• Sedation on ITU
    • Non-pharmacological aids
      • Communication
      • Physiotherapy
      • Feeding and hydration
    • Pharmacological
      • Propofol
        • High clearance, metabolism due to hepatic degredation to glucorunide metabolites
      • Thiopentone
        • Only used in status epilepticus now
        • Can exhibit zero order kinetics
      • Etomidate
        • Inhibits 11β-hydroxylase
        • Shown to increase mortality on ITU
      • Ketamine
        • Phencyclidine derivative
        • NMDA antagonist
        • Not used routinely due to SNS side effects
      • Neuroleptics
        • Haloperidol
          • Antipsychosis due to central D2 agonism
          • IV 1-2.5mg for aggitation
          • Hepatic metabolism
        • Chlorpromazine
          • Less used due to S/E
      • BDZs
        • Modulate the effects of GABAa ligand gated Clˉ channel
        • Midazolam
          • 0.04-0.2mg/kg/hr
      • Opioids
        • Remi
          • 0.1-0.0.2μcg/kg/min
          • Can cause acute withdrawal symptoms
      • Clonidine
        • 50-150μcg tds bolus or via infusion
        • T1/2e = 8hrs
        • Hepatic metabolism, metabolites excreted in urine
    • Sleep
      • Non-pharmacological
        • Modification of environment
        • music/TV
        • Links to the outside world
      • Pharmacological
        • Zopiclone
        • Melatonin
    • Sedation breaks
      • Should be undertaken daily
      • Only restart when obeying comands fully or aggitated
      • Reduces duration of ventilation
      • Reduces length of stay
      • No increases in extubation
    • Monitoring seadation
      • Why?
        • Oversedation
          • Increase time on ventilatory support
          • Prolong stay on ITU
        • Undersedation
          • Hyper-catabolism
          • Immunosupression
          • Hypercoagulability
          • Increased SNS activity
      • Scoring tools
        • Ramsay Score
          • 1
            • Anxious, aggitated/restless or both
          • 2
            • Co-operative, tranquil
          • 3
            • Responds to commands only
          • 4
            • Brisk response to light glabellar tap or loud auditory stimulus
          • 5
            • Sluggish response to glabellar tap or loud auditory stimulus
          • 6
            • Exhibits no response
        • Addenbrookes
        • Bloomsbury
      • Instrumental measurement
        • EEG
        • BIS
    • CEACCP
      Link:ceaccp.oxfordjournals.org/content/8/2/50.full.pdf