Affiliation:
1. Division of Anaesthesiology and Perioperative Medicine, Singapore General Hospital, Singapore
2. Changi General Hospital, Singapore
3. Faculty of Medicine Nursing and Health Sciences, Monash University, Australia
Abstract
Introduction: Critically ill patients often require sedation for comfort and to
facilitate therapeutic interventions. Sedation practice guidelines provide an evidencebased framework with recommendations that can help improve key sedation-related
outcomes. Materials and Methods: We conducted a narrative review of current
guidelines and recent trials on sedation. Results: From a practice perspective, current
guidelines share many limitations including lack of consensus on the definition
of light sedation, optimal frequency of sedation assessment, optimal timing for
light sedation and consideration of combinations of sedatives. We proposed several
strategies to address these limitations and improve outcomes: 1) early light sedation
within the first 48 hours with time-weighted monitoring (overall time spent in
light sedation in the first 48 hours—sedation intensity—has a dose-dependent
relationship with mortality risk, delirium and time to extubation); 2) provision of
analgesia with minimal or no sedation where possible; 3) a goal-directed and balanced
multimodal approach that combines the benefits of different agents and minimise
their side effects; 4) use of dexmedetomidine and atypical antipsychotics as a
sedative-sparing strategy to reduce weaning-related agitation, shorten ventilation
time and accelerate physical and cognitive rehabilitation; and 5) a bundled approach
to sedation that provides a framework to improve relevant clinical outcomes.
Conclusion: More effort is required to develop a practical, time-weighted sedation
scoring system. Emphasis on a balanced, multimodal appraoch that targets light
sedation from the early phase of acute critical illness is important to achieve optimal
sedation, lower mortality, shorten time on ventilator and reduce delirium.
Ann Acad Med Singapore;49:215–25
Key words: Analgesia, Benzodiazepine, Critical Care, Dexmedetomidine, Propofol
Publisher
Academy of Medicine, Singapore
Cited by
9 articles.
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