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Critical Care Sedation Critical Care Sedation Angelo Rafaele De Gaudio Stefano Romagnoli Editors Critical Care Sedation Editors Angelo Raffaele De Gaudio Stefano Romagnoli Department of Anesthesia and Department of Anesthesia and Critical Care Critical Care Azienda Ospedaliero-Universitaria Azienda Ospedaliero-Universitaria Careggi Careggi Firenze Firenze Italy Italy ISBN 978-3-319-59311-1 ISBN 978-3-319-59312-8 (eBook) https://doi.org/10.1007/978-3-319-59312-8 © Springer International Publishing AG 2018 This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifcally the rights of translation, reprinting, reuse of illustrations, recita- tion, broadcasting, reproduction on microflms or in any other physical way, and transmission or infor- mation storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publica- tion does not imply, even in the absence of a specifc statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, express or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affliations. Printed on acid-free paper This Springer imprint is published by Springer Nature The registered company is Springer International Publishing AG The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland Preface In the last 20 years, victims of critical illness have become increasingly elderly and frequently subject to multiple organ dysfunction. Critical illness is currently defned by certain syndromes, such as sepsis or acute renal failure, or by physiological alterations, such as shock states or hypoxemia. It is hence often necessary to inte- grate the more traditional subspecialties of medicine into critical care practice. For these reasons, critical care demands continuous advances in technology, therapeu- tics, and monitoring to improve the prognosis of disease states that infuence organ physiology, especially in elderly patients. Attention to sedation and analgesia in intensive care units (ICUs) has evolved during the last years, and signifcant evidence of its infuence on patient outcomes has emerged. In light of this, those privileged to take care of patients in the ICU have witnessed a dramatic evolution from former practices of deep sedation lasting for several days to a gentler approach that treats “light sedation” for cooperative patients as the indisputably preferable option. Patients’ brains are vulnerable organs in the context of the multiple organ dysfunction that commonly characterizes critically ill patients. Sedation causes both brief and long-lasting injury that may manifest delir- ium and cognitive impairment. This book, with its precious contributions from authors selected from physicians and researchers who handle sedatives and analgesics in their daily clinical practice, provides readers with an overview of current knowledge and the most up-to-date lit- erature. The contents are designed to cover a number of issues directly or indirectly related to analgo-sedation in the ICU. Drugs currently in use (e.g., benzodiazepines or propofol) and newer molecules or applications (e.g., dexmedetomidine, halogenates) are discussed in relation to different aspects of patient care, including stress response, pain management, instrumental and clinical monitoring, the immune system, and sleep quality and quantity. Issues such as pediatric population, neuromuscular block- ing agents, regional anesthesia techniques, and delirium are also addressed. Our aim was to design a text that would both revise and update the basic subject matter while directing practitioners toward the confdent use of a specifc drug or technique. As editors, we found the revision of individual manuscripts rewarding, and we believe that the subject matter displays a healthy balance between theoretical under- standing and practical clinical implementation. We hope that readers will fnd the chapters both informative and useful for improving patient care in their everyday clinical practice. v vi Preface Finally, we wish to thank the editorial team members of Springer International Publishing AG; Mr. Andrea Ridolf, Clinical Medicine Books Editor; and Mr. Rakesh Kumar Jotheeswaran, Project Coordinator, for having provided support in editing all chapters of this book. Florence, Italy A. Raffaele De Gaudio, M.D. Stefano Romagnoli, M.D. Contents 1 Critical Care Sedation: The Concept . 1 Giovanni Zagli and Lorenzo Viola 2 The Stress Response of Critical Illness: Which Is the Role of Sedation? . 