HHE Emergency care supplement 2018 - Page 11

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 11 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