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Management of Pain, Agitation and Delirium in the Intensive Care Units

중환자실 환자의 통증, 진정 및 섬망 관리

  • Jeon, Kyeongman (Division of Pulmonary and Critical Care Medicine, Department of Medicine and Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine)
  • 전경만 (성균관대학교 의과대학 삼성서울병원 호흡기내과, 중환자의학과)
  • Published : 2014.05.01

Abstract

Pain, agitation and delirium (PAD) occur frequently in mechanically ventilated patients in the intensive care unit (ICU). Consequently, analgesics and sedatives are frequently administered to critically ill patients with the aim of treating PAD, decreasing the physiological stress response, and improving synchrony with mechanical ventilation. However, many of the analgesics and sedatives in current use can lead to adverse outcomes, including longer durations of mechanical ventilation, prolonged ICU stays, delirium, and an increased risk of death, particularly when these agents are administered at excessive doses for prolonged periods. The purpose of this review is to provide an overview of the initial evaluation and monitoring of, and the medications commonly prescribed for, PAD. Moreover, we highlight the major recommendations of the recent guidelines published by the Korean Society of Critical Care Medicine and American College of Critical Care Medicine.

Keywords

References

  1. Desbiens NA, Wu AW, Broste SK, et al. Pain and satisfaction with pain control in seriously ill hospitalized adults: findings from the SUPPORT research investigations: for the SUPPORT investigators: study to understand prognoses and preferences for outcomes and risks of treatments. Crit Care Med 1996;24:1953-1961. https://doi.org/10.1097/00003246-199612000-00005
  2. Maldonado JR. Delirium in the acute care setting: characteristics, diagnosis and treatment. Crit Care Clin 2008;24:657-722. https://doi.org/10.1016/j.ccc.2008.05.008
  3. Patel SB, Kress JP. Sedation and analgesia in the mechanically ventilated patient. Am J Respir Crit Care Med 2012;185:486-497. https://doi.org/10.1164/rccm.201102-0273CI
  4. Reade MC, Finfer S. Sedation and delirium in the intensive care unit. N Engl J Med 2014;370:444-454. https://doi.org/10.1056/NEJMra1208705
  5. Korean Society of Critical Care Medicine. Guideline for sedation and analgesia in adult intensive care units [Internet]. Seoul: Korean Society of Critical Care Medicine, 2014c [cited April 23, 2014]. Available from: http://ksccm.inforang.com/file/notice/KJCCM_file03.pdf.
  6. Barr J, Fraser GL, Puntillo K, et al. Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit. Crit Care Med 2013;41:263-306. https://doi.org/10.1097/CCM.0b013e3182783b72
  7. Novaes MA, Aronovich A, Ferraz MB, Knobel E. Stressors in ICU: patients' evaluation. Intensive Care Med 1997;23:1282-1285. https://doi.org/10.1007/s001340050500
  8. Chanques G, Sebbane M, Barbotte E, Viel E, Eledjam JJ, Jaber S. A prospective study of pain at rest: incidence and characteristics of an unrecognized symptom in surgical and trauma versus medical intensive care unit patients. Anesthesiology 2007;107:858-860. https://doi.org/10.1097/01.anes.0000287211.98642.51
  9. Epstein J, Breslow MJ. The stress response of critical illness. Crit Care Clin 1999;15:17-33. https://doi.org/10.1016/S0749-0704(05)70037-3
  10. Akca O, Melischek M, Scheck T, et al. Postoperative pain and subcutaneous oxygen tension. Lancet 1999;354:41-42. https://doi.org/10.1016/S0140-6736(99)00874-0
  11. Ahlers SJ, van Gulik L, van der Veen AM, et al. Comparison of different pain scoring systems in critically ill patients in a general ICU. Crit Care 2008;12:R15. https://doi.org/10.1186/cc6789
  12. Chanques G, Viel E, Constantin JM, et al. The measurement of pain in intensive care unit: comparison of 5 self-report intensity scales. Pain 2010;151:711-721. https://doi.org/10.1016/j.pain.2010.08.039
  13. Puntillo K, Pasero C, Li D, et al. Evaluation of pain in ICU patients. Chest 2009;135:1069-1074. https://doi.org/10.1378/chest.08-2369
