March 2002 / Volume 47 / Number 3 / Page 334
Sedation and Paralysis During Mechanical Ventilation
IntroductionTreatment of anxiety and delirium, provision of adequate analgesia, and, when necessary, amnesia in critically ill patients is humane and may reduce the incidence of post-traumatic stress disorders. Injudicious use of sedatives and paralytics to produce a passive and motionless patient, however, may prolong weaning and length of stay in the intensive care unit. This report reviews indications and choices for pharmacologic treatment of anxiety, delirium, agitation, and provision of anesthesia in critically ill patients. The choice of pharmacologic agents is made difficult by complex or poorly understood pharmacokinetics, drug actions, and adverse effects in critically ill patients. Advantages, adverse effects, and limitations of drug treatment, including use of neuromuscular blocking drugs and use of sedatives and analgesia during the withdrawal of life-sustaining measures are reviewed.
Terms and Definitions
Anesthesia and Deep Sedation
Neuromuscular Blocking Drugs
Possible Indications for Pharmacological Paralysis
Difficulties with Neuromuscular Blockade
Choice of Neuromuscular Blocking Drug
Delivery of Neuromuscular Blocking Drugs
Monitoring of Neuromuscular Function
Reversal of Neuromuscular Blockade
Pharmacologic Intervention During End-of-Life Care
Post-traumatic stress disorder is common in survivors of critical illness. Among acute respiratory distress syndrome patients, those recalling multiple distressing experiences during their intensive care unit (ICU) stay had the highest degree of impairment after recovery from acute illness. Treatment of anxiety and delirium, provision of adequate analgesia and, when necessary, amnesia is not only humane, but may reduce the incidence of post-traumatic stress disorders in survivors. Excessive use of sedatives and neuromuscular blocking drugs (NMBDs), however, may prolong the duration of mechanical ventilation and ICU stay. Finding an appropriate balance between relief of pain, anxiety, and discoordination during mechanical ventilation, and wakefulness and the ability to breathe spontaneously is a challenge for those caring for critically ill patients.