Semin Respir Crit Care Med 2021; 42(01): 098-111
DOI: 10.1055/s-0040-1716736
Review Article

Optimal Sedation and Pain Management: A Patient- and Symptom-Oriented Paradigm

Yahya Shehabi
1  Monash Health School of Clinical Sciences, Monash University, Clayton, Victoria, Melbourne, Australia
2  Prince of Wales Clinical School of Medicine, University of New South Wales, Randwick, New South Wales, Sydney, Australia
,
Wisam Al-Bassam
1  Monash Health School of Clinical Sciences, Monash University, Clayton, Victoria, Melbourne, Australia
,
Adrian Pakavakis
1  Monash Health School of Clinical Sciences, Monash University, Clayton, Victoria, Melbourne, Australia
,
Brendan Murfin
1  Monash Health School of Clinical Sciences, Monash University, Clayton, Victoria, Melbourne, Australia
,
Belinda Howe
3  The Australian and New Zealand Intensive Care Research Centre, Monash University, School of Public Health and Preventive Medicine, Melbourne, Victoria, Australia
› Author Affiliations

Abstract

In the critically ill patient, optimal pain and sedation management remains the cornerstone of achieving comfort, safety, and to facilitate complex life support interventions. Pain relief, using multimodal analgesia, is an integral component of any orchestrated approach to achieve clinically appropriate goals in critically ill patients. Sedative management, however, remains a significant challenge. Subsequent studies including most recent randomized trials have failed to provide strong evidence in favor of a sedative agent, a mode of sedation or ancillary protocols such as sedative interruption and sedative minimization. In addition, clinical practice guidelines, despite a comprehensive evaluation of relevant literature, have limitations when applied to individual patients. These limitations have been most apparent during the coronavirus disease 2019 pandemic. As such, there is a need for a mindset shift to a practical and achievable sedation strategy, driven by patients' characteristics and individual patient needs, rather than one cocktail for all patients. In this review, we present key principles to achieve patient-and symptom-oriented optimal analgesia and sedation in the critically ill patients. Sedative intensity should be proportionate to care complexity with due consideration to an individual patient's modifiers. The use of multimodal analgesics, sedatives, and antipsychotics agents—that are easily titratable—reduces the overall quantum of sedatives and opioids, and reduces the risk of adverse events while maximizing clinical benefits. In addition, critical considerations regarding the choice of sedative agents should be given to factors such as age, medical versus operative diagnosis, and cardiovascular status. Specific populations such as trauma, neurological injury, and pregnancy should also be taken into account to maximize efficacy and reduce adverse events.



Publication History

Publication Date:
21 September 2020 (online)

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