Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
Review
. 2016 May 5;20(1):128.
doi: 10.1186/s13054-016-1294-5.

Optimizing sedation in patients with acute brain injury

Mauro Oddo  1   2 , Ilaria Alice Crippa  3   4   5 , Sangeeta Mehta  6 , David Menon  7 , Jean-Francois Payen  8 , Fabio Silvio Taccone  5 , Giuseppe Citerio  3   4
Affiliations
Review

Optimizing sedation in patients with acute brain injury

Mauro Oddo et al. Crit Care. .

Abstract

Daily interruption of sedative therapy and limitation of deep sedation have been shown in several randomized trials to reduce the duration of mechanical ventilation and hospital length of stay, and to improve the outcome of critically ill patients. However, patients with severe acute brain injury (ABI; including subjects with coma after traumatic brain injury, ischaemic/haemorrhagic stroke, cardiac arrest, status epilepticus) were excluded from these studies. Therefore, whether the new paradigm of minimal sedation can be translated to the neuro-ICU (NICU) is unclear. In patients with ABI, sedation has 'general' indications (control of anxiety, pain, discomfort, agitation, facilitation of mechanical ventilation) and 'neuro-specific' indications (reduction of cerebral metabolic demand, improved brain tolerance to ischaemia). Sedation also is an essential therapeutic component of intracranial pressure therapy, targeted temperature management and seizure control. Given the lack of large trials which have evaluated clinically relevant endpoints, sedative selection depends on the effect of each agent on cerebral and systemic haemodynamics. Titration and withdrawal of sedation in the NICU setting has to be balanced between the risk that interrupting sedation might exacerbate brain injury (e.g. intracranial pressure elevation) and the potential benefits of enhanced neurological function and reduced complications. In this review, we provide a concise summary of cerebral physiologic effects of sedatives and analgesics, the advantages/disadvantages of each agent, the comparative effects of standard sedatives (propofol and midazolam) and the emerging role of alternative drugs (ketamine). We suggest a pragmatic approach for the use of sedation-analgesia in the NICU, focusing on some practical aspects, including optimal titration and management of sedation withdrawal according to ABI severity.

PubMed Disclaimer

Figures

Fig. 1
Fig. 1
Suggested approach to the management of sedation–analgesia in neurointensive care patients. Note: clinical and neuro-radiological follow-up and indications to intracranial monitoring must be evaluated in all patients. High intracranial pressure (ICP) defined as >20 mmHg
See this image and copyright information in PMC

References

    1. Barr J, Fraser GL, Puntillo K, Ely EW, Gelinas C, Dasta JF, et al. Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit. Crit Care Med. 2013;41:263–306. doi: 10.1097/CCM.0b013e3182783b72. - DOI - PubMed
    1. Jackson DL, Proudfoot CW, Cann KF, Walsh T. A systematic review of the impact of sedation practice in the ICU on resource use, costs and patient safety. Crit Care. 2010;14:R59. doi: 10.1186/cc8956. - DOI - PMC - PubMed
    1. Oddo M, Steiner LA. Sedation and analgesia in the neurocritical care unit. In: Smith M, Kofke WA, Citerio G, editors. Oxford textbook of neurocritical care. Oxford: Oxford University Press; 2016.
    1. Mehta S, Burry L, Cook D, Fergusson D, Steinberg M, Granton J, et al. Daily sedation interruption in mechanically ventilated critically ill patients cared for with a sedation protocol: a randomized controlled trial. JAMA. 2012;308:1985–92. doi: 10.1001/jama.2012.13872. - DOI - PubMed
    1. Strom T, Martinussen T, Toft P. A protocol of no sedation for critically ill patients receiving mechanical ventilation: a randomised trial. Lancet. 2010;375:475–80. doi: 10.1016/S0140-6736(09)62072-9. - DOI - PubMed

MeSH terms