Anxiolysis, analgesia, sedation, and amnesia are accepted goals of intensive care. Inadequate pain therapy and sedation not only restrict the comfort of critically ill patients but may also cause specific complications. Elevated catecholamine plasma levels may lead to disturbances of the microcirculation, myocardial ischemia and infarction, cerebral disturbances, and renal failure. Patients with cardiovascular diseases are at particular risk. Thus adequate analgesia and sedation should be integral elements in the management of critically ill patients. Sympathetic hyperactivity, due to severe pain as well as analgesic overtreatment, may result in increased morbidity (Table 1). Therefore complete stress reduction should be restricted to the most critical phases of intensive care therapy.
Table 1 Adverse effects of under- and overtreatment with analgesics
The large variety of recommended drugs and drug combinations demonstrates that the optimal analgesic and sedation regimen does not exist. Instead, the various substances and measures should be adjusted individually considering the underlying diseases and the specific situation, the accompanying therapeutic measures, the expected duration of treatment, and the treatment phase. Specific problems arise in patients during withdrawal from alcohol, opioids, or benzodiazepines, in patients with systemic inflammatory response syndrome, and during weaning from long-term mechanical ventilation.
Consideration of the continual changes in the analgesic and sedative demands of critically ill patients is of particular importance for optimal therapy. Thus, during the early phase after surgery or trauma, pain therapy is of utmost importance. Later in intensive care, the importance of pain therapy decreases while sedation becomes increasingly difficult. Tolerance to opioids and benzodiazepines may occur after only a few days of treatment and may be facilitated by continuous administration.
Analgesia and sedation are primarily independent goals of intensive care. Thus, at least in long-term ventilated patients, fixed drug combinations of analgesics and hypnotics are not useful. Even experienced intensivists may frequently underestimate analgesic requirements and treat agitation and/or sympathetic hyperactivity syndromes with excessive doses of sedatives, when administration of effective analgesic measures, such as epidural opioids (3-5 mg morphine), would eliminate the need for sedatives and systemic opioids almost entirely. If analgesia is insufficient, the analgesic dosage, the analgesic itself, or the analgesic method should be adjusted to the patient's demands. Simultaneous administration of hypnotics and analgesics requires a knowledge of possible synergistic and antagonistic interactions between the various substances.
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It seems like you hear it all the time from nearly every one you know I'm SO stressed out!? Pressures abound in this world today. Those pressures cause stress and anxiety, and often we are ill-equipped to deal with those stressors that trigger anxiety and other feelings that can make us sick. Literally, sick.