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Author: Admin | 2025-04-28
You are here: Home / IBCC / Analgesia and sedation for the critically ill patientCONTENTSspectrum of medications availablePure analgesicsAcetaminophenKetamine, pain-dose ➡️Methocarbamol(Lidocaine)(NSAIDs)Analgosedatives (analgesia > sedation)OpioidsOpioid PCAGabapentinoidsTizanidineSedalgesics (sedation > analgesia)DexmedetomidineClonidineKetamine, high-dose infusion ➡️Pure sedatives Propofol ➡️GuanfacinePhenobarbital ➡️(Melatonin)(Benzodiazepines)(Hydroxyzine)Antipsychotics / anti-agitationButyrophenones (haloperidol & droperidol) ➡️Olanzapine ➡️Quetiapine ➡️Chlorpromazine ➡️Lurasidone ➡️Valproic acid ➡️underlying concepts & construction of regimensGeneral schema for the intubated patientConcept of multi-modal therapyTargeting pain, anxiety, and agitated deliriumDaily sedation interruption?Analgesia for patient on chronic buprenorphine ➡️general schema for the intubated patient(back to contents)links to specific medications listed above:Continuous basal analgesia:AcetaminophenKetamine gttAlpha-2 agonists:DexmedetomidineClonidineGuanfacineTizanidineAntipsychotics:HaloperidolQuetiapineOlanzapinechoice of propofol vs. dexmedetomidine infusion Most patients will require a sedative infusion. The best agents appear to be propofol or dexmedetomidine. There is no solid evidence that either of these agents is superior to the other.Factors which could favor propofol:Anticipated long duration of intubation.Seizures.Elevated intracranial pressure.Need for deep sedation to facilitate ventilator synchrony.Factors which could favor dexmedetomidine:Patient is approaching extubation.Sympathetic overdrive state (e.g., sympathomimetic intoxication, opioid withdrawal).addition of adjunctive agents (e.g., scheduled atypical antipsychotics or oral alpha-2 agonists)Most patients will do fine with a low or moderate dose of propofol or dexmedetomidine – so they will require no additional sedative. However, some patients may benefit from the addition of one or more basal sedative agents. The role of basal agents may include:(1) In some cases, these are required to achieve control of refractory agitation.(2) More commonly, basal agents may be used to reduce the required dose of propofol or dexmedetomidine. Decreasing the dose of propofol or dexmedetomidine may avoid problems with these agents (e.g., hemodynamic instability, propofol infusion syndrome, or dexmedetomidine tolerance/withdrawal).⚠️ Basal adjunctive sedatives are not readily titratable, so these cannot be immediately stopped when the patient is ready for extubation. Consequently, low doses of basal sedatives should usually be used (doses that wouldn't compromise respiration or airway protection). Using excessively high doses of basal sedation which may delay extubation.refractory pain/agitation:Valproic acid may be useful for refractory agitation.Dissociative ketamine infusion: If all else fails, then another option is a dissociative-dose ketamine infusion (e.g., 1-5 mg/kg/hour). (33068459) This may be necessary for patients with profound hypotension, which limits the ability to give sedatives (e.g., propofol, alpha-2 agonists, or phenobarbital). After the patient is fully dissociated with ketamine, other sedatives and analgesics should be discontinued.acetaminophen(back to contents)dose 💊Most patients: 650-1,000 mg q6hr (up to 4 grams/day).Severe alcoholism, stable cirrhosis, or weight (25477978)Avoid entirely in:Acute liver injury or decompensated cirrhosis.Neutropenia (may blunt detection of a neutropenic fever).For patients with ongoing pain this should be scheduled, to provide a baseline level of analgesia.Acetaminophen may be given PO, PR, or IV. PO is preferred, because IV is expensive (although this varies in different countries).Available RCTs have found no difference in efficacy between IV versus oral route.indications/advantages Acetaminophen is a mild-moderately effective analgesic with an outstanding safety profile. It forms the first level of the analgesic ladder due to its safety, rather than its efficacy. Acetaminophen is often overlooked because it isn't very potent. However, scheduled acetaminophen may nonetheless play a useful role in multi-modal analgesia.
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