  14. Payen JF, Bru O, Bosson JL, et al. Assessing pain in critically ill sedated patients by using a behavioral pain scale. Crit Care Med 2001;29:2258-2263. https://doi.org/10.1097/00003246-200112000-00004
  15. Gelinas C, Fillion L, Puntillo KA, Viens C, Fortier M. Validation of the critical-care pain observation tool in adult patients. Am J Crit Care 2006;15:420-427.
  16. Erstad BL, Puntillo K, Gilbert HC, et al. Pain management principles in the critically ill. Chest 2009;135:1075-1086. https://doi.org/10.1378/chest.08-2264
  17. Devlin JW, Roberts RJ. Pharmacology of commonly used analgesics and sedatives in the ICU: benzodiazepines, propofol, and opioids. Crit Care Clin 2009;25:431-449. https://doi.org/10.1016/j.ccc.2009.03.003
  18. Weinshilboum R. Inheritance and drug response. N Engl J Med 2003;348:529-537. https://doi.org/10.1056/NEJMra020021
  19. Hughes MA, Glass PS, Jacobs JR. Context-sensitive halftime in multicompartment pharmacokinetic models for intravenous anesthetic drugs. Anesthesiology 1992;76:334-341. https://doi.org/10.1097/00000542-199203000-00003
  20. Malacrida R, Fritz ME, Suter PM, Crevoisier C. Pharmacokinetics of midazolam administered by continuous intravenous infusion to intensive care patients. Crit Care Med 1992;20:1123-1126. https://doi.org/10.1097/00003246-199208000-00010
  21. Kapila A, Glass PS, Jacobs JR, et al. Measured context-sensitive half-times of remifentanil and alfentanil. Anesthesiology 1995;83:968-975. https://doi.org/10.1097/00000542-199511000-00009
  22. Trescot AM, Datta S, Lee M, Hansen H. Opioid pharmacology. Pain Physician 2008;11(2 Suppl):S133-153.
  23. Sessler CN, Varney K. Patient-focused sedation and analgesia in the ICU. Chest 2008;133:552-565. https://doi.org/10.1378/chest.07-2026
  24. Vinik HR, Kissin I. Rapid development of tolerance to analgesia during remifentanil infusion in humans. Anesth Analg 1998;86:1307-1311.
  25. Strom T, Martinussen T, Toft P. A protocol of no sedation for critically ill patients receiving mechanical ventilation: a randomised trial. Lancet 2010;375:475-480. https://doi.org/10.1016/S0140-6736(09)62072-9
  26. Ramsay MA, Savege TM, Simpson BR, Goodwin R. Controlled sedation with alphaxalone-alphadolone. Br Med J 1974;2:656-659. https://doi.org/10.1136/bmj.2.5920.656
  27. Riker RR, Picard JT, Fraser GL. Prospective evaluation of the Sedation-Agitation Scale for adult critically ill patients. Crit Care Med 1999;27:1325-1329. https://doi.org/10.1097/00003246-199907000-00022
  28. Sessler CN, Gosnell MS, Grap MJ, et al. The Richmond Agitation-Sedation Scale: validity and reliability in adult intensive care unit patients. Am J Respir Crit Care Med 2002;166:1338-1344. https://doi.org/10.1164/rccm.2107138
  29. Spina SP, Ensom MH. Clinical pharmacokinetic monitoring of midazolam in critically ill patients. Pharmacotherapy 2007;27:389-398. https://doi.org/10.1592/phco.27.3.389
  30. Bauer TM, Ritz R, Haberthur C, et al. Prolonged sedation due to accumulation of conjugated metabolites of midazolam. Lancet 1995;346:145-147. https://doi.org/10.1016/S0140-6736(95)91209-6
  31. Pandharipande P, Shintani A, Peterson J, et al. Lorazepam is an independent risk factor for transitioning to delirium in intensive care unit patients. Anesthesiology 2006;104:21-26. https://doi.org/10.1097/00000542-200601000-00005
  32. Cammarano WB, Pittet JF, Weitz S, Schlobohm RM, Marks JD. Acute withdrawal syndrome related to the administration of analgesic and sedative medications in adult intensive care unit patients. Crit Care Med 1998;26:676-684. https://doi.org/10.1097/00003246-199804000-00015
  33. Wilson KC, Reardon C, Theodore AC, Farber HW. Propylene glycol toxicity: a severe iatrogenic illness in ICU patients receiving IV benzodiazepines: a case series and prospective, observational pilot study. Chest 2005;128:1674-1681. https://doi.org/10.1378/chest.128.3.1674
  34. Carson SS, Kress JP, Rodgers JE, et al. A randomized trial of intermittent lorazepam versus propofol with daily interruption in mechanically ventilated patients. Crit Care Med 2006;34:1326-1332. https://doi.org/10.1097/01.CCM.0000215513.63207.7F
