| Guías alemanas para el manejo de la analgesia, sedación y delirio en cuidados intensivos. Versión corta |
Evidence and consensus-based German guidelines for the management of analgesia, sedation and delirium in intensive care-short version.
Martin J, Heymann A, Bäsell K, Baron R, Biniek R, Bürkle H, Dall P, Dictus C, Eggers V, Eichler I, Engelmann L, Garten L, Hartl W, Haase U, Huth R, Kessler P, Kleinschmidt S, Koppert W, Kretz FJ, Laubenthal H, Marggraf G, Meiser A, Neugebauer E, Neuhaus U, Putensen C, Quintel M, Reske A, Roth B, Scholz J, Schröder S, Schreiter D, Schüttler J, Schwarzmann G, Stingele R, Tonner P, Tränkle P, Treede RD, Trupkovic T, Tryba M, Wappler F, Waydhas C, Spies C.
Department of Anesthesiology and Operative Intensive Care, Klinik am Eichert, Göppingen, Germany.
Ger Med Sci. 2010 Feb 2;8:Doc02.
Abstract
Targeted monitoring of analgesia, sedation and delirium, as well as their appropriate management in critically ill patients is a standard of care in intensive care medicine. With the undisputed advantages of goal-oriented therapy established, there was a need to develop our own guidelines on analgesia and sedation in intensive care in Germany and these were published as 2(nd) Generation Guidelines in 2005. Through the dissemination of these guidelines in 2006, use of monitoring was shown to have improved from 8 to 51% and the use of protocol-based approaches increased to 46% (from 21%). Between 2006-2009, the existing guidelines from the DGAI (Deutsche Gesellschaft für Anästhesiologie und Intensivmedizin) and DIVI (Deutsche Interdisziplinäre Vereinigung für Intensiv- und Notfallmedizin) were developed into 3(rd) Generation Guidelines for the securing and optimization of quality of analgesia, sedation and delirium management in the intensive care unit (ICU). In collaboration with another 10 professional societies, the literature has been reviewed using the criteria of the Oxford Center of Evidence Based Medicine. Using data from 671 reference works, text, diagrams and recommendations were drawn up. In the recommendations, Grade "A" (very strong recommendation), Grade "B" (strong recommendation) and Grade "0" (open recommendation) were agreed. As a result of this process we now have an interdisciplinary and consensus-based set of 3(rd) Generation Guidelines that take into account all critically illness patient populations. The use of protocols for analgesia, sedation and treatment of delirium are repeatedly demonstrated. These guidelines offer treatment recommendations for the ICU team. The implementation of scores and protocols into routine ICU practice is necessary for their success.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2830566/pdf/GMS-08-02.pdf
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| Estrategias para optimizar analgesia y sedación |
Strategies to optimize analgesia and sedation.
Schweickert WD, Kress JP.
Division of Pulmonary, Allergy and Critical Care, University of Pennsylvania Medical Center, Spruce Street, Philadelphia, Pennsylvania 19104, USA.
Crit Care. 2008;12 Suppl 3:S6. Epub 2008 May 14.
Abstract
Achieving adequate but not excessive sedation in critically ill, mechanically ventilated patients is a complex process. Analgesics and sedatives employed in this context are extremely potent, and drug requirements and metabolism are unpredictable. Clinicians must have heightened awareness of the potential for enduring effects and are encouraged to employ strategies that maximize benefit while minimizing risk. Successful sedation protocols have three basic components: frequent assessments for pain, anxiety, and agitation using a reproducible scale; combination therapy coupling opioids and sedatives; and, most importantly, careful communication between team members, with a particular recognition that the bedside nurse must be empowered to pair assessments with drug manipulation. In recent years, two broad categories of sedation protocols have achieved clinical success in terms of decreasing duration of mechanical ventilation and intensive care unit length of stay by minimizing drug accumulation. Patient-targeted sedation protocols (the first category) rely on structured assessments to guide a careful schema of titrated drug escalation and withdrawal. Variation exists in the assessment tool utilized, but the optimal goal in all strategies is a patient who is awake and can be readily examined. Alternatively, daily interruption of continuous sedative infusions (the second category) may be employed to focus care providers on the goal of achieving a period of awakening in the earliest phases of critical illness possible. Newer literature has focused on the safety of this strategy and its comparison with intermittent drug administration. Ongoing investigations are evaluating the broad applicability of these types of protocols, and currently one may only speculate on whether one strategy is superior to another
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2391265/pdf/cc6151.pdf
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