Adult sedation and analgesia in a resource limited intensive care unit – A Systematic Review and evidence based guideline

Abstract

Background Sedation and analgesia are essential in the intensive care unit in order to promote control of pain, anxiety, prevent loss of materials, accidental extubation and improve the synchrony of patients with ventilator. However, excess of these medications leads to an increased morbidity and mortality, and thus demands protocol. Methods Preferred Reporting Items for Systematic Reviews and the Meta-Analysis Protocol have been used to undertake this review. Pub Med, Cochrane Library, and Google Scholar search engines were used to find up-to-date evidence that helps to draw recommendations and conclusions. Results In this Guideline and Systematic Review, we have used 16 Systemic Review and Meta-Analysis, 3 Evidence-Based Guidelines and 10 RCT Meta-Analysis, 6 Systemic Reviews of Non-randomized Studies, 8 Randomized Clinical Trials, 11 Cohort Studies, 5 Cross-Sectional Studies and 1 Case Report with their respective study descriptions. Discussion Analgesia, which as a sedation basement can reduce sedative use, is key aspect of treatment in ICU patients, and we can also conclude that an analgesic sedation regimen can reduce the occurrence of delirium by reducing sedatives. The aim of this guideline and the systematic review is to write up and formulate analgesia-based sedation for limited resource settings. Conclusions Analgesia and sedation are effective in critically ill patients; however, too much sedation is associated with longer periods of mechanical ventilation and longer duration of ICU stay. Poorly managed ICU patients have a delirium rate of up to 80%, increased mortality, longer hospital stays, higher hospital costs and bad long-term outcomes.

Review of remimazolam and sedatives in the intensive care unit

“…BDZs are well-established drugs that are inexpensive and provide powerful anxiolysis and amnesia. However, sedation using non-BDZ drugs has been shown to improve the clinical outcome of critically ill patients better than BDZs in terms of incidence of delirium and prolonged, and unpredicted sedation [ 11 , 12 ]. We compared sedatives that can be used for deep sedation in the ICU in Table 1 .…”

“…Carboxylesterase enzymes can be found in the cytosol and the rough endoplasmic reticulum of tissues [ 41 ], and remimazolam is metabolized by this tissue esterase (particularly, the liver) to an inactive carboxy acid metabolite, CNS 7054 [ 5 , 12 , 13 ]. CNS 7054 has a PK profile with a smaller volume of distribution, slower clearance rate, and a longer mean residence time in comparison to remimazolam [ 42 ], and has a 400-fold lower affinity for the GABA-A receptor [ 43 ].…”

Tools Are Needed to Promote Sedation Practices for Mechanically Ventilated Patients

“…(58)(59)(60)(61). For the vast majority of ICU MV patients, deep sedation is unnecessary and should be avoided (62). Oversedation is therefore suspected when MV patients are sedated at the depths below RASS−2.…”

Seeking the Light in Intensive Care Unit Sedation: The Optimal Sedation Strategy for Critically Ill Patients

“…Failure to control pain and agitation can have detrimental effects both in the short-and long-term perspective. Poorly controlled pain and agitation have been associated with worsening of the critical condition, increase in sympathetic tone, and increased rate of accidental removal of medical devices such as endotracheal tubes and vascular catheters (1)(2)(3). Moreover, uncontrolled pain during ICU stay is related to a higher incidence of chronic pain, post-traumatic stress disorder (PTSD) symptoms, and a lower health-related quality of life (HRQoL).…”