Analgosedation for ICU Sedation and Pain Management

Abstract and Introduction

Abstract

Sedation practices in the critical care unit have been trending toward lighter sedation since the start of the new millennium, but patients continue to experience inadequate pain management and excessive sedation. This paper includes a brief examination of the problem of pain management in the ICU; trends in sedation practices, including light sedation and the daily interruption of sedation; and a literature review of analgosedation. While the analgosedation literature is relatively sparse, it offers a promising, patient-centered method for managing the triad of pain, agitation, and delirium, while reducing common complications associated with long-term ventilation. This paper concludes with a recommended method for analgosedation, the nursing implications, and a discussion of limitations and recommendations.

Introduction

Pain is a common experience among critically ill patients and is often unrecognized and/or undertreated, which can hinder a patient's recovery (Alderson & McKechnie, 2013; Joshi & Ogunnaike, 2005; Pasero, et al., 2009; Stites, 2013). Because of the nature of critically ill patients' ailments, mechanical ventilation is often a necessary lifesaving intervention that can impede the assessment of pain (McConville & Kress, 2012; Wunsch et al., 2010). Sedative hypnotic drugs such as benzodiazepines and general anesthetics are favored in current sedation practices; however, both have been associated with side effects that delay recovery and neither have analgesic properties (Devabhakthuni, Armahizer, Dasta, & Kane-Gill, 2012; Kress, Pohlman, O'Connor, & Hall, 2000; Maraboto, 2013; Mehta, McCullagh, & Burry, 2009; Weinert & Calvin, 2007). To complicate matters, many patients experience oversedation, which delays recovery further (Devabhakthuni et al., 2012; Mehta et al., 2009). To mitigate oversedation, daily interruptions of sedation have become accepted as a key practice for minimizing sedative use and its associated complications (Kress et al., 2000; Pun & Dunn, 2007b; Sedwick, Lance-Smith, Reeder, & Nardi, 2012; Siegele, 2009). Analgosedation is another sedative-minimizing technique; while not eliminating the use of sedatives entirely, it prioritizes pain control and analgesia use, saving sedative agents for rescue therapy only (Devabhakthuni et al., 2012). Clearly, pain management is of utmost importance in the critical care setting, as prevalent sedative practices may not optimally minimize sedative use and may lead to uncontrolled levels of pain among critically ill patients. Analgosedation, an emerging practice, is explored in this article with the hope of providing better pain management and sedation to critically ill patients.

Table 1. Analgosedation Studies, Their Populations, and Methods Used
Study	ICU Population*	Methods/Drugs Compared
Breen et al., 2005	Medical and postsurgical patients	Analgosedation: Remifentanil infusion with midazolam infusion PRN vs. Traditional sedation: Midazolam-based infusion PLUS fentanyl OR morphine infusions for pain control
Carrer et al., 2007	Surgical	Analgosedation: Morphine infusion with diazepam bolus PRN vs. Analgosedation: Morphine infusion plus reminfentanil infusion with midazolam bolus PRN
Chinachoti et al., 2002	General	Analgosedation: Remifentanil infusion with midazolam infusion PRN vs. Analgosedation: Morphine infusion with midazolam infusion PRN
Dahaba et al., 2004	Orthopedic and general surgery	Analgosedation: Remifentanil infusion with midazolam infusion PRN vs. Analgosedation: Morphine infusion with midazolam infusion PRN
Egerod et al., 2010	Neurological	Analgosedation (postintervention): Remifentanil infusion (3–5 days) OR fentanyl (for traumatic brain injury or estimated longer need) with propofol infusion PRN (until limit) THEN midazolam bolus/infusion PRN THEN phenobarbital OR pentobarbital OR thiopental PRN (considered because of neurological population) vs. Traditional sedation (preintervention): propofol OR midazolam infusion PLUS fentanyl or morphine
Karabinis et al., 2004	Neurological: brain injury or neurosurgery	Analgosedation: Remifentanil infusion with propofol (1–3 days) THEN midazolam infusions PRN vs. Traditional sedation: Propofol (1–3 days) THEN midazolam infusions PLUS fentanyl or morphine
Muellejans et al., 2004	Cardiac, general surgical, or medical	Analgosedation: Remifentanil infusion with propofol infusion PRN vs. Analgosedation: Fentanyl infusion with propofol infusion PRN
Muellejans et al., 2006	Cardiac surgery	Analgosedation: Remifentanil infusion with propofol infusion PRN vs. Traditional sedation: Midazolam infusion PLUS fentanyl infusion
Rozendaal et al., 2009	Medical and surgical	Analgosedation: Remifentanil infusion with propofol infusion PRN vs. Traditional sedation: Propofol OR midazolam OR lorazepam infusions with fentanyl OR morphine infusions
Strøm et al., 2010	Medical and surgical	Analgosedation: Morphine boluses only vs. Analgosedation: Propofol infusion (48 hours) then midazolam infusion PLUS morphine boluses

Table 1. Analgosedation Studies, Their Populations, and Methods Used

Study

ICU Population*

Methods/Drugs Compared

Breen et al., 2005

Medical and postsurgical patients

Analgosedation: Remifentanil infusion with midazolam infusion PRN
vs.
Traditional sedation: Midazolam-based infusion PLUS fentanyl OR morphine infusions for pain control

Carrer et al., 2007

Surgical

Analgosedation: Morphine infusion with diazepam bolus PRN
vs.
Analgosedation: Morphine infusion plus reminfentanil infusion with midazolam bolus PRN

Chinachoti et al., 2002

General

Analgosedation: Remifentanil infusion with midazolam infusion PRN
vs.
Analgosedation: Morphine infusion with midazolam infusion PRN

Dahaba et al., 2004

Orthopedic and general surgery

Analgosedation: Remifentanil infusion with midazolam infusion PRN
vs.
Analgosedation: Morphine infusion with midazolam infusion PRN

Egerod et al., 2010

Neurological

Analgosedation (postintervention): Remifentanil infusion (3–5 days) OR fentanyl (for traumatic brain injury or estimated longer need) with propofol infusion PRN (until limit) THEN midazolam bolus/infusion PRN THEN phenobarbital OR pentobarbital OR thiopental PRN (considered because of neurological population)
vs.
Traditional sedation (preintervention): propofol OR midazolam infusion PLUS fentanyl or morphine

Karabinis et al., 2004

Neurological: brain injury or neurosurgery

Analgosedation: Remifentanil infusion with propofol (1–3 days) THEN midazolam infusions PRN
vs.
Traditional sedation: Propofol (1–3 days) THEN midazolam infusions PLUS fentanyl or morphine

Muellejans et al., 2004

Cardiac, general surgical, or medical

Analgosedation: Remifentanil infusion with propofol infusion PRN
vs.
Analgosedation: Fentanyl infusion with propofol infusion PRN

Muellejans et al., 2006

Cardiac surgery

Analgosedation: Remifentanil infusion with propofol infusion PRN
vs.
Traditional sedation: Midazolam infusion PLUS fentanyl infusion

Rozendaal et al., 2009

Medical and surgical

Analgosedation: Remifentanil infusion with propofol infusion PRN
vs.
Traditional sedation: Propofol OR midazolam OR lorazepam infusions with fentanyl OR morphine infusions

Strøm et al., 2010

Medical and surgical

Analgosedation: Morphine boluses only
vs.
Analgosedation: Propofol infusion (48 hours) then midazolam infusion PLUS morphine boluses