Editor’s Choice-The cardiovascular implications of sedatives in the cardiac intensive care unit

Abstract

Patients admitted to the cardiac intensive care unit frequently develop multi-organ system dysfunction associated with their cardiac disease. In many cases, invasive mechanical ventilation is required, which often necessitates sedation for patient-ventilator synchrony, reduction of work of breathing, and patient comfort. In this paper, we describe the use of common sedatives available in the endotracheally intubated critically ill patient and emphasize the clinical and cardiovascular effects. We review γ-aminobutyric acid agonists such as etomidate, benzodiazepines, and propofol, the centrally acting α-agonist dexmedetomidine, and the N-methyl-D-aspartate receptor antagonist ketamine. Additionally, we outline the use of opioids and their role in potentiating other sedatives. We note that some sedatives are associated with increased delirium rates, and emphasize that judicious strategies minimizing sedative use are associated with decreases in morbidity and mortality. We also discuss standardized sedation assessment scales and highlight the importance of sedation weaning. Finally, we offer recommendations for sedation use during therapeutic hypothermia, and discuss the use of adjuvant neuromuscular blocking agents.

Hypothermic properties of dexmedetomidine provide neuroprotection in rats following cerebral ischemia‑reperfusion injury

“…Dexmedetomidine (Dex) is a highly selective α 2 -adrenergic receptor agonist that is commonly used as a sedative and analgesic in the intensive care unit (24); it has been reported to display synergistic effects with hypothermia (25,26). Consequently, based on previous observations that hypothermia can alleviate neuronal damage following CA, it was hypothesized in the present study that Dex administration after CA may result in improved neural function and reduced apoptosis and autophagy.…”

Interhospital Transfer of Patients With Acute Pulmonary Embolism

“…However, opioids can act synergistically with other sedatives, such as propofol, and exacerbate hypotension. 36 In critically ill patients, rapid sequence intubation has been shown to increase the success rate of intubation. 37 During the peri-intubation period, avoiding hypoxemia and hypercapnia is important, because the pulmonary vasculature is particularly susceptible to reactive vasoconstriction.…”

“…Vasopressors/Inotropes Effects on Right Heart36,40,41 [CI, PVR [[SVR [HR The b 1 effect has shown to improve PA/RV coupling in animal models; improves RV myocardial oxygen delivery ultrasound-guided punctures and avoidance of noncompressible sites can reduce bleeding risk, an important caveat because thrombolytics, surgery, or extracorporeal membrane oxygenation may become necessary after the transfer. The inherent value of central and arterial line placement includes the ability to administer vasoactive drugs, real-time hemodynamic monitoring, avoidance of further arterial and venous site punctures after thrombolysis, and conversion into extracorporeal membrane oxygenation lines if needed.…”

Incidence, Predictors, and Outcomes of Failure of Noninvasive Ventilation in Acute Heart Failure Hospitalization

“…17 Although this finding is intuitive, the magnitude of the effect is important to understand and should also serve as an impetus to improve these adverse outcomes. Clinicians could consider several potential means to improve this prognosis, such as improved patient selection for NIV, avoidance of inappropriate pharmacologic sedation for patients maintained on NIV, 34,35 intensivist and cardiac intensivist management, [36][37][38][39] and use of a dedicated respiratory therapy team to deliver NIV. 40 A compelling direction for future study is the use of highflow nasal cannula therapy in these patients, which could reduce work of breathing and improve ventilation/perfusion matching, but this requires further research.…”