9 A. Raffaele De Gaudio, Matteo Bonifazi, and Stefano Romagnoli 3 Pain Management in Critically Ill Patient . 21 Cosimo Chelazzi, Silvia Falsini, and Eleonora Gemmi 4 Common Practice and Guidelines for Sedation in Critically Ill Patients . 35 Massimo Girardis, Barbara Rossi, Lorenzo Dall’Ara, and Cosetta Cantaroni 5 The Subjective and Objective Monitoring of Sedation . 47 Carla Carozzi and Dario Caldiroli 6 Intravenous Sedatives and Analgesics . 69 Francesco Barbani, Elena Angeli, and A. Raffaele De Gaudio 7 Volatile Anesthetics for Intensive Care Unit Sedation . 103 Giovanni Landoni, Omar Saleh, Elena Scarparo, and Alberto Zangrillo 8 Regional Anaesthesia Techniques for Pain Control in Critically Ill Patients . 121 Francesco Forfori and Etrusca Brogi 9 Neuromuscular Blocking Agents . 139 Elena Bignami and Francesco Saglietti 10 Sedation and Hemodynamics . 155 Federico Franchi, Loredana Mazzetti, and Sabino Scolletta 11 Sedation and the Immune System . 167 Gianluca Villa, Chiara Mega, and Angelo Senzi vii viii Contents 12 Sleep in the ICU . 185 Stefano Romagnoli, Rosa Giua, and A. Raffaele De Gaudio 13 Delirium in the Critically Ill Patients . 197 Fulvio Pinelli, Elena Morettini, and Elena Cecero 14 Sedation in Pediatric Critically Ill Patients . 213 Cristiana Garisto, Alessandra Rizza, and Zaccaria Ricci 15 Sedation in Cardiac Surgery Intensive Care Unit . 245 Sergio Bevilacqua and Ilaria Galeotti Index . 257 About the Authors A. Raffaele De Gaudio is Full Professor of Anesthesiology and Intensive Care at the University of Florence and Director of Postgraduate School of Anesthesiology and Intensive Care. He is working at Careggi University Hospital in Florence as Director of the Department of Anesthesia and Intensive Care. He is Past President of the Italian Society of Intensive Care (SITI) and Vice President of the Italian Society of Anesthesiology and Intensive Care. His research areas cover different felds such as sedation in ICU, infection and sepsis in critically ill patient, critical care nephrology, perioperative medicine, acute pain, and palliative medicine in ICU. Stefano Romagnoli is an anesthesiologist and intensivist at the Department of Anesthesia and Critical Care at the Careggi University Hospital in Florence. He is Secretary-General of the Italian Society of Intensive Care. His main interests are anesthesia and intensive care in adult cardiac surgery, vascular surgery, and thoracic surgery. Dr. Romagnoli is an expert in hemodynamic monitoring and management (from pulmonary artery catheters to minimally invasive tools and echocardiography). Additional felds of interest are sedation in critically ill patients, critical care nephrology, renal replace- ment, and blood purifcation therapies. He is the author of a number of papers pub- lished in international, peer-reviewed, indexed journals including Critical Care Medicine, Anesthesia & Analgesia, Plos One, and Critical Care. ix List of Contributors Elena Angeli, M.D. Department of Health Science, University of Florence, Florence, Italy Francesco Barbani, M.D. Department of Anesthesia and Intensive Care, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy Sergio Bevilacqua, M.D. Cardiac Anaesthesia and Intensive Care Unit, Department of Anesthesia and Intensive Care, Azienda Ospedaliera Universitaria Careggi, Florence, Italy Elena Bignami, M.D. Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientifc Institute, Milan, Italy Matteo Bonifazi, M.D. Department of Health Science, University of Florence, Florence, Italy Etrusca Brogi, M.D. Department of Anaesthesia and Intensive Care, University of Pisa, Pisa, Italy Dario Caldiroli, M.D. Fondazione I.R.C.C.S. Istituto Neurologico Carlo Besta, Milan, Italy Cosetta Cantaroni, M.D. Department of Anaesthesiology and Intensive Care, University of Modena and Reggio Emilia, Modena, Italy Carala Carozzi, M.D. Fondazione I.R.C.C.S. Istituto Neurologico Carlo Besta, Milan, Italy Elena Cecero, M.D. Department of Health Science, University of Florence, Florence, Italy Cosimo Chelazzi, M.D., Ph.D. Department of Anesthesia and Intensive Care, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy Lorenzo Dall’Ara, M.D. Cattedra di Anestesia e Rianimazione Struttura Complessa di Anestesia e Rianimazione, Università degli Studi di Modena e Reggio Emilia, Modena, Italy xi xii List of Contributors A. Raffaele De Gaudio, M.D. Department of Anesthesia
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