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Semin Neurol 2008; 28(5): 611-630
DOI: 10.1055/s-0028-1105970
© Thieme Medical Publishers

Sedation and Pain Management in Acute Neurological Disease

Marek A. Mirski1 , John J. Lewin2
  • 1Neurosciences Critical Care Unit/Neuroanesthesiology, The Johns Hopkins University, Baltimore, Maryland
  • 2Departments of Pharmacy Services and Anesthesiology and Critical Care Medicine, The Johns Hopkins Medical Institutions, Baltimore, Maryland
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Publikationsdatum:
29. Dezember 2008 (online)

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ABSTRACT

The optimum provision of pharmacological sedation of the critically ill neurological patient requires defining the underlying etiology of agitation or need for sedation to determine the optimal agent: pain management, anxiolysis, or treatment of delirium. An appropriate regimen can then be decided upon based on the profiles of action of the several common classes of sedative agents. Methods to both evaluate the efficacy of sedation as well as titration to a predefined clinical goal are important tools toward safe administration of drugs that often have serious adverse effects. Recognition of an individualized approach is also necessary as patients will vary considerably with respect to the kinetics and pharmacodynamics of sedative therapy. The drug classes often selected for sedation in an intensive care unit will be reviewed as well as the metrics by which physicians can achieve their objectives in a safe manner.

KEYWORDS

Sedation - scales - pharmacokinetics - intensive care unit - toxicity

REFERENCES

APPENDIX: SPECIFIC SEDATION SCALES USED IN THE INTENSIVE CARE UNIT

Motor Activity Assessment Scale
Score Description Definition
0 Unresponsive Does not move with noxious stimulus[*]
1 Responsive only to noxious stimuli Opens eyes OR raises eyebrows OR turns head toward stimulus OR moves limbs with noxious stimulus*
2 Responsive to touch OR name Opens eyes OR raises eyebrows OR turns head toward stimulus OR moves limbs when touched or name is loudly spoken
3 Calm and cooperative No external stimulus is required to elicit movement AND patient is adjusting sheets or clothes purposefully and follows commands
4 Restless and cooperative No external stimulus is required to elicit movement AND patient is picking at sheets or tubes OR uncovering self and follows commands
5 Agitated No external stimulus is required to elicit movement AND attempting to sit up OR moves limbs out of bed AND does not consistently follow commands (e.g., will lie down when asked but soon reverts back to attempts to sit up or move limbs out of bed)
6 Dangerously agitated, uncooperative No external stimulus is required to elicit movement AND patient is pulling at tubes or catheters OR thrashing side to side OR striking at staff OR trying to climb out of bed AND does not calm down when asked

1 Noxious stimulus, suctioning, OR 5 seconds of vigorous orbital, sternal, or nail bed pressure. Adapted from Devlin et al.[19]

Riker Sedation-Agitation Scale (SAS)
Score Category Description
7 Dangerous agitation Pulling at endotracheal tube, trying to remove catheters, climbing over bedrail, striking at staff, thrashing side-to-side
6 Very agitated Does not calm despite frequent verbal reminding of limits, requires physical restraints, biting endotracheal tube
5 Agitated Anxious or mildly agitated, attempting to sit up, calms down on verbal instructions
4 Calm, cooperative Calm, easily aroused, follows commands
3 Sedated Difficult to arouse, awakens to verbal stimuli or gentle shaking but drifts off again, follows simple commands
2 Very sedated Arouses to physical stimuli but does not communicate or follow commands, may move spontaneously
1 Unarousable Minimal or no response to noxious stimuli, does not communicate or follow commands
Adapted from Riker et al.[17]
Richmond Agitation-Sedation Scale
Score Term Description
+4 Combative Overtly combative or violent; immediate danger to staff
+3 Very agitated Pulls on or removes tube(s) or catheter(s) or has aggressive behavior toward staff
+2 Agitated Frequent nonpurposeful movement or patient–ventilator dyssynchrony
+1 Restless Anxious or apprehensive, but movements not aggressive or vigorous
0 Alert and calm
-1 Drowsy Not fully alert, but has sustained (> 10 seconds) awakening, with eye contact, to voice
-2 Light sedation Briefly (< 10 seconds) awakens with eye contact to voice
-3 Moderate sedation Any movement (but no eye contact) to voice
-4 Deep sedation No response to voice, but any movement to physical stimulation
-5 Unarousable No response to voice or physical stimulation
Adapted from Sessler et al.[20]
AVRIPAS: Revised Sedation Scale
Agitation Alertness
1. Unresponsive to command/physical stimulation 1. Difficult to arouse, eyes remain closed
2. Appropriate response to physical stimuli/calm 2. Mostly sleeping, eyes closed
3. Mild anxiety/delirium/agitation (calms easily) 3. Dozing intermittently, arouses easily
4. Moderate anxiety/delirium/agitation 4. Awake, calm
5. Severe anxiety/delirium/agitation 5. Wide awake, hyperalert
Respiration
1. Intubated, no spontaneous effort
2. Respirations even, synchronized with ventilator
3. Mild dyspnea/tachypnea, occasional asynchrony
4. Frequent dyspnea/tachypnea, ventilator asynchrony
5. Sustained, severe dyspnea/tachypnea
Patient Classification Sedation Goal
Acutely ill (weaning not a goal) 5–9
Ventilated patient being weaned 7–10
Chronic ventilated patient (weaning not a goal) 6–9
Nonventilated patient 7–9
Adapted from Avripas et al.[22]
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Procedure for Scoring the Minnesota Sedation Assessment Tool (MSAT)

  1. Record the highest level of unstimulated spontaneous motor activity observed in the last 10 minutes.

  2. Walk to the right shoulder and observe eye opening and/or tracking.

  3. If no eye opening, call first name and “open your eyes!”

  4. If no eye opening yet, shake right shoulder firmly, call first name and “open your eyes!”

  5. Choose the arousal scale category appropriate for the patient's response to procedures 2 to 4.

  6. Judge the current quality of the sedation therapy as “adequate,” “oversedated,” or “undersedated.” Use any clinical information available to you in addition to the scale levels.

MOTOR ACTIVITY SCALE

  • Movement of central muscle group (back or abdominal muscles)

  • Movement of proximal limbs (hip or shoulder)

  • Movement of distal limbs or head and neck muscles

  • No spontaneous movement

Note: Disregard respiratory efforts, cough, swallowing, eye movement, or isolated tiny muscle contractions.

AROUSAL SCALE

  • Eyes open spontaneously with tracking

  • Eyes open spontaneously, but not tracking

  • Eyes closed, but open to sound of voice

  • Eyes closed, but open to shoulder shake plus sound of voice

  • Eyes stay closed, but other patient movement observed in response to stimulation

  • Eyes stay closed and no patient movement observed in response to stimulation

Adapted from Weinert and McFarland.[25]

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Marek MirskiM.D. Ph.D. 

Department of Anesthesiology and Critical Care Medicine, Division of Neuroanesthesia/Neurosciences Critical Care

The Johns Hopkins Hospital, 600 North Wolfe Street, Meyer 8-140, Baltimore, MD 21287

eMail: mmirski@jhmi.edu