Sedation and analgesia strategies in the neuro intensive care unit

Abstract

Intensivists are often plagued with the challenges of managing critically ill patients in the neurocritical intensive care unit (neuro ICU); one such challenge is the level of illness and the need for sedation, inhibiting the provider’s ability to adequately assess the patient. Most sedatives alter neurological and physical exam findings, only compounding potential barriers to providing the best care for each patient. It is important to emphasize that even in the altered mentation of these patients, physical and neurological exams reign supreme as diagnostic tools and should be used in conjunction with multimodal neuromonitoring methods, rather than labs or imaging alone. Additionally, selecting the appropriate analgesic(s) and sedative(s) based on these findings are highly important when determining the best course of individualized management. Thus, providers in the neuro ICU should be highly familiar with the appropriate analgesic and sedative options available in order to determine not only which may be best for each patient, but to also better understand how each drug may impact assessment findings. This comprehensive review aims to provide a structured overview of the pertinent sedatives commonly used in neuro ICUs, their risks and benefits, and how providers can best utilize each in practice to further improve patient outcomes. The novel contribution of this work provides comparative drug tables, dosing guidance for pediatric and very elderly (> 85-years-old) populations, and an exploration into the future possibilities of utilizing artificial intelligence and the human gut microbiome to further enhance the prospects of precision medicine.

Keywords: Anesthesia; Dexmedetomidine; Critical care; Hemodynamic monitoring; Intensive care unit outcomes; Intensive care; Medical intensive care unit; Multidisciplinary critical care; Neurocritical care; Neuro intensive care unit

Core Tip: It can be challenging for providers to manage critically ill patients in the neuro intensive care unit (ICU) due to the many factors hindering their ability to adequately assess the patient, such as altered baseline mental status as well as the addition of analgesics and sedatives. Relying on labs and imaging findings alone are often inadequate to assess patients and these multimodal neuroimaging methods should always be used adjunctively with comprehensive and thorough physical and neurological exams. This paper provides a structured overview of commonly used sedatives in the neuro ICU to assist intensivists in developing more individualized management decisions for each patient in hopes to further improve patient outcomes.