Sedation & Pain Management PDF

Sedation &pain management By Dr/ Roeya Mahmoud Aboelnasr Gadallah Lecturer of Emergency Medicine & traumatology Faculty of Medicine-Tanta University  Light sedation & management of pain in ICU patients should be implemented to avoid complications and conflicts with other management goal...

Sedation &pain management By Dr/ Roeya Mahmoud Aboelnasr Gadallah Lecturer of Emergency Medicine & traumatology Faculty of Medicine-Tanta University  Light sedation & management of pain in ICU patients should be implemented to avoid complications and conflicts with other management goals e.g. weaning from mechanical ventilation and early mobilisation. Pain 1. Use validated scales to monitor pain i.e. Behavioral Pain Score (BPS) or Critical Care Pain Observational Tool (CPOT) in the unconscious, and Visual Analogue Score (VAS) in the conscious patients. 2. Assess pain at least 4 hourly. 3. Institute pain management when pain score is: a. ≥ 5 for BPS b. ≥ 3 for CPOT c. ≥ 3 for VAS 4. Opioid based analgesia remains the mainstay of pain management. 5. Consider adjuncts to an opioid to reduce the dose of opioid and/or reduce severity of pain. a. Paracetamol either administered intravenously, orally or per rectal b. IV ketamine in post-surgical patients 6. Patient-controlled analgesia (PCA) can be provided for awake and cooperative patients. 7. Use an analgesic prior to a procedure that may cause pain, with the lowest effective dose possible and timed so that the peak effect coincides with the procedure. 8. Use gabapentin or carbamazepine with opioids for neuropathic pain e.g. Guillain- Barré syndrome. 9. Consider regional analgesia in selected surgical or trauma patients e.g. thoracic epidural analgesia in post-operative abdominal aortic aneurysm surgery or traumatic rib fractures. Sedation 1. Assess sedation every 4 hours. 2. Aim for light sedation, with patient being awake, calm and comfortable. 3. Use analgesia-first sedatives (morphine or fentanyl) in mechanically ventilated patients. 4. If additional sedatives are required, a. non-benzodiazepines (propofol or dexmedetomidine) are preferred over benzodiazepines due to lower incidence of delirium. If propofol or dexmedetomidine is used, consider patient’s haemodynamic status, anticipated duration of sedation, drug availability and cost. b. in haemodynamically unstable patient, either: i. add intravenous midazolam - initiate at 1 mg/hr and titrate by 1 mg/hr every 30 minutes to achieve sedation goal. ii. use “high” dose fentanyl alone - initiate at 50 mcg/hr and titrate by 25 mcg/hr every 15 minutes. Maximum 500 mcg/hr. 5. Aim for deep sedation in the following patients: a. head injury on cerebral protection b. post cardiac arrest care c. on high vasopressors or inotropes d. on high ventilatory settings e. prone position f. massive pulmonary haemorrhage g. severe bronchial asthma h. tetanus i. on neuromuscular blocking agent 6. If deep sedation is required, add either intravenous infusion of midazolam or propofol or both. 7. Reassess daily need for deep sedation and wean sedatives when no longer required. 8. Consider dexmedetomidine in patients who are unable to wean off the ventilator due to agitated delirium. 9. Use benzodiazepines to provide amnesia for procedures or in patients with anxiety, seizures, alcohol withdrawal or palliation.