Consensus Statement on Analgo-sedation in Neurocritical Care and Review of Literature
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Consensus Statement on Analgo-sedation in Neurocritical Care and Review of Literature. Indian J Crit Care Med 2021; 25 (2):126-133.
Aim and objective: Our main objective in developing this consensus is to bring together a set of most agreed-upon statements from a panel of global experts that would act as a guide for clinicians working in neurocritical care units (NCCUs). Background: Given the physiological benefits of analgo-sedation in the NCCU, there is little information on their tailoring in the NCCU. This lack of evidence and guidelines on the use of sedation and analgesia in patients with neurological injury leads to a variation in clinical care based on patient requirements and institutional protocols. Review results: Thirty-nine international experts agreed to be a member of this consensus panel. A Delphi method based on a Web-based questionnaire developed with Google Forms on a secure institute server was used to seek opinions of experts. Questions were related to sedation and analgesia in the neurocritical care unit. A predefined threshold of agreement was established as 70% to support any recommendation, strong, moderate, or weak. No recommendations were made below this threshold. Responses were collected from all the experts, summated, and expressed as percentage (%). After three rounds, consensus could be reached for 6 statements related to analgesia and 5 statements related to sedation. Consensus could not be reached for 10 statements related to analgesia and 5 statements related to sedation. Conclusion: This global consensus statement may help in guiding practitioners in clinical decision-making regarding analgo-sedation in the NCCUs, thereby helping in improving patient recovery profiles. Clinical significance: In the lack of high-level evidence, the recommendations may be seen as the current best clinical practice.
Vanaclocha N, Chisbert V, Quilis V, Bilotta F, Badenes R. Sedation during neurocritical care. J Neuroanaesth Crit Care 2019;6:56–61. DOI: 10.1055/s-0039-1688897.
Chester K, Greene KN, Brophy GM. Sedation in the critical care unit. In: Prabhakar H, Ali Z. Textbook of Neuroanesthesia and Neurocritical Care, Vol II, 1st ed. Singapore: Springer; 2019. p. 299–318. DOI: 10.1007/978-981-13-3390-3_21.
Fischer M, Jackson M, Abd-Elsayed A. Pain in the neurocritical care unit. In: Prabhakar H, Ali Z. Textbook of Neuroanesthesia and Neurocritical Care, Vol II, 1st ed. Singapore: Springer; 2019. p. 319–331. DOI: 10.1007/978-981-13-3390-3_22.
Hannawi Y, Ziai WC. Analgesia, sedation, and paralysis in the neurocritical care Unit. In: Torbey MT. Neurocritical Care, 2nd ed. Cambridge: Cambridge University Press; 2019. p. 33–49. DOI: 10.1017/9781107587908.005.
Devlin JW, Skrobik Y, Gélinas C, Needham DM, Slooter AJC, Pandharipande PP, et al. Clinical practice guidelines for the prevention and management of pain, agitation/sedation, delirium, immobility, and sleep disruption in adult patients in the ICU. Crit Care Med 2018;46(9):e825–e873. DOI: 10.1097/CCM.0000000000003299.
Teitelbaum JS, Ayoub O, Skrobik Y. A critical appraisal of sedation, analgesia and delirium in neurocritical care. Can J Neurol Sci 2011;38(6):815–825. DOI: 10.1017/s0317167100012385.
May TL, Riker RR, Fraser GL, Hirsch KG, Agarwal S, Duarte C, et al. Variation in sedation and neuromuscular blockade regimens on outcome after cardiac arrest. Crit Care Med 2018;46(10):e975–e980. DOI: 10.1097/CCM.0000000000003301.
Meyfroidt G, Smith M. Focus on delirium, sedation and neuro critical care 2019: towards a more brain-friendly environment? Intensive Care Med 2019;45(9):1292–1294. DOI: 10.1007/s00134-019-05701-2.
Oddo M, Crippa IA, Mehta S, Menon D, Payen J-F, Taccone FS, et al. Optimizing sedation in patients with acute brain injury. Crit Care 2016;20(1):128. DOI: 10.1186/s13054-016-1294-5.
Roberts DJ, Haroon B, Hall RI. Sedation for critically ill or injured adults in the intensive care unit: a shifting paradigm. Drugs. 2012;72(14):1881–1916. DOI: 10.2165/11636220-000000000-00000.