  35. Fong JJ, Kanji S, Dasta JF, Garpestad E, Devlin JW. Propofol associated with a shorter duration of mechanical ventilation than scheduled intermittent lorazepam: a database analysis using Project IMPACT. Ann Pharmacother 2007;41:1986-1991. https://doi.org/10.1345/aph.1K296
  36. Pandharipande PP, Pun BT, Herr DL, et al. Effect of sedation with dexmedetomidine vs lorazepam on acute brain dysfunction in mechanically ventilated patients: the MENDS randomized controlled trial. JAMA 2007;298:2644-2653. https://doi.org/10.1001/jama.298.22.2644
  37. Arroliga AC, Thompson BT, Ancukiewicz M, et al. Use of sedatives, opioids, and neuromuscular blocking agents in patients with acute lung injury and acute respiratory distress syndrome. Crit Care Med 2008;36:1083-1088. https://doi.org/10.1097/CCM.0B013E3181653895
  38. Riker RR, Shehabi Y, Bokesch PM, et al. Dexmedetomidine vs midazolam for sedation of critically ill patients: a randomized trial. JAMA 2009;301:489-499. https://doi.org/10.1001/jama.2009.56
  39. Esmaoglu A, Ulgey A, Akin A, Boyaci A. Comparison between dexmedetomidine and midazolam for sedation of eclampsia patients in the intensive care unit. J Crit Care 2009;24:551-555. https://doi.org/10.1016/j.jcrc.2009.02.001
  40. Zhang H, Wang W, Gao W, et al. Effect of propofol on the levels of neurotransmitters in normal human brain: a magnetic resonance spectroscopy study. Neurosci Lett 2009;467:247-251. https://doi.org/10.1016/j.neulet.2009.10.052
  41. Aitkenhead AR, Pepperman ML, Willatts SM, et al. Comparison of propofol and midazolam for sedation in critically ill patients. Lancet 1989;2:704-709.
  42. Kress JP, O'Connor MF, Pohlman AS, et al. Sedation of critically ill patients during mechanical ventilation: a comparison of propofol and midazolam. Am J Respir Crit Care Med 1996;153:1012-1018. https://doi.org/10.1164/ajrccm.153.3.8630539
  43. Chamorro C, de Latorre FJ, Montero A, et al. Comparative study of propofol versus midazolam in the sedation of critically ill patients: results of a prospective, randomized, multicenter trial. Crit Care Med 1996;24:932-939. https://doi.org/10.1097/00003246-199606000-00010
  44. Barrientos-Vega R, Mar Sanchez-Soria M, Morales-Garcia C, Robas-Gomez A, Cuena-Boy R, Ayensa-Rincon A. Prolonged sedation of critically ill patients with midazolam or propofol: impact on weaning and costs. Crit Care Med 1997;25:33-40. https://doi.org/10.1097/00003246-199701000-00009
  45. Hall RI, Sandham D, Cardinal P, et al. Propofol vs midazolam for ICU sedation: a Canadian multicenter randomized trial. Chest 2001;119:1151-1159. https://doi.org/10.1378/chest.119.4.1151
  46. Venn RM, Hell J, Grounds RM. Respiratory effects of dexmedetomidine in the surgical patient requiring intensive care. Crit Care 2000;4:302-308. https://doi.org/10.1186/cc712
  47. Pasin L, Greco T, Feltracco P, et al. Dexmedetomidine as a sedative agent in critically ill patients: a meta-analysis of randomized controlled trials. PLoS One 2013;8:e82913. https://doi.org/10.1371/journal.pone.0082913
  48. U.S. Food and Drug Administration. Highlights of prescribing information, Precedex (dexmedetomidine hydrochloride) injection [Internet]. Silver spring: U.S. Food and Drug Administration, 2014c [cited April 22, 2014]. Available from: http://www.accessdata.fda.gov/drugsatfda_docs/label/2013/021038s022lbl.pdf.
  49. Jakob SM, Ruokonen E, Grounds RM, et al. Dexmedetomidine vs midazolam or propofol for sedation during prolonged mechanical ventilation: two randomized controlled trials. JAMA 2012;307:1151-1160. https://doi.org/10.1001/jama.2012.304
  50. Ely EW, Shintani A, Truman B, et al. Delirium as a predictor of mortality in mechanically ventilated patients in the intensive care unit. JAMA 2004;291:1753-1762. https://doi.org/10.1001/jama.291.14.1753
  51. Lin SM, Liu CY, Wang CH, et al. The impact of delirium on the survival of mechanically ventilated patients. Crit Care Med 2004;32:2254-2259. https://doi.org/10.1097/01.CCM.0000145587.16421.BB
