Sedación en UCI/ICU sedation

Optimizando el uso sostenido de sedación en paciente con ventilación mecánica: centrándose en la seguridad


Optimizing sustained use of sedation in mechanically ventilated patients: focus on safety.
Arnold HM, Hollands JM, Skrupky LP, Mice ST.
Department of Pharmacy, Barnes-Jewish Hospital, St. Louis, MO 63110, USA.
Curr Drug Saf. 2010 Jan;5(1):6-12.
Abstract
Optimizing sustained use of ICU sedation in mechanically ventilated patients requires careful consideration of drug-specific characteristics (E.G. pharmacokinetics), consideration of potential adverse effects in susceptible patients, and utilization of sedation-minimizing strategies. In the era of anxiolytic dosing protocols adjusted to specific patient behaviors as defined by sedation scales in conjunction with daily interruption, midazolam is a reasonable option for long-term sedation. Propofol is an appealing agent for ICU sedation due to it's pharmacokinetic profile and a reduced propensity to result in prolonged sedation. However, care should be taken to monitor for potential devastating adverse effects including hypertriglyceridemia and propofol-related infusion syndrome (PRIS). Dexmedetomidine unreliably provides adequate sedation at doses currently approved by the FDA, though upward titration of dexmedetomidine coupled with rescue benzodiazepines and/or fentanyl appears to be safe and comparable to benzodiazepines in the achievement of light to moderate Richmond Agitation Sedation Scale (RASS) goals. Clinicians should closely monitor patients receiving dexmedetomidine for hemodynamic-altering bradycardia. Strategies that promote frequent patient assessment with corresponding sedative dose minimization have demonstrated the benefits of limiting oversedation. Implementation of a sedation protocol requires careful consideration of ICU resources and staffing such that efforts made are sustainable and will be safe and effective for the patient population affected.


http://www.eurekaselect.com/70525/article


Dexmedetomidina vs midazolam para sedación en pacientes graves: estudio randomizado

Dexmedetomidine vs midazolam for sedation of critically ill patients: a randomized trial.
Riker RR, Shehabi Y, Bokesch PM, Ceraso D, Wisemandle W, Koura F, Whitten P, Margolis BD, Byrne DW, Ely EW, Rocha MG; SEDCOM (Safety and Efficacy of Dexmedetomidine Compared With Midazolam) Study Group. Collaborators (66)
Torres Boden M, Ceraso D, Raimondi A, Gonzalez M, Shehabi Y, Turner A, Ernest D, Dobb G, Dias F, Rocha M, Baruzzi A, da Silva I, Rezende E, Margolin G, Feldman J, Tillinghast J, Geller E, Singla N, Dexter J, Jones K, Tang J, Cheng E, Douglas I, Fulda G, Herr D, Anderson L, Kett D, Basile J, Silverboard H, Cowen J, Margolis B, Whitten P, Simpson S, Bradley J, Koura F, Conrad S, Shanholtz C, Kahn R, Riker R, Bekemeyer W, Simonds D, Morrow L, Littman J, Shander A, Cuibotaru R, Dicpinigaitis P, George L, Groth M, Carpati C, Kaufman D, Wilson J, Ordal J, Schoenhals J, Haupt M, Hoyt J, Flume P, Handshoe D, Pugazhenthi M, Ramsay M, Cardenas V, Minkowitz H, Fujii T, Baker A, Henderson S, Freebairn R, McHugh G.
University of Vermont College of Medicine, USA. rikerr@mmc.org
JAMA. 2009 Feb 4;301(5):489-99. doi: 10.1001/jama.2009.56. Epub 2009 Feb 2
Abstract
CONTEXT: Gamma-aminobutyric acid receptor agonist medications are the most commonly used sedatives for intensive care unit (ICU) patients, yet preliminary evidence indicates that the alpha(2) agonist dexmedetomidine may have distinct advantages. OBJECTIVE: To compare the efficacy and safety of prolonged sedation with dexmedetomidine vs midazolam for mechanically ventilated patients. DESIGN, SETTING, AND PATIENTS: Prospective, double-blind, randomized trial conducted in 68 centers in 5 countries between March 2005 and August 2007 among 375 medical/surgical ICU patients with expected mechanical ventilation for more than 24 hours. Sedation level and delirium were assessed using the Richmond Agitation-Sedation Scale (RASS) and the Confusion Assessment Method for the ICU. INTERVENTIONS: Dexmedetomidine (0.2-1.4 microg/kg per hour [n = 244]) or midazolam (0.02-0.1 mg/kg per hour [n = 122]) titrated to achieve light sedation (RASS scores between -2 and +1) from enrollment until extubation or 30 days. MAIN OUTCOME MEASURES: Percentage of time within target RASS range. Secondary end points included prevalence and duration of delirium, use of fentanyl and open-label midazolam, and nursing assessments. Additional outcomes included duration of mechanical ventilation, ICU length of stay, and adverse events. RESULTS: There was no difference in percentage of time within the target RASS range (77.3% for dexmedetomidine group vs 75.1% for midazolam group; difference, 2.2% [95% confidence interval {CI}, -3.2% to 7.5%]; P = .18). The prevalence of delirium during treatment was 54% (n = 132/244) in dexmedetomidine-treated patients vs 76.6% (n = 93/122) in midazolam-treated patients (difference, 22.6% [95% CI, 14% to 33%]; P < .001). Median time to extubation was 1.9 days shorter in dexmedetomidine-treated patients (3.7 days [95% CI, 3.1 to 4.0] vs 5.6 days [95% CI, 4.6 to 5.9]; P = .01), and ICU length of stay was similar (5.9 days [95% CI, 5.7 to 7.0] vs 7.6 days [95% CI, 6.7 to 8.6]; P = .24). Dexmedetomidine-treated patients were more likely to develop bradycardia (42.2% [103/244] vs 18.9% [23/122]; P < .001), with a nonsignificant increase in the proportion requiring treatment (4.9% [12/244] vs 0.8% [1/122]; P = .07), but had a lower likelihood of tachycardia (25.4% [62/244] vs 44.3% [54/122]; P < .001) or hypertension requiring treatment (18.9% [46/244] vs 29.5% [36/122]; P = .02). CONCLUSIONS: There was no difference between dexmedetomidine and midazolam in time at targeted sedation level in mechanically ventilated ICU patients. At comparable sedation levels, dexmedetomidine-treated patients spent less time on the ventilator, experienced less delirium, and developed less tachycardia and hypertension. The most notable adverse effect of dexmedetomidine was bradycardia.
http://jama.jamanetwork.com/article.aspx?articleid=183300




Atentamente
Dr. Juan Carlos Flores-Carrillo
Anestesiología y Medicina del Dolor
www.anestesia-dolor.org