figure 1
Algorithm for the management of sedation in the neurointensive care units
High ICP Yes
Sedation analgesia Propofol Titrated to ICP monitoring
Reduce / stop sedation / analgesia Titrated to ICP monitoring
No Clinical deterioration
Clinical examination +/ - brain imaging
Pain Yes
Analgesia Fentanyl
No
Agitation / delirium Yes
Anxiolytics α2 agonists Haloperidol
No
Ventilator asynchrony
Yes
Ventilator adjustment
No No sedation
Adapted from reference 1
because of its high lipid solubility , thereby prolonging time to awakening . 43
Barbiturates The use of barbiturates has been limited owing to their undesirable side effect profile , for example , immunosupressant properties and negative ionotropic effects . Pentobarbital is an extended drug used for refractory status epilepticus or elevated ICP . 44 – 46 They are considered second-line therapy for the control of ICP , after propofol .
Dexmedetomidine Dexmedetomidine is an alpha-2 agonist acting on the central nervous system , with a rapid onset and termination of activity . It offers mild to moderate sedation without significant respiratory depression , analgesic effects and less delirium than with benzodiazepines . 47 Side effects include bradycardia and hypotension , with bradycardia being the most typical haemodynamic effect . 48
Grof and Bledsoe demonstrated that neurocritically ill patients may require high doses of dexmedetomidine to achieve desired levels of sedation and to wean off adjunctive analgesic and / or sedative agents . Infusions may be started at doses from 0.4 – 1mg / kg / hour in neurocritical care patients to achieve target levels of sedation . 44
In a study by Erdman et al , limiting dose titration to every 30 min and omitting a bolus dose resulted in no significant difference in the prevalence of hypotension or bradycardia between dexmedetomidine and propofol . 49
It also appears to shorten time to extubation
71 HHE 2018 | hospitalhealthcare . com