Barr J, Fraser GL, Puntillo K, 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(1):263–306. DOI: 10.1097/CCM.0b013e3182783b72.
Skrobik Y, Chanques G. The pain, agitation, and delirium practice guidelines for adult critically ill patients: a post-publication perspective. Ann Intensive Care 2013;3(1):9. DOI: 10.1186/2110-5820-3-9.
Rajajee V, Riggs B, Seder DB. Emergency neurological life support: airway, ventilation, and sedation. Neurocrit Care 2017;27(Suppl 1):4–28. DOI: 10.1007/s12028-017-0451-2.
de Jong A, Molinari N, de Lattre S, et al. Decreasing severe pain and serious adverse events while moving intensive care unit patients: a prospective interventional study (the NURSE-DO project). Crit Care 2013;17(2):R74. DOI: 10.1186/cc12683.
Merskey H, Bogduk N. Classification of chronic pain: descriptions of chronic pain syndromes and definitions of pain terms. Task Force on Taxonomy of the International Association for the Study of Pain. 2nd ed. Seattle, WA: IASP Press; 1994.
Devlin JW, Marquis F, Riker RR, Robbins T, Garpestad E, Fong JJ, et al. Combined didactic and scenario-based education improves the ability of intensive care unit staff to recognize delirium at the bedside. Crit Care 2008;12(1):R19. DOI: 10.1186/cc6793.
Herr K, Coyne PJ, Ely E, Gélinas C, Manworren RCB. Pain assessment in the patient unable to self-report: clinical practice recommendations in support of the ASPMN 2019 position statement. Pain Manag Nurs 2019;20(5):404–417. DOI: 10.1016/j.pmn.2019.07.005.
Arbour C, Choiniere M, Topolovec-Vranic J, Loiselle CG, Puntillo K, Gélinas C. Detecting pain in traumatic brain-injured patients with different levels of consciousness during common procedures in the ICU: typical or atypical behaviors? Clin J Pain 2014;30(11):960–969. DOI: 10.1097/AJP.0000000000000061.
Yu A, Teitelbaum J, Scott J, Gesin G, Russell B, Huynh T, et al. Evaluating pain, sedation, and delirium in the neurologically critically ill-feasibility and reliability of standardized tools: a multi-institutional study. Crit Care Med 2013;41(8):2002–2007. DOI: 10.1097/CCM.0b013e31828e96c0.
Dehghani H, Tavangar H, Ghandehari A. Validity and reliability of behavioral pain scale in patients with low level of consciousness due to head trauma hospitalized in intensive care unit. Arch Trauma Res 2014;3(1):e18608. DOI: 10.5812/atr.18608.
Echegaray-Benites C, Kapoustina O, Gélinas C. Validation of the use of the Critical-Care Pain Observation Tool (CPOT) with brain surgery patients in the neurosurgical intensive care unit. Intensive Crit Care Nurs 2014;30(5):257–265. DOI: 10.1016/j.iccn.2014.04.002.
Joffe AM, McNulty B, Boitor M, Marsh R, Gélinas C. Validation of the Critical-Care Pain Observation Tool in brain-injured critically ill adults. J Crit Care 2016;36:76–80. DOI: 10.1016/j.jcrc.2016.05.011.
Shan K, Cao W, Yuan Y, Hao J-J, Sun X-M, He X, et al. Use of the critical-care pain observation tool and the bispectral index for the detection of pain in brain-injured patients undergoing mechanical ventilation: a STROBE-compliant observational study. Medicine (Baltimore) 2018;97(22):e10985. DOI: 10.1097/MD.0000000000010985.
Devabhakthuni S, Armahizer MJ, Dasta JF, Kane-Gill SL. Analgosedation: a paradigm shift in intensive care unit sedation practice. Ann Pharmacother 2012;46(4):530–540. DOI: 10.1345/aph.
Karabinis A, Mandragos K, Stergiopoulos S, Komnos A, Soukup J, Speelberg B, et al. Safety and efficacy of analgesia-based sedation with remifentanil versus standard hypnotic-based regimens in intensive care unit patients with brain injuries: a randomised, controlled trial [ISRCTN50308308]. Crit Care 2004;8(4):R268–280. DOI: 10.1186/cc2896.
Skrobik Y, Ahern S, Leblanc M, Marquis F, Awissi DK, Kavanagh BP. Protocolized intensive care unit management of analgesia, sedation, and delirium improves analgesia and subsyndromal delirium rates. Anesth Analg 2010;111(2):451–463. DOI: 10.1213/ANE.0b013e3181d7e1b8.
