Sedation practices in the Neurocritical Care Unit

INTRODUCTION

Neurologically injured patients often require sedation for

• Facilitating endotracheal intubation and mechanical ventilation

• Management of intracranial hypertension

• Control of pain, anxiety and distress (PAD).

The goal of sedation in these circumstances is to produce a reproducible neurological examination in a calm, cooperative patient, with maintenance of adequate cerebral perfusion pressure (CPP) while limiting intracranial pressure (ICP).

This study is written to promote understanding of sedation practices in the Neurocritical Care Unit and to provide the readers a basic knowledge of principles of sedation.

• REFERENCES

• 1 Morita T, Tsuneto S, Shima Y. Definition of sedation for symptom relief: A systematic literature review and a proposal of operational criteria. J Pain Symptom Manage 2002; 24: 447-53
• 2 Le T. Sedation and pain management in intensive care. 7th ed.. Elsevier; 2014
• 3 Devabhakthuni S, Armahizer MJ, Dasta JF, Kane-Gill SL. Analgosedation: A paradigm shift in intensive care unit sedation practice. Ann Pharmacother 2012; 46: 530-40
• 4 Skoglund K, Enblad P, Marklund N. Monitoring and sedation differences in the management of severe head injury and subarachnoid hemorrhage among neurocritical care centers. J Neurosci Nurs 2013; 45: 360-8
• 5 Kress JP, Pohlman AS, O'Connor MF, Hall JB. Daily interruption of sedative infusions in critically ill patients undergoing mechanical ventilation. N Engl J Med 2000; 342: 1471-7
• 6 Burry L, Rose L, McCullagh IJ, Fergusson DA, Ferguson ND, Mehta S. Daily sedation interruption versus no daily sedation interruption for critically ill adult patients requiring invasive mechanical ventilation. Cochrane Database Syst Rev 2014; 7: CD009176
• 7 Skoglund K, Enblad P, Marklund N. Effects of the neurological wake-up test on intracranial pressure and cerebral perfusion pressure in brain-injured patients. Neurocrit Care 2009; 11: 135-42
• 8 Skoglund K, Hillered L, Purins K, Tsitsopoulos PP, Flygt J, Engquist H. et al. The neurological wake-up test does not alter cerebral energy metabolism and oxygenation in patients with severe traumatic brain injury. Neurocrit Care 2014; 20: 413-26
• 9 Ramsay MA, Savege TM, Simpson BR, Goodwin R. Controlled sedation with alphaxalone-alphadolone. Br Med J 1974; 2: 656-9
• 10 Chernik DA, Gillings D, Laine H, Hendler J, Silver JM, Davidson AB. et al. Validity and reliability of the Observer's Assessment of Alertness/Sedation Scale: Study with intravenous midazolam. J Clin Psychopharmacol 1990; 10: 244-51
• 11 Riker RR, Picard JT, Fraser GL. Prospective evaluation of the Sedation-Agitation Scale for adult critically ill patients. Crit Care Med 1999; 27: 1325-9
• 12 Devlin JW, Boleski G, Mlynarek M, Nerenz DR, Peterson E, Jankowski M. et al. Motor Activity Assessment Scale: A valid and reliable sedation scale for use with mechanically ventilated patients in an adult surgical intensive care unit. Crit Care Med 1999; 27: 1271-5
• 13 Weinert C, McFarland L. The state of intubated ICU patients: Development of a two-dimensional sedation rating scale for critically ill adults. Chest 2004; 126: 1883-90
• 14 de Lemos J, Tweeddale M, Chittock D. Measuring quality of sedation in adult mechanically ventilated critically ill patients. the Vancouver Interaction and Calmness Scale. Sedation Focus Group. J Clin Epidemiol 2000; 53: 908-19
• 15 Avripas MB, Smythe MA, Carr A, Begle RL, Johnson MH, Erb DR. Development of an intensive care unit bedside sedation scale. Ann Pharmacother 2001; 35: 262-3
