Analgesia, sedation, and paralysis

The recent evolution of critical care management has emphasized the need to minimize continuous deep sedation and paralysis to improve outcome and decrease length of stay in the intensive care unit (ICU). This recommendation is especially important in patients with neurologic dysfunction. In this sense, sedative regimens in the neurologic ICU have been well ahead of general ICU doctrine. One of the primary tenets of care of these patients is the capacity to perform repeated neurologic exams as the optimal means of assessing the patients’ condition. With respect to bedside evaluation and titration of sedation, the neurologically injured patient may indeed be the most difficult ICU population to manage. Cognitive dysfunction leads to increased fear, restlessness, and agitation from the inability to understand one's predicament. Yet even modest sedation may mask subtle neurologic deterioration, hence the need for close nursing and physician support and observation, and titrating medications as needed without impairing neurologic evaluation. Patients with traumatic brain injury (TBI) constitute the hallmark brain disorder when discussing difficult sedation paradigms. They are often agitated and at risk of injury to self or the medical staff caring for them. Many TBI patients are also withdrawing from chronic alcohol and drug use, and this must be factored into the choice and duration of sedation.SEDATION Indications for Sedation Before initiation of sedation in any ICU patient, it is imperative to exclude all alternative explanations for agitation, confusion, or sympathetic hyperactivity.