial found that a restrictive strategy of RBC transfusion (hemoglobin goal 7-9 g/dL) was associated with in-hospital mortality lower than that with a more liberal approach, which calls into question the 38% hematocrit goal in the EPO trials. Furthermore, preliminary results from an economic analysis of EPO use in the ICU setting have demonstrated that EPO is not cost-effective. CONCLUSIONS: Given the controversies surrounding EPO administration in critically ill patients, institutions are encouraged to develop EPO guidelines to help ensure the most appropriate use of this expensive product. Additional studies regarding patients most likely to benefit from EPO therapy, the most effective dosing regimen, and use of adjunctive therapies are needed.     

Sedation and paralysis during mechanical ventilation

Treatment of anxiety and delirium, provision of adequate analgesia, and, when necessary, amnesia in critically ill patients is humane and may reduce the incidence of post-traumatic stress disorders. Injudicious use of sedatives and paralytics to produce a passive and motionless patient, however, may prolong weaning and length of stay in the intensive care unit. This report reviews indications and choices for pharmacologic treatment of anxiety, delirium, agitation, and provision of anesthesia in critically ill patients. The choice of pharmacologic agents is made difficult by complex or poorly understood pharmacokinetics, drug actions, and adverse effects in critically ill patients. Advantages, adverse effects, and limitations of drug treatment, including use of neuromuscular blocking drugs and use of sedatives and analgesia during the withdrawal of life-sustaining measures are reviewed.     

Use of patient-controlled analgesia with critically ill patients: a risk/benefit analysis.

Patient-controlled analgesia (PCA), a system by which patients self-administer intravenous doses of narcotics using specially programmed infusion pumps, has been used for pain management in acute care settings for nearly two decades. The safety and effectiveness of PCA has been documented in many acutely ill patient populations. Its introduction into critical care practice in the last five years has provided an important adjunct to traditional methods of pain management. However, intravenous narcotics of any type can provoke hemodynamic or respiratory complications in these compromised patients. Nursing expertise is a key factor in the successful implementation of PCA in critically ill patients.     

Continuous subcutaneous infusion of opiates at end-of-life

OBJECTIVE: To review pertinent controlled trials using the continuous subcutaneous infusion of opioids (CSIO) at end-of-life and offer insight to pharmacists and clinicians into the appropriate use of this route of administration. DATA SOURCES: A MEDLINE search for information regarding the subcutaneous administration of opioids in terminally ill patients (1975-December 2002) was conducted using the key words subcutaneous, narcotics, morphine, hydromorphone, fentanyl, pain, hospices, and palliative care. Additional references were located through review of bibliographies of the articles cited. Case reports and postsurgical studies were excluded. Searches were limited to English-language studies using humans. STUDY SELECTION AND DATA EXTRACTION: Experimental and observational studies were evaluated, using prospective trials as the evidence base for conclusions and including pertinent retrospective trials as they relate to the subcutaneous infusion of opioids at end-of-life. DATA SYNTHESIS: CSIO is effective and safe for use in terminal illness. Appropriate situations for consideration of CSIO are when difficulties arise in using the oral route, standard oral opiate therapy has failed adequate trials, the patient has limited intravenous access, adequate supervision of the CSIO is present, and CSIO will not unduly limit the functional activity of the patient. CONCLUSIONS: CSIO has a proven role in the management of pain at end-of-life. CSIO should not be considered the first route for administration of opiates, but does offer distinct advantages in the appropriate setting. CSIO continues to be a choice for end-of-life patients and is gradually becoming a standard practice in palliative medicine.     

Updates in Pediatric Regional Anesthesia and Its Role in the Treatment of Acute Pain in the Ambulatory Setting

Purpose of Review

The purpose of this review is to summarize the latest advances in pediatric regional anesthesia with special emphasis on its role in the ambulatory surgical setting.

Recent Findings

Undertreated pain in children following ambulatory surgery is not a rare occurrence and it is associated with increased morbidity and significant psychosocial harm. Use of regional anesthesia as part of the anesthetic approach in the ambulatory setting is safe when performed on children under general anesthesia and inclusion of certain adjuncts improves block outcomes. Ultrasonographic visualization during blockade improves safety and prolongs duration. Ambulatory continuous nerve blocks in older children are safe, efficacious, and associated with high patient and caregiver satisfaction rates.

Summary

In the ever-growing field of pediatric same-day surgery, safe and efficient flow through the perioperative period necessitates use of a multimodal approach, of which regional anesthesia is but one important component. Perioperative complications are minimized with less opioid use, and yet appropriate pain management must be ensured. Pediatric regional anesthesia has been shown to be exceedingly safe under general anesthesia. Findings demonstrate that advances in ultrasound technology have contributed to safer and longer-lasting analgesia. It facilitates the development of new methods by which regional anesthesia can improve postoperative analgesia in children upon discharge and beyond.

     

Perioperative Management in Reverse Total Shoulder Arthroplasty

Purpose of ReviewA successful reverse total shoulder arthroplasty requires careful preoperative planning and perioperative management. Preoperative comorbidity risks, perioperative pain management, and postoperative rehabilitation are all critical components of this arthroplasty. The current review examines available literature to guide the perioperative care of the reverse total shoulder arthroplasty patient.Recent FindingsOne of the most important advances for shoulder arthroplasty in recent years has been heightened awareness of various modalities for perioperative pain management. A number of recent studies have focused on the options for regional blockade as a critical tool for postoperative pain relief and the use of either continuous interscalene blocks or single shot blocks are supported. Additional studies are necessary to define the best local anesthetic agent and delivery mechanism to provide appropriate pain relief with a low side effect profile.SummaryManagement of the patient throughout the perioperative course is a critical component in achieving better patient outcomes delivering high quality patient care. An orthopedic surgery team focused on perioperative management is better positioned to decrease adverse events and improve patient outcomes after reverse total shoulder arthroplasty.