• 16 Sessler CN, Gosnell MS, Grap MJ, Brophy GM, O'Neal PV, Keane KA. et al. The Richmond Agitation-Sedation Scale: Validity and reliability in adult intensive care unit patients. Am J Respir Crit Care Med 2002; 166: 1338-44
• 17 De Jonghe B, Cook D, Griffith L, Appere-de-Vecchi C, Guyatt G, Théron V. et al. Adaptation to the Intensive Care Environment (ATICE): Development and validation of a new sedation assessment instrument. Crit Care Med 2003; 31: 2344-54
• 18 Mirski MA, LeDroux SN, Lewin 3^rd JJ, Thompson CB, Mirski KT, Griswold M. Validity and reliability of an intuitive conscious sedation scoring tool: The nursing instrument for the communication of sedation. Crit Care Med 2010; 38: 1674-84
• 19 Barr J, Fraser GL, Puntillo K, Ely EW, Gélinas C, Dasta JF. et al. Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit. Crit Care Med 2013; 41: 263-306
• 20 Nasraway Jr. SS, Wu EC, Kelleher RM, Yasuda CM, Donnelly AM. How reliable is the Bispectral Index in critically ill patients? A prospective, comparative, single-blinded observer study. Crit Care Med 2002; 30: 1483-7
• 21 Tonner PH, Wei C, Bein B, Weiler N, Paris A, Scholz J. Comparison of two bispectral index algorithms in monitoring sedation in postoperative intensive care patients. Crit Care Med 2005; 33: 580-4
• 22 Vivien B, Di Maria S, Ouattara A, Langeron O, Coriat P, Riou B. Overestimation of Bispectral Index in sedated intensive care unit patients revealed by administration of muscle relaxant. Anesthesiology 2003; 99: 9-17
• 23 Schuller PJ, Newell S, Strickland PA, Barry JJ. Response of bispectral index to neuromuscular block in awake volunteers. Br J Anaesth 2015; 115 Suppl (Suppl. 01) I95-103
• 24 Messner M, Beese U, Romstöck J, Dinkel M, Tschaikowsky K. The bispectral index declines during neuromuscular block in fully awake persons. Anesth Analg 2003; 97: 488-91
• 25 Mantz J. Evaluation of the depth of sedation in neurocritical care: Clinical scales, electrophysiological methods and BIS. Ann Fr Anesth Reanim 2004; 23: 535-40
• 26 Page VJ, Ely EW, Gates S, Zhao XB, Alce T, Shintani A. et al. Effect of intravenous haloperidol on the duration of delirium and coma in critically ill patients (Hope-ICU): A randomised, double-blind, placebo-controlled trial. Lancet Respir Med 2013; 1: 515-23
• 27 Al-Qadheeb NS, Skrobik Y, Schumaker G, Pacheco MN, Roberts RJ, Ruthazer RR. et al. Preventing ICU subsyndromal delirium conversion to delirium with low-dose IV haloperidol: A double-blind, placebo-controlled pilot study. Crit Care Med. 2015 [Epub ahead of print].
• 28 Kline AE, Hoffman AN, Cheng JP, Zafonte RD, Massucci JL. Chronic administration of antipsychotics impede behavioral recovery after experimental traumatic brain injury. Neurosci Lett 2008; 448: 263-7
• 29 Phelps TI, Bondi CO, Ahmed RH, Olugbade YT, Kline AE. Divergent long-term consequences of chronic treatment with haloperidol, risperidone, and bromocriptine on traumatic brain injury-induced cognitive deficits. J Neurotrauma 2015; 32: 590-7
• 30 Hutchens MP, Memtsoudis S, Sadovnikoff N. Propofol for sedation in neuro-intensive care. Neurocrit Care 2006; 4: 54-62
• 31 Brain Trauma Foundation, American Association of Neurological Surgeons, Congress of Neurological Surgeons, Joint Section on Neurotrauma and Critical Care, AANS/CNS. Bratton SL, Chestnut RM, Ghajar J, McConnell Hammond FF. et al. Guidelines for the management of severe traumatic brain injury. XI. Anesthetics, analgesics, and sedatives. J Neurotrauma 2007; 24 Suppl (Suppl. 01) S71-6
