figure 1
Algorithm for the management of sedation in the neurointensive care units
High ICP
Yes
Sedation analgesia
Propofol
Titrated to ICP
monitoring
Reduce/stop
sedation/analgesia
Titrated to ICP
monitoring
No Clinical deterioration Clinical examination
+/- brain imaging
Pain Yes Analgesia
Fentanyl
Yes Anxiolytics
α2 agonists
Haloperidol
Yes Ventilator
adjustment
No
Agitation/delirium
No
Ventilator
asynchrony
No
No sedation
Adapted from reference 1
because of its high lipid solubility, thereby
prolonging time to awakening. 43
Barbiturates
The use of barbiturates has been limited owing to
their undesirable side effect profile, for example,
immunosupressant properties and negative
ionotropic effects. Pentobarbital is an extended
drug used for refractory status epilepticus or
elevated ICP. 44–46 They are considered second-line
therapy for the control of ICP, after propofol.
Dexmedetomidine
Dexmedetomidine is an alpha-2 agonist acting on
the central nervous system, with a rapid onset
and termination of activity. It offers mild to
moderate sedation without significant respiratory
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HHE 2018 | hospitalhealthcare.com
depression, analgesic effects and less delirium
than with benzodiazepines. 47 Side effects include
bradycardia and hypotension, with bradycardia
being the most typical haemodynamic effect. 48
Grof and Bledsoe demonstrated that
neurocritically ill patients may require high doses
of dexmedetomidine to achieve desired levels of
sedation and to wean off adjunctive analgesic
and/or sedative agents. Infusions may be started
at doses from 0.4–1mg/kg/hour in neurocritical
care patients to achieve target levels of sedation. 44
In a study by Erdman et al, limiting dose
titration to every 30 min and omitting a bolus
dose resulted in no significant difference in the
prevalence of hypotension or bradycardia
between dexmedetomidine and propofol. 49
It also appears to shorten time to extubation