Results (Midazolam):
In an intensive care situation, a tranquil patient who is readily
awakened but whose normal sleep-wake cycle is preserved is a common
target degree of sedation. Mechanical ventilation might be difficult for
certain individuals and they may require more sedation to have it done.
The risk of overstimulation persists regardless of the sedative agent
used. When sedative medicines are used in continuous infusions, there is
a larger risk of adverse effects, such as prolonged mechanical breathing
and ICU and hospital admissions, and an increased risk of nosocomial
infection. Sedation can also cause cardiac or respiratory depression,
which must be quickly diagnosed and dealt with to avoid hypoxic brain
injury, cardiac arrest, or death. Many sedative drugs, including as
benzodiazepines and opioids, may have a prolonged and unpredictable
duration of effect in critically sick patients because of the
redistribution and accumulation of active metabolites. The accumulation
of the parent substance or its active metabolites might lead to undue
sedation; hence care should be taken while delivering continuous
infusions.
Conversely, a lack of sedation and analgesia can lead to undesirable
consequences, such as a patient’s discomfort or harm due to a lack of
compliance or unpleasant physiological or psychological responses to
stress. To avoid the persistent effects of sedation, the appropriate
level of sedation should be determined at the start of treatment and
re-evaluated on a frequent basis with active tapering of the infusion
rate. The American Society of Health-System Pharmacists (ASHP) and the
Society of Critical Care Medicine (SCCM) both support using sedation
guidelines, algorithms, or protocols..
The scientific community has not yet agreed on the characteristics of an
ideal agent for moderate sedation. Patients can generally anticipate a
rapid onset of action, predictability of
pharmacodynamics/pharmacokinetics, and a swift restoration of mental and
physical faculties with such a drug.
These benzodiazepines, which include diazepam and clonazepam, have long
been the most frequently used sedatives in intensive care units and were
included in the 2002 SCCM/ASHP clinical practice guidelines for
sedation. Apart from its potency and the presence or absence of active
metabolites, benzodiazepines have distinct characteristics. It is
critical to take caution when delivering benzodiazepines via continuous
infusion due to the accumulation of the parent agent or active
metabolites, which can result in hours to days of over sedation and
tolerance. According to the SCCM/ASHP guidelines, acutely agitated
patients should be administered diazepam and midazolam, with midazolam
being preferred for short-term usage due to the unexpected awakening and
time to extubation associated with infusions lasting more than 48–72
hours. Clonazepam’s gradual onset of effect makes it more suitable for
long-term sedation than for acute agitation. It can be given as a
continuous infusion or as an intermittent infusion. Flumazenil, a
benzodiazepine antagonist, should not be used frequently in patients who
have been on benzodiazepines for an extended period of time due to the
risk of withdrawal symptoms and increased myocardial oxygen demand.
SCCM/ASHP recommends propofol as the preferred sedative for patients who
require rapid awakening (for example, during extubation or neurological
testing). Triglyceride monitoring is recommended after two days of
propofol infusion, as long-term or high-dose propofol therapy may result
in hypertriglyceridemia.
Due to their ease of administration, favorable tolerability profiles,
and predictable actions, commonly used sedatives such as intimidate,
ketamine, and midazolam (in combination with midazolam), as well as the
opioids fentanyl (in combination with midazolam), and remifentanil, have
become the agents of choice for procedural sedation from pain that does
not respond well to opioid analgesics, such as sympathetically prolonged
neuropathic pain, may benefit from the use of 2-adrenergic agonists. The
SCCM/ASHP guidelines were issued before it was known whether or not to
employ 2-adrenergic receptor agonists to sedate patients in an intensive
care unit, despite the fact that current clinical evidence supports
their use as sedatives.