Zeiler FA, AlSubaie F, Zeiler K, Bernard F, Skrobik Y. Analgesia in neurocritical care: an international survey and practice audit. Crit Care Med 2016;44(5):973–980. DOI: 10.1097/CCM.0000000000001602.
Brain Trauma Foundation; American Association of Neurological Surgeons; Congress of Neurological Surgeons; Guidelines for the management of severe traumatic brain injury. XI. Anesthetics, analgesics, and sedatives. J Neurotrauma 2007;24 Suppl 1:S71–S76. DOI: 10.1089/neu.2007.9985.
Brophy GM, Bell R, Claassen J, Alldredge B, Bleck TP, Glauser T, et al. Guidelines for the evaluation and management of status epilepticus. Neurocrit Care 2012;17(1):3–23. DOI: 10.1007/s12028-012-9695-z.
Glauser T, Shinnar S, Gloss D, Alldredge B, Arya R, Bainbridge J, et al. Evidence-based guideline: treatment of convulsive status epilepticus in children and adults: report of the guideline committee of the american epilepsy society. Epilepsy Curr 2016;16(1):48–61. DOI: 10.5698/1535-7597-16.1.48.
Skoglund K, Enblad P, Marklund N. Monitoring and sedation differences in the management of severe head injury and subarachnoid hemorrhage among neurocritical care centers. J Neurosci Nurs 2013;45(6):360–368. DOI: 10.1097/JNN.0b013e3182a3cf4f.
Hemphill S, McMenamin L, Bellamy MC, Hopkins PM. Propofol infusion syndrome: a structured literature review and analysis of published case reports. Br J Anaesth 2019;122(4):448–459. DOI: 10.1016/j.bja.2018.12.025.
Carney N, Totten AM, O'Reilly C, Ullman JS, Hawryluk GWJ, Bell MJ, et al. Guidelines for the management of severe traumatic brain injury, fourth edition. Neurosurgery 2017;80(1):6–15. DOI: 10.1227/NEU.0000000000001432.
Jakob SM, Ruokonen E, Grounds RM, Sarapohja T, Garratt C, Pocock SJ, et al. Dexmedetomidine vs midazolam or propofol for sedation during prolonged mechanical ventilation: two randomized controlled trials. JAMA 2012;307(11):1151–1160. DOI: 10.1001/jama.2012.304.
Pandharipande PP, Pun BT, Herr DL, Maze M, Girard TD, Miller RR, et al. Effect of sedation with dexmedetomidine vs lorazepam on acute brain dysfunction in mechanically ventilated patients: the MENDS randomized controlled trial. JAMA 2007;298(22):2644–2653. DOI: 10.1001/jama.298.22.2644.
Hoy SM, Keating GM. Dexmedetomidine: a review of its use for sedation in mechanically ventilated patients in an intensive care setting and for procedural sedation. Drugs 2011;71(11):1481–1501. DOI: 10.2165/11207190-000000000-00000.
Tang JF, Chen PL, Tang EJ, May TA, Stiver SI. Dexmedetomidine controls agitation and facilitates reliable, serial neurological examinations in a non-intubated patient with traumatic brain injury. Neurocrit Care 2011;15(1):175–181. DOI: 10.1007/s12028-009-9315-8.
Humble SS, Wilson LD, Leath TC, Marshall MD, Sun DZ, Pandharipande PP, et al. ICU sedation with dexmedetomidine after severe traumatic brain injury. Brain Inj 2016;30(10):1266–1270. DOI: 10.1080/02699052.2016.1187289.
Tsaousi GG, Lamperti M, Bilotta F. Role of dexmedetomidine for sedation in neurocritical care patients: a qualitative systematic review and meta-analysis of current evidence. Clin Neuropharmacol 2016;39(3):144–151. DOI: 10.1097/WNF.0000000000000151.
Tran A, Blinder H, Hutton B, English SW. A systematic review of alpha-2 agonists for sedation in mechanically ventilated neurocritical care patients. Neurocrit Care 2018;28(1):12–25. DOI: 10.1007/s12028-017-0388-5.
Carelli S, De Pascale G, Filetici N, Bocci MG, Maresca GM, Cutuli SL, et al. The place of dexmedetomidine light sedation in patients with acute brain injury. Crit Care 2019;23(1):340. DOI: 10.1186/s13054-019-2637-9.
