Practice parameters for intravenous analgesia and sedation for adult patients in the intensive care unit: An executive summary. Shapiro BA, Warren J, Egol AB, Greenbaum DM, Jacobi J, Nasraway SA, Schein RM, Spevetz A, Stone JR. Crit Care Med 1995;23:1596-1600.
This set of practice parameters to guide the sedation and analgesia needs of adult patients in the ICU environment was developed by a task force of over 40 experts in disciplines related to sedation and analgesia convened from the American College of Critical Care Medicine. These recommendations are formulated from personal experience, review of texts, and an extensive Medline search of appropriate peer reviewed literature over a year's period.
Six recommendations are voiced in this article:
FOR ANALGESIA
FOR SEDATION:
Comment by D. Crippen:
Here they are, folks, the long awaited "guidelines" from the pros at SCCM. I do have a few concerns:
They correctly tag Haloperidol as the treatment of choice for "delirium", but they don't define it very well, nor do they examine it's relationship with "agitation". If the patient suffers from stress induced brain failure leading to delirium, neuroleptics are exceedingly effective, especially in a continuous infusion, avoiding therapeutic "peaks" and "valleys". However, if the patient is agitated simply because of pain, anxiety and discomfort, the ability of haloperidol in any route of administration to deliver analgesia, anxiolysis, anterograde amnesia and musculoskeletal relaxation is minimal.
The underlying, untreated etiologies of these varieties of agitation combined with the side effects generated by inappropriate drug therapy may interfere with intended treatment. Further clinical signs and symptoms could be clouded, length of stay in the ICU may increase, the number of lab tests ordered may increase, as well as the number of consultants contacted and money spent on the care plan.
Conclusion. Any time a committee comes up with something, I automatically wax suspicious, especially when they use as their data base the mish mash of "data" out there that is VERY weak. I don't think there are too many surprises though. I could quibble with some of it but, by and large, I think it is pretty close to what we have been doing. At least it is a start.
This diatribe seems to be a pretty good thumbnail sketch but a little on the anemic side when simple concepts turn complicated. They come to conclusions that are pretty accurate superficially, but when the picture gets clouded, their choices might fall apart.
Malcolm Fisher:
The fearless leader has previewed some nice guidelines to help me give analgesia and sedation. I am into guidelines.
This set of practice parameters to guide the sedation and analgesia needs of adult patients in the ICU environment was developed by a task force of over 40 experts in disciplines related to sedation and analgesia convened from the American College of Critical Care Medicine. These recommendations are formulated from personal experience, review of texts, and an extensive Medline search of appropriate peer reviewed literature over a year's period.
Colleges in Australia are big into Guidelines too. A copy is always made on a stone tablet because although they are called guidelines they have a habit of become cast in stone. And while DR Streat can happily go along giving his diazepam because under ACC in the Quarter Acre Pavlova Paradise (NZ) as he is impossible to sue I have to worry about breaching guidelines as lawyers get copies of them.
Of the six recommendations are voiced in this article:
Can we still use tricyclics in the long term?. We have also found Prozac pretty useful. From time to time. And you can nick some for yourself.
Stephen Streat:
These guidelines seem peculiarly constructed for an alien environment where costs, risks and cost-effectiveness all have different values and meanings. Here in Kiwiland (like over the ditch in Oz) we think these recommendations are strange - were there any drug companies involved in the guidelines ? sponsoring them perhaps... We like guidelines too but we dont expect that this sort of a guideline can be used very effectively as a blunt instrument to enforce conformity to some (minimum or lower) standard of care.
I'll peg my colours to the mast (again) and (almost) echo Malcolm Fishers specific responses :
Yes, it is possible to produce histamine hypotension in euvolaemic patients with bolus morphine but you have to give at least 1mg/kg push - preferably 2 or 3 mg/kg. Interestingly they dont wheeze even when they flush up a treat. After the histamine goes ( 3-5 minutes) the central sympatholysis often persists, if you have given a total of 3-5 mg/kg morphine anyway - this is a useful way of blocking all that horrible hypertensive, hypovolaemic vasoconstriction that you see in young fit trauma patients who have had long pre-hospital transport times and have switched on their conservation catechols to the max. I have never seen a morphine allergy in over 10,000 patients. I guess there must be one somewhere.
Great oral premedication but whats different about it from diazepam in prolonged use... I dont give benzodiazepines for `anxiety' anyway - I give them to produce sedation (=sleep or coma during neuromuscular blockade) and amnesia (=if they are [dimly] aware lets at least do what we can to prevent memory of all this). It works too - we are producing data on amnesia in critical care survivors - see Brisbane ANZICS meeting 1995.
Barbiturates are good anticonvulsants too and can do two things for the price (next to nothing) of one. Chlorpromazine (Intravenous) in small doses is a great alphablocker and can facilitate cooling without recourse to curarisation.
We have used tricyclics a bit in recovering GBS or other chronic pain syndromes with limited success (and for the odd patient with severe depression) but have no experience with fluoxetine (other than managing the consequences of self-inflicted overdose).
Finally although Malcolm makes a point about New Zealands Accident Compensation legislation I can assure you that such legislation does not make NZ doctors any less aware of their legal risks. You may not be aware of NZs peculiar manslaughter law which allows a doctor to be convicted for manslaughter for simple mistake (human error), even under conditions of extreme emergency or clinical difficulty rather than for negligent mistake or similarly evident lack of care. This is in contrast to other (Commonwealth including Australia) jurisdictions which require a higher standard of proof. Also, NZ ACC legislation has recently been revised (=poorer coverage for the patients, lower risk to the government, increase in risk to the medical profession) and an increase in the (mal)practice of medicine through the courts is anticipated by all players, including the medical malpractice insurers, reflected in fees. (See : Cost containment: the Pacific. New Zealand. Streat-S; Judson-JA. New-Horiz. 1994 Aug; 2(3): 392-403).