  52. Ouimet S, Kavanagh BP, Gottfried SB, Skrobik Y. Incidence, risk factors and consequences of ICU delirium. Intensive Care Med 2007;33:66-73. https://doi.org/10.1007/s00134-006-0399-8
  53. Farrell KR, Ganzini L. Misdiagnosing delirium as depression in medically ill elderly patients. Arch Intern Med 1995;155:2459-2464. https://doi.org/10.1001/archinte.1995.00430220119013
  54. Kishi Y, Kato M, Okuyama T, et al. Delirium: patient characteristics that predict a missed diagnosis at psychiatric consultation. Gen Hosp Psychiatry 2007;29:442-445. https://doi.org/10.1016/j.genhosppsych.2007.05.006
  55. Devlin JW, Fong JJ, Schumaker G, O'Connor H, Ruthazer R, Garpestad E. Use of a validated delirium assessment tool improves the ability of physicians to identify delirium in medical intensive care unit patients. Crit Care Med 2007;35:2721-2724. https://doi.org/10.1097/01.CCM.0000292011.93074.82
  56. Spronk PE, Riekerk B, Hofhuis J, Rommes JH. Occurrence of delirium is severely underestimated in the ICU during daily care. Intensive Care Med 2009;35:1276-1280. https://doi.org/10.1007/s00134-009-1466-8
  57. Van Eijk MM, van den Boogaard M, van Marum RJ, et al. Routine use of the confusion assessment method for the intensive care unit: a multicenter study. Am J Respir Crit Care Med 2011;184:340-344. https://doi.org/10.1164/rccm.201101-0065OC
  58. Bergeron N, Dubois MJ, Dumont M, Dial S, Skrobik Y. Intensive Care Delirium Screening Checklist: evaluation of a new screening tool. Intensive Care Med 2001;27:859-864. https://doi.org/10.1007/s001340100909
  59. Ely EW, Margolin R, Francis J, et al. Evaluation of delirium in critically ill patients: validation of the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU). Crit Care Med 2001;29:1370-1379. https://doi.org/10.1097/00003246-200107000-00012
  60. Ely EW, Inouye SK, Bernard GR, et al. Delirium in mechanically ventilated patients: validity and reliability of the confusion assessment method for the intensive care unit (CAM-ICU). JAMA 2001;286:2703-2710. https://doi.org/10.1001/jama.286.21.2703
  61. Heo EY, Lee BJ, Hahm BJ, et al. Translation and validation of the Korean Confusion Assessment Method for the Intensive Care Unit. BMC Psychiatry 2011;11:94. https://doi.org/10.1186/1471-244X-11-94
  62. Skrobik Y. Delirium prevention and treatment. Crit Care Clin 2009;25:585-591. https://doi.org/10.1016/j.ccc.2009.05.003
  63. Schiemann A, Hadzidiakos D, Spies C. Managing ICU delirium. Curr Opin Crit Care 2011;17:131-140. https://doi.org/10.1097/MCC.0b013e32834400b5
  64. Van Rompaey B, Elseviers MM, Schuurmans MJ, Shortridge-Baggett LM, Truijen S, Bossaert L. Risk factors for delirium in intensive care patients: a prospective cohort study. Crit Care 2009;13:R77. https://doi.org/10.1186/cc7892
  65. Inouye SK, Zhang Y, Jones RN, Kiely DK, Yang F, Marcantonio ER. Risk factors for delirium at discharge: development and validation of a predictive model. Arch Intern Med 2007;167:1406-1413. https://doi.org/10.1001/archinte.167.13.1406
  66. Girard TD, Pandharipande PP, Carson SS, et al. Feasibility, efficacy, and safety of antipsychotics for intensive care unit delirium: the MIND randomized, placebo-controlled trial. Crit Care Med 2010;38:428-437. https://doi.org/10.1097/CCM.0b013e3181c58715
  67. Rea RS, Battistone S, Fong JJ, Devlin JW. Atypical antipsychotics versus haloperidol for treatment of delirium in acutely ill patients. Pharmacotherapy 2007;27:588-594. https://doi.org/10.1592/phco.27.4.588
  68. Devlin JW, Roberts RJ, Fong JJ, et al. Efficacy and safety of quetiapine in critically ill patients with delirium: a prospective, multicenter, randomized, double-blind, placebo-controlled pilot study. Crit Care Med 2010;38:419-427. https://doi.org/10.1097/CCM.0b013e3181b9e302
  69. Devlin JW, Skrobik Y. Antipsychotics for the prevention and treatment of delirium in the intensive care unit: what is their role? Harv Rev Psychiatry 2011;19:59-67. https://doi.org/10.3109/10673229.2011.565247

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