James ML, Olson DM, Graffagnino C. A pilot study of cerebral and haemodynamic physiological changes during sedation with dexmedetomidine or propofol in patients with acute brain injury. Anaesth Intensive Care 2012;40(6):949–957. DOI: 10.1177/0310057X1204000605.
Erdman MJ, Doepker BA, Gerlach AT, Phillips GS, Elijovich L, Jones GM. A comparison of severe hemodynamic disturbances between dexmedetomidine and propofol for sedation in neurocritical care patients. Crit Care Med 2014;42(7):1696–1702. DOI: 10.1097/CCM.0000000000000328.
Roberts DJ, Hall RI, Kramer AH, Robertson HL, Gallagher CN, Zygun DA. Sedation for critically ill adults with severe traumatic brain injury: a systematic review of randomized controlled trials. Crit Care Med 2011;39(12):2743–2751. DOI: 10.1097/CCM.0b013e318228236f.
Rai S, Drislane FW. Treatment of refractory and super-refractory status epilepticus. Neurotherapeutics 2018;15(3):697–712. DOI: 10.1007/s13311-018-0640-5.
Riker RR, Fugate JE, Participants in the International Multi-disciplinary Consensus Conference on Multimodality Monitoring. Clinical monitoring scales in acute brain injury: assessment of coma, pain, agitation, and delirium. Neurocrit Care 2014;21 Suppl 2:S27–S37. DOI: 10.1007/s12028-014-0025-5.
Deogaonkar A, Gupta R, DeGeorgia M, Sabharwal V, Gopakumaran B, Schubert A, et al. Bispectral Index monitoring correlates with sedation scales in brain-injured patients. Crit Care Med 2004;32(12):2403–2406. DOI: 10.1097/01.ccm.0000147442.14921.a5.
Ogilvie MP, Pereira BMT, Ryan ML, Gomez-Rodriguez JC, Pierre EJ, Livingstone AS, et al. Bispectral index to monitor propofol sedation in trauma patients. J Trauma 2011;71(5):1415–1421. DOI: 10.1097/TA.0b013e3182178b8b.
Olson DM, Thoyre SM, Peterson ED, Graffagnino C. A randomized evaluation of bispectral index-augmented sedation assessment in neurological patients. Neurocrit Care 2009;11(1):20–27. DOI: 10.1007/s12028-008-9184-6.
Marklund N. The neurological wake-up test-a role in neurocritical care monitoring of traumatic brain injury patients? Front Neurol 2017;8:540. DOI: 10.3389/fneur.2017.00540.
Anifantaki S, Prinianakis G, Vitsaksaki E, Katsouli V, Mari S, Symianakis A, et al. Daily interruption of sedative infusions in an adult medical-surgical intensive care unit: randomized controlled trial. J Adv Nurs 2009;65(5):1054–1560. DOI: 10.1111/j.1365-2648.2009.04967.x.
Helbok R, Badjatia N. Is daily awakening always safe in severely brain injured patients?. Neurocrit Care 2009;11(2):133–134. DOI: 10.1007/s12028-009-9262-4.
Helbok R, Kurtz P, Schmidt MJ, Stuart MR, Fernandez L, Connolly SE, et al. Effects of the neurological wake-up test on clinical examination, intracranial pressure, brain metabolism and brain tissue oxygenation in severely brain-injured patients. Crit Care 2012;16(6):R226. DOI: 10.1186/cc11880.
Skoglund K, Enblad P, Marklund N. Effects of the neurological wake-up test on intracranial pressure and cerebral perfusion pressure in brain-injured patients. Neurocrit Care 2009;11(2):135–142. DOI: 10.1007/s12028-009-9255-3.
Skoglund K, Enblad P, Hillered L, Marklund N. The neurological wake-up test increases stress hormone levels in patients with severe traumatic brain injury. Crit Care Med 2012;40(1):216–222. DOI: 10.1097/CCM.0b013e31822d7dbd.
Skoglund K, Hillered L, Purins K, Tsitsopoulos PP, Flygt J, Engquist H, et al. The neurological wake-up test does not alter cerebral energy metabolism and oxygenation in patients with severe traumatic brain injury. Neurocrit Care 2014;20(3):413–426. DOI: 10.1007/s12028-013-9876-4.