Chapter 20 ICU sedation and pain management

2001 American College of Critical Care Medicine (ACCM) Sedation Guidelines were developed to help guide the practitioner in the usage of sedatives and opiates for prolonged sedation and analgesia. Both sedation and analgesia should be administered to mechanically ventilated patients to achieve a level of comfort. The ACCM recommends the following drugs based on individual patient need.

Sedation

Lorazepam (Ativan)

• Mechanism of action-Binds to CNS GABA receptors and produces an inhibitory effect on neuronal excitability through hyperpolarization and stabilization.
  
• Dose-Start at 0.01-0.1 mg/kg/hr IV and titrate per RASS scale.
  
• Pharmacokinetics -Onset: IV 5 minutes. Metabolism: Hepatic to inactive compounds. Half-life elimination: Adults: 8–12 hours, prolonged with cirrhosis, congestive heart failure, obesity, usage > 72 hours, and elderly.
  
• Pearls – ACCM guidelines recommend lorazepam use for long term sedation (> 72 hr). Studies show that time to extubation was shorter with lorazepam than midazolam.

Midazolam (Versed)

• Mechanism of action– Binds to CNS GABA receptors and produces an inhibitory effect on neuronal excitability through hyperpolarization and stabilization.
  
• Dose-Start at 0.04-0.2 mg/kg/hour and titrate per RASS scale.
  
• Pharmacokinetics– Onset: IV 1–5 minutes. Metabolism: Extensively hepatic via CYP3A4 with active metabolite. Half-life elimination: 1–4 hours, prolonged with cirrhosis, congestive heart failure, obesity, usage > 72 hours, and elderly.
  
• Pearls-Good choice for short periods of sedation. Half-life of midazolam is profoundly increased when used > 72 hrs. Build-up of drug and active metabolite results in prolonged times to extubation once sedation is stopped.

Propofol (Diprivan)

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