Strategies to optimize analgesia and sedation

Ensuring patient comfort and safety is a universal goal for critical care practitioners. Patients undergoing mechanical ventilation experience significant stress superimposed on their acute medical problem, ranging from anxiety about their surroundings and condition to distress with potential pain from necessary nursing care and procedures. Non-pharmacologic therapies such as comfortable positioning in bed and verbal reassurance are reasonable initial considerations, but a need for sedatives and analgesics to promote tolerance to the intensive care unit (ICU) environment is typically the rule.Sedation needs vary widely in mechanically ventilated patients. ICU patients frequently exhibit unpredictable pharmacology with accumulation of drug in tissue stores, resulting in a prolonged clinical effect. Other variables that confound attempts to predict drug effect include renal and hepatic dysfunction, drug-drug interactions, hypoproteinemia, and shock. As a result, sedatives and analgesics must be titrated to discernible and reproducible clinical end-points. Because the drugs used in this context are extremely potent, clinicians must have heightened awareness of the potential for enduring effects and are encouraged to employ strategies that maximize benefit while minimizing risk.The risk for untreated pain or agitation is a primary concern. Most mechanically ventilated patients experience some degree of pain even in the absence of surgical incisions or trauma [1,2]. Accordingly, it is critical for clinicians to direct initial attention toward analgesia when they administer 'sedation'. Untreated pain may cause many adverse effects, including increased endogenous catecholamine activity, myocardial ischemia, hypercoagulability, hypermetabolic states, sleep deprivation, anxiety, and delirium [3]; treating this pain has been shown to ameliorate some of these effects [4]. Untreated agitation, particularly in the delirious patient, may result in similar problems, including pati