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CHAPTER 22: Pain Control, Sedation, and Use of Muscle Relaxants 145

predispose to hypoglycemia in critically ill patients. 26,27 Observational
studies have reported a clear relationship between poor outcome in criti- • While the administration of sedatives and analgesics to the criti-
cally ill patients and BG variability. 28,29 cally ill patient is indicated for a variety of conditions ranging from
relief of suffering to facilitation of lung protective strategies of
CONCLUSIONS AND CURRENT RECOMMENDATIONS mechanical ventilation, continued reassessment of the need for
and means of providing sedation is necessary to prevent the pro-
Several issues related to IIT are left unsolved, including the optimal BG longation of mechanical ventilation.
target, the categories of patients who could benefit from IIT, and the • Intravascular catheters, endotracheal intubation, suctioning,
logistical requirements for a safe and reliable glucose control. Technical immobility, and underlying illnesses all may cause pain in the
advances that could improve the quality and safety of glucose control critically ill patient. While physical remedies always should be
include continuous intravascular glucose monitoring and computerized tried—eg, repositioning a patient to alleviate arthritic pain—most
automated algorithms for insulin infusion. Meanwhile, recommendations patients require intravenous narcotics at least initially. Thus ade-
for the daily practice are needed. In the absence of unequivocal evidence quate sedation begins with adequate analgesia.
from clinical trials, formal expert recommendations have been issued
for hospital inpatients and for critically ill and postoperative patients. 30,31 • Regional pain control techniques, such as with epidural catheter–
These guidelines based on exhaustive reviews of the literature available administered anesthetics or opiates, can be highly effective at achiev-
in 2009 by panels of experts consistently recommend that glucose level ing pain control in the postoperative patient. The placement and
should be maintained below 180 mg/dL in critically ill patients. removal of such catheters require correction of any underlying coagu-
lation abnormalities in order to reduce the risk of epidural hematoma.
• The evaluation of sedation adequacy can only be performed at the
KEY REFERENCES bedside and is facilitated by the use of a validated sedation scale,
• Brownlee M. Biochemistry and molecular cell biology of diabetic such as the Richmond Agitation-Sedation Scale, along with a pro-
complications. Nature. 2001;414:813-820. tocol for the systematic assessment and administration of sedatives
• Brunkhorst FM, Engel C, Bloos F, et al. Intensive insulin therapy and analgesics.
and pentastarch resuscitation in severe sepsis? N Engl J Med. • Although both continuous and intermittent bolus strategies for
2008;358:125-139. sedative administration have been advocated, the two strategies
• Dungan KM, Braithwaite SS, Preiser JC. Stress hyperglycaemia. have not been compared directly in a large, randomized, controlled
trial. Regardless of the approach used, some patients require larger
Lancet. 2009;23:1798-1807. doses of sedatives—often in excess of drug manufacturer guide-
• NICE-SUGAR Study Investigators, Finfer S, Chittock DR, et lines. Thus the level of sedation must be reassessed continuously
al. Intensive versus conventional glucose control in critically ill and a protocol for downward titration of sedation applied.
patients. N Engl J Med. 2009;360:1283-1297. • If continuous administration is used, daily sedative interruption
• Preiser JC, Devos P, Ruiz-Santana S, et al. A prospective ran- is recommended to prevent drug accumulation, allow the per-
domised multi-centre controlled trial on tight glucose control formance of a neurologic examination, and permit reassessment
by intensive insulin therapy in adult intensive care units: the of the need for sedation. If resedation is required, restarting the
Glucontrol study. Intensive Care Med. 2009;35:1738-1748. infusion at half the previous dose, with subsequent titration as
• Shepherd PR, Kahn BB. Glucose transporters and insulin action. necessary, is a useful strategy for systematic downward titration.
N Engl J Med. 1999;341:248-257. • Prolonged (>48 hours) neuromuscular blockade should be used as
• Van den Berghe G, Wouters P, Weekers F, et al. Intensive insulin a last resort owing to the high incidence of neuromuscular com-
therapy in the critically ill patients. N Engl J Med. 2001;345:1359-1367. plications associated with this practice in critically ill patients. In
particular, the administration of these agents in combination with
high-dose corticosteroids is discouraged.
REFERENCES

Complete references available online at www.mhprofessional.com/hall Administration of analgesics and sedatives is commonplace in the ICU.
Unfortunately, many early studies of analgesic and sedative medications
were performed in the operating room, a setting very different from the
CHAPTER Pain Control, Sedation, and ICU. The clinician must recognize the diverse and often unpredictable
effects of critical illness on the pharmacokinetics and pharmacodynam-
22 Use of Muscle Relaxants ics of sedatives and analgesics. Failure to recognize these effects may lead
to inadequate or excessive sedation. Sedatives and analgesics may cause
Sarah Sokol prolonged alterations in mental status and may mask the development
Bhakti K. Patel of coincident complications of critical illness. Data studying the effects
Ishaq Lat of analgesia and sedation in the ICU have accumulated in the last two
John P. Kress decades and have had important influences on this aspect of critical
care. As outcomes data have become available, analgesia and sedation
practices driven by protocol guidelines have emerged.
KEY POINTS
INDICATIONS FOR SEDATION AND ANALGESIA
• Sedatives and analgesics used commonly in the care of critically
ill patients often exhibit pharmacokinetics and pharmacodynam- Analgesia and sedation needs vary widely in ICU patients. Although
ics that are significantly different when compared with studies of nonpharmacologic means such as comfortable positioning in bed and
their use in other arenas, such as the operating room. Knowledge verbal reassurance should be considered initially, treatment with anal-
of these differences is crucial to designing a sedation protocol for gesic and sedative agents is frequently needed. An effective approach to
the critically ill patient. the use of analgesics and sedatives in critically ill patients begins with
an understanding of the various indications for their use in this setting.

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