Informative and target level-controlled
Changes in analgosedation
The last few years have brought about a fundamental change in the concepts of analgesia and sedation. While in the 80s and 90s of the last century the deep sedation was preferred, today new therapy methods, ventilators and drugs enable rapid and short-term adjustment of the sedation depth to the invasiveness of the currently required measures.
The aim of the measures is therefore no longer the fully sedated, mechanically ventilated patient but the slightly sedated/analgesic treated, painless patient who spontaneously breathes on the ventilator, tolerates the mechanical support by the ventilator, is alert when addressed and reacts adequately.
Only in the state of slight analgosedation the respiratory drive of the patient with the pathophysiologically important innervation of the diaphragm as main breathing muscle is intact, it is of utmost importance for the preservation of the lung function and the pulmonary gas exchange or its restoration.
Deeper degrees of sedation cause the loss of spontaneous breathing with increase of the mechanical ventilation part and consecutive degradation of the lung function and should therefore be avoided. This is accompanied by a reduction of puff coughing so that the risk of secondary pulmonary infections increases due to the reduction of the bronchial clearance function.
The influencing of the state of consciousness as a result of deep analgosedation also leads to a deterioration of the communication with the patient and thus affects the evaluation of his neurological state. Only short-acting medication allows the regular (e.g. daily) termination of the sedation, for example for the neurological assessability of the patient.
Furthermore, the mobilization of the patient is aggravated which in turn favours the prolongation of mechanical ventilation.
Clinically significant is also the dose-dependent disturbance of the intestinal motility, mainly by analgesics of the opioid type. The formation of an enteral nutrition is delayed if not impossible. It is known, for instance, that the intestinal wall already before a manifest paralytic ileus becomes more permeable for biogenic amines, endotoxins and bacteria due to insufficient perfusion and lack of stimulation by enteral nutrition.
The disturbed function of the gastrointestinal tract with the limitation of the intestinal motility is therefore also considered as the “motor of multiple organ failure”.
|too little||too much|
|Stress||Impairment of bronchial clearance|
|Unrest, Sweating||aggravated mobilization|
|Hypertension, Tachycardia||Hypotension, Bradycardia|
|Delirium||Veiling of complications|
In any case, with ventilated patients as a result of an adequate sedation and analgesia
- an early weaning
- an early extubation
- and, as a result, a shortened intensive care treatment should be possible.
In the selection of the substances to be used the duration to be expected for sedation and analgesia should be taken into account in order to benefit from the different specific pharmacological features of the substances used.