• 32 Jones GM, Doepker BA, Erdman MJ, Kimmons LA, Elijovich L. Predictors of severe hypotension in neurocritical care patients sedated with propofol. Neurocrit Care 2014; 20: 270-6
• 33 Mirski MA, Lewin 3^rd JJ. Sedation and analgesia in acute neurologic disease. Curr Opin Crit Care 2010; 16: 81-91
• 34 Roberts DJ, Hall RI, Kramer AH, Robertson HL, Gallagher CN, Zygun DA. Sedation for critically ill adults with severe traumatic brain injury: A systematic review of randomized controlled trials. Crit Care Med 2011; 39: 2743-51
• 35 Tipps LB, Coplin WM, Murry KR, Rhoney DH. Safety and feasibility of continuous infusion of remifentanil in the neurosurgical intensive care unit. Neurosurgery 2000; 46: 596-601
• 36 Engelhard K, Reeker W, Kochs E, Werner C. Effect of remifentanil on intracranial pressure and cerebral blood flow velocity in patients with head trauma. Acta Anaesthesiol Scand 2004; 48: 396-9
• 37 Girard F, Moumdjian R, Boudreault D, Chouinard P, Bouthilier A, Ruel M. The effect of sedation on intracranial pressure in patients with an intracranial space-occupying lesion: Remifentanil versus propofol. Anesth Analg 2009; 109: 194-8
• 38 Hosseinzadeh H, Eydi M, Ghaffarlou M, Ghabili K, Golzari SE, Bazzazi AM. Administration of remifentanil in establishing a more stable post-anesthesia cardiovascular status in neurosurgical procedures. J Cardiovasc Thorac Res 2012; 4: 21-4
• 39 Leone M, Albanèse J, Viviand X, Garnier F, Bourgoin A, Barrau K. et al. The effects of remifentanil on endotracheal suctioning-induced increases in intracranial pressure in head-injured patients. Anesth Analg 2004; 99: 1193-8
• 40 Bilotta F, Branca G, Lam A, Cuzzone V, Doronzio A, Rosa G. Endotracheal lidocaine in preventing endotracheal suctioning-induced changes in cerebral hemodynamics in patients with severe head trauma. Neurocrit Care 2008; 8: 241-6
• 41 Kim SH, Stoicea N, Soghomonyan S, Bergese SD. Remifentanil-acute opioid tolerance and opioid-induced hyperalgesia: A systematic review. Am J Ther 2015; 22: e62-74
• 42 Sperry RJ, Bailey PL, Reichman MV, Peterson JC, Petersen PB, Pace NL. Fentanyl and sufentanil increase intracranial pressure in head trauma patients. Anesthesiology 1992; 77: 416-20
• 43 Hocker SE, Fogelson J, Rabinstein AA. Refractory intracranial hypertension due to fentanyl administration following closed head injury. Front Neurol 2013; 4: 3
• 44 Albanèse J, Viviand X, Potie F, Rey M, Alliez B, Martin C. Sufentanil, fentanyl, and alfentanil in head trauma patients: A study on cerebral hemodynamics. Crit Care Med 1999; 27: 407-11
• 45 Schregel W, Weyerer W, Cunitz G. Opioids, cerebral circulation and intracranial pressure. Anaesthesist 1994; 43: 421-30
• 46 Purrucker JC, Renzland J, Uhlmann L, Bruckner T, Hacke W, Steiner T. et al. Volatile sedation with sevoflurane in intensive care patients with acute stroke or subarachnoid haemorrhage using AnaConDa®: An observational study. Br J Anaesth 2015; 114: 934-43
• 47 Misra S, Koshy T. A review of the practice of sedation with inhalational anaesthetics in the intensive care unit with the AnaConDa(®) device. Indian J Anaesth 2012; 56: 518-23
• 48 Meiser A, Laubenthal H. Inhalational anaesthetics in the ICU: Theory and practice of inhalational sedation in the ICU, economics, risk-benefit. Best Pract Res Clin Anaesthesiol 2005; 19: 523-38
• 49 Bösel J, Purrucker JC, Nowak F, Renzland J, Schiller P, Pérez EB. et al. Volatile isoflurane sedation in cerebrovascular intensive care patients using AnaConDa(®): Effects on cerebral oxygenation, circulation, and pressure. Intensive Care Med 2012; 38: 1955-64
