Enfermera

Clinical practice guidelines for the sustained use of sedatives and analgesics in the critically ill adult
Judith Jacobi, PharmD, FCCM, BCPS; Gilles L. Fraser, PharmD, FCCM; Douglas B. Coursin, MD; Richard R. Riker, MD; Dorrie Fontaine, RN, DNSc, FAAN; Eric T. Wittbrodt, PharmD; Donald B. Chalfin, MD, MS, FCCM; Michael F. Masica, MD, MPH; H. Scott Bjerke, MD; William M. Coplin, MD; David W.Crippen, MD, FCCM; Barry D. Fuchs, MD; Ruth M. Kelleher, RN; Paul E. Marik, MDBCh, FCCM; Stanley A. Nasraway, Jr, MD, FCCM; Michael J. Murray, MD, PhD, FCCM; William T. Peruzzi, MD, FCCM; Philip D. Lumb, MB, BS, FCCM. Developed through the Task Force of the American College of Critical Care Medicine (ACCM) of the Society of Critical Care Medicine (SCCM), in collaboration with the American Society ofHealth-System Pharmacists (ASHP), and in alliance with the American College of Chest Physicians; and approved by the Board of Regents of ACCM and the Council of SCCM and the ASHP Board of Directors
aintaining an optimal level of comfort and safety for critically ill patients is a universal goal for critical care practitioners. The American College of Critical Care Medicine (ACCM) of the Society ofCritical Care Medicine’s (SCCM’s) practice parameters for the optimal use of sedatives and analgesics was published in 1995 and recommended a tiered approach to the use of sedatives and analgesics, largely on the basis of expert opinion (1). These clinical practice guidelines replace the previously published parameters and include an evaluation of the literature published since 1994 comparing theuse of these agents. The reader should refer to the accompanying introduc-

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tion for a description of the methodology used to develop these guidelines (2). This document is limited to a discussion of prolonged sedation and analgesia. Consistent with the previous practice guidelines, this document pertains to patients older than 12 years. The majority of the discussion focuses on the care ofpatients during mechanical ventilation. A discussion of regional techniques is not included. Appendix A summarizes the recommendations made herein.

ANALGESIA
In these guidelines, “analgesia” is defined as the blunting or absence of sensation of pain or noxious stimuli. Intensive care unit (ICU) patients commonly have pain and physical discomfort from obvious factors, such as preexistingdiseases, invasive procedures, or trauma. Patient pain and discomfort can also be caused by monitoring and therapeutic devices (such as catheters, drains, noninvasive ventilating devices, and endotracheal tubes), routine nursing care (such as airway suctioning, physical therapy, dressing changes, and patient mobilization), and prolonged immobility (3, 4). Unrelieved pain may contribute to inadequatesleep, possibly causing exhaustion and disorientation. Agitation in an ICU patient may result from inadequate pain relief. Unrelieved pain evokes a stress response characterized by tachycardia, increased myocardial oxygen consumption, hypercoagulability, immunosuppression, and persistent catabolism (5, 6). The com-

The American College of Critical Care Medicine (ACCM), which honors individuals fortheir achievements and contributions to multidisciplinary critical care medicine, is the consultative body of the Society of Critical Care Medicine (SCCM) that possesses recognized expertise in the practice of critical care. The College has developed administrative guidelines and clinical practice parameters for the critical care practitioner. New guidelines and practice parameters arecontinually developed, and current ones are systematically reviewed and revised. Special thanks to E. Wesley Ely, MD, for his contribution to the section on delirium. Address correspondence to Society of Critical Care Medicine, 701 Lee Street, Suite 200, Des Plaines, IL 60016. Available at www.sccm.org Key Words: analgesia; sedation; evidence-based medicine; fentanyl; hydromorphone; morphine; lorazepam;...