Journal of Emergency and Critical Care Medicine. January 2018.
“Sedation in the intensive care patient is a fine art…”. Rather than a modified general anaesthetic of the past, we now take into account advances in ventilator technology, and consider how length of stay, iatrogenic effects, delirium and extended rehabilitation may be affected by the way that sedation is performed.
Trauma patients potentially have the added complications of multi-system dysfunction, significant analgesic requirements and repeated surgeries. They often require deep sedation to control pain, anxiety and agitation, allowing initial and subsequent management of their conditions, to include active treatments such as traction, splinting, dressing change etc.
The paper runs through some commonly used drugs, including propofol, opioids, benzodiazepines, ketamine, barbiturates and α2 agonists, describing some pharmacokinetics and pharmacodynamics of these drugs.
Sedation needs to be monitored to minimise over- and under-sedation, and thus the effects on multiple organ systems, in addition to side effects from prolonged immobility and potential immunosuppressive effects of many sedative agents. Commonly used sedation scores are discussed.
Pain, Agitation and Delirium in the Trauma Patient
The physiological effects of poorly treated pain are discussed, regional techniques may need to be considered. The risk of chronic (moderately severe) pain at 1 year post-injury is around 60% of patients with major trauma.
The causes and effects of agitation in the trauma patient are mentioned, with special attention to sleep deprivation, and that we should consider the noise, light and environment that patients are subject to. Potential for withdrawal from alcohol, nicotine, drugs (illicit or iatrogenic) need to be considered with respect to agitation. The risk and level of delirium need to be assessed and measures taken to reduce this.
Sedation in the Brain Injured Patient
In addition to the aforementioned aspects of care, patients with a head injury need to be appropriately managed to prevent a secondary injury. Control of intracranial pressure, arterial blood pressure, adequacy of ventilation and decreasing risks of cerebral hypermetabolism (e.g. seizures) are crucial.
Clinical Observations, Sedation Holds and Weaning
Close monitoring of injuries is required to for early diagnosis of deterioration. Sedation may interfere with clinical observations and additional investigations will contribute to the whole picture. Sedation holds may be necessary for patient assessment, and has also been shown to be beneficial in reducing time to extubation and length of stay.
Sedation in the trauma patient is a complex issue. Many hospitals use care bundles such as the PAD guidelines or ABCDE bundle to ensure a multi-disciplinary approach. The end goal is a “calm, cooperative, comfortable patient who makes a smooth and swift journey through the ICU…with minimal long term psychological disturbance”.
Discussion from Journal Club
The focus of our discussion was mostly the curveballs trauma patients can throw and to remember to pay attention to detail.
Summary by Dr PY Kuo. Journal Club 01 March 2018.