• 50 Belopavlovic M, Buchthal A. Modification of ketamine-induced intracranial hypertension in neurosurgical patients by pretreatment with midazolam. Acta Anaesthesiol Scand 1982; 26: 458-62
• 51 Schulte Am Esch J, Pfeifer G, Thiemig I, Entzian W. The influence of intravenous anaesthetic agents on primarily increased intracranial pressure. Acta Neurochir (Wien) 1978; 45: 15-25
• 52 Schmidt A, Ryding E, Akeson J. Racemic ketamine does not abolish cerebrovascular autoregulation in the pig. Acta Anaesthesiol Scand 2003; 47: 569-75
• 53 Engelhard K, Werner C, Möllenberg O, Kochs E. S(+)-ketamine/propofol maintain dynamic cerebrovascular autoregulation in humans. Can J Anaesth 2001; 48: 1034-9
• 54 Schmidt A, Øye I, Akeson J. Racemic, S(+)- and R(-)-ketamine do not increase elevated intracranial pressure. Acta Anaesthesiol Scand 2008; 52: 1124-30
• 55 Schmittner MD, Vajkoczy SL, Horn P, Bertsch T, Quintel M, Vajkoczy P. et al. Effects of fentanyl and S(+)-ketamine on cerebral hemodynamics, gastrointestinal motility, and need of vasopressors in patients with intracranial pathologies: A pilot study. J Neurosurg Anesthesiol 2007; 19: 257-62
• 56 Bourgoin A, Albanèse J, Léone M, Sampol-Manos E, Viviand X, Martin C. Effects of sufentanil or ketamine administered in target-controlled infusion on the cerebral hemodynamics of severely brain-injured patients. Crit Care Med 2005; 33: 1109-13
• 57 Loflin R, Koyfman A. When used for sedation, does ketamine increase intracranial pressure more than fentanyl or sufentanil?. Ann Emerg Med 2015; 65: 55-6
• 58 Zeiler FA, Zeiler KJ, Teitelbaum J, Gillman LM, West M. Modern inhalational anesthetics for refractory status epilepticus. Can J Neurol Sci 2015; 42: 106-15
• 59 Zeiler FA, Teitelbaum J, West M, Gillman LM. The ketamine effect on ICP in traumatic brain injury. Neurocrit Care 2014; 21: 163-73
• 60 Wang X, Ding X, Tong Y, Zong J, Zhao X, Ren H. et al. Ketamine does not increase intracranial pressure compared with opioids: Meta-analysis of randomized controlled trials. J Anesth 2014; 28: 821-7
• 61 Albanèse J, Arnaud S, Rey M, Thomachot L, Alliez B, Martin C. Ketamine decreases intracranial pressure and electroencephalographic activity in traumatic brain injury patients during propofol sedation. Anesthesiology 1997; 87: 1328-34
• 62 Caricato A, Tersali A, Pitoni S, De Waure C, Sandroni C, Bocci MG. et al. Racemic ketamine in adult head injury patients: Use in endotracheal suctioning. Crit Care 2013; 17: R267
• 63 Bourgoin A, Albanèse J, Wereszczynski N, Charbit M, Vialet R, Martin C. Safety of sedation with ketamine in severe head injury patients: Comparison with sufentanil. Crit Care Med 2003; 31: 711-7
• 64 Kolenda H, Gremmelt A, Rading S, Braun U, Markakis E. Ketamine for analgosedative therapy in intensive care treatment of head-injured patients. Acta Neurochir (Wien) 1996; 138: 1193-9
• 65 Mayberg TS, Lam AM, Matta BF, Domino KB, Winn HR. Ketamine does not increase cerebral blood flow velocity or intracranial pressure during isoflurane/nitrous oxide anesthesia in patients undergoing craniotomy. Anesth Analg 1995; 81: 84-9
• 66 Umunna BP, Tekwani K, Barounis D, Kettaneh N, Kulstad E. Ketamine for continuous sedation of mechanically ventilated patients. J Emerg Trauma Shock 2015; 8: 11-5
• 67 Cohen L, Athaide V, Wickham ME, Doyle-Waters MM, Rose NG, Hohl CM. The effect of ketamine on intracranial and cerebral perfusion pressure and health outcomes: A systematic review. Ann Emerg Med 2015; 65: 43-51.e2