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Semin Respir Crit Care Med 2013; 34(02): 201-215
DOI: 10.1055/s-0033-1342983
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Pharmacological Management of Sedation and Delirium in Mechanically Ventilated ICU Patients: Remaining Evidence Gaps and Controversies

John W. Devlin
1   Department of Pharmacy Practice, School of Pharmacy, Northeastern University, Boston, Massachusetts
2   Division of Pulmonary, Critical Care, and Sleep Medicine, Tufts Medical Center, Boston, Massachusetts
,
Gilles L. Fraser
3   Department of Critical Care and Pharmacy, Maine Medical Center, Portland, Maine
4   Tufts University School of Medicine, Boston, Massachusetts
,
E. Wesley Ely
5   Department of Medicine, Division of Pulmonary and Critical Care, Vanderbilt University Medical Center, Nashville, Tennessee
6   Center for Health Services Research, Vanderbilt University Medical Center, Nashville, Tennessee
7   Tennessee Valley Veteran's Affairs Geriatric Research Education and Clinical Center (VA-GRECC), Nashville, Tennessee
,
John P. Kress
8   Department of Medicine, Section of Pulmonary and Critical Care, University of Chicago Medical Center, Chicago, Illinois
,
Yoanna Skrobik
9   Department of Critical Care, Hopital Maisonneuve Rosemont, Montreal, Quebec, Canada
10   Faculty of Medicine, Universite of Montreal, Montreal, Quebec, Canada
,
Joseph F. Dasta
11   College of Pharmacy, The Ohio State University, Columbus, Ohio
12   College of Pharmacy, The University of Texas, Austin, Texas
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Publikationsdatum:
28. Mai 2013 (online)

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Abstract

Although pharmacotherapy remains the mainstay for the prevention and treatment of pain, anxiety, and delirium (PAD) in the intensive care unit (ICU), many of the PAD-related medications currently used may lead to unintended consequences, particularly when these agents are administered at excessive doses for prolonged periods. The method by which these medications are administered and titrated is increasingly being recognized as potentially affecting patient outcomes as much as the drug itself. Drugs once thought to have a pharmacologically desirable profile in reducing PAD have been shown to have either little benefit, the potential for significant risk associated with any benefit, or in some cases, the potential to worsen patient outcome. The recently published American College of Critical Care Medicine (ACCM) Pain, Agitation, and Delirium Clinical Practice Guidelines provide 12 medication-related recommendations surrounding the prevention and treatment of PAD. This paper (1) provides the ICU bedside clinician with more background on the most important, and in some cases most contentious and challenging areas, of sedation and delirium pharmacotherapy in the critical care setting; (2) provides an update on the most recent evidence surrounding the prevention and treatment of agitation and delirium in ICU; and (3) highlights areas that require further investigation and provide practical strategies by which to apply current evidence in this area to daily ICU practice.

Keywords

pain - sedation - benzodiazepine - delirium - drug therapy - critical illness - intensive care unit - propofol - dexmedetomidine - opioid - antipsychotic