Sedation in ICU: Balancing Comfort and Safety

This report gives a brief about sedation, the importance of fentanyl and midazolam, the rationale for replacing midazolam with propofol, and the importance of dexmedetomidine.

Sedation

Sedation is basically administering the patient with a sedative drug or medication in order to produce the state of sleep as well as calm. The patient post-laparotomy was admitted to ICU and was in septic shock. The patient was sedated as well as ventilated within ICU. Sedation mainly allows the patient to reduce their depression and thus their response to the external stimulation generally decreases. It has a vital role within care of critically and extremely ill patient. It encompasses the large number of spectrum of the symptoms control, which mainly varies between the patients as well as among individuals throughout their entire illness. The heavy seduction within critical care helps in facilitating the endotracheal tube tolerance as well as ventilator synchronization (Mistraletti et al., 2015). The critically ill and unwell patients are routinely and daily provided with analgesia as well as sedation to prevent the pain as well as anxiety and thus improve the synchrony along with mechanical ventilation.

Oversedation sometimes commonly takes place and is mainly associated with the worse and bad clinical outcomes, which mainly includes longer time upon the mechanical ventilation and prolonged stay within intensive care unit. Analgesia as well as sedation are mainly encountered for providing the patient with comfort and thus ensuring the safety of patient while reducing the response of stress. The oversedation mainly takes place frequently and is generally associated with the longer time upon the mechanical ventilation. Modifying the sedation delivery through incorporating analgesia as well as sedation protocols is associated with the improvements within patient outcomes. It should be administered within clinical management of the critically ill patients. The important parameter which is being considered for determining the patient outcome depends on the amount of sedation and the period of sedation which is given to the patient.

Importance of Fentanyl & Midazolam

Although there are large number of medications which are available, the patient initially was sedated with Fentanyl as well as Midazolam and was kept under this medication for few days. Fentanyl is considered as one of the most important medication because it helps the patient step out of depression and lowers their discomfort. It is basically the opioids which reduce the respiratory depression. Within the liver, the norfentanyl that is generally rendered inactive through hydroxylation helps in the metabolism of Fentanyl (Nagaraj et al., 2018). Fentanyl is primarily the synthetic opioid that has a rapid onset as well as mainly acts for a short period of time. In general, the doses of around 25-100 micrograms of the fentanyl are administered in every 10 minutes until and unless the pain decreases and is under controlled. It is mainly followed by the infusion rates of around 250 micrograms per hour. It generally has a large and bulky volume of distribution, which is secondary and different to its lipophilicity. Therefore, the important accumulation of the drug as well as prolonged administration of Fentanyl makes the patient feel unstable and then sedation becomes easier.

The patient was also administered Midazolam for the procedural sedation and was encountered for few days. Midazolam is basically the benzodiazepine medication, which is mainly used for the purpose of sedation before the diagnostic as well as therapeutic procedures in medicine. It is the imidazole benzodiazepine which has the depressant effect upon the central nervous system and thus has few adverse effect (Nagaraj et al., 2016). The patient was kept under this medication along with Fentanyl to stabilize the central nervous system of the patient. The doctors find out that when the patient was administered with Midazolam as the only sedative, it produced less effect and was the less effective sedation as compared to the other medication. Thus, it is more effective when used along with Fentanyl. Midazolam is basically metabolized with liver to the active compounds. It has the extreme clearance of benzodiazepine, thus rendering it the most suitable for sedation as infusion. It is certainly utilized as bolus method for producing the sedation.

Rationale for replacing Midazolam with Propofol

The patient, who for the next few days was administered with Fentanyl and Midazolam, was not showing any recovery or positive sign, thus the doctors decided to change the medications. The doctors later on shifted their focus to Propofol. Fentanyl was not changed and was continuously administered; only Midazolam was replaced with Propofol. It has been found that Propofol is generally considered as the most effective medication when it comes to sedation in comparison to Midazolam and thus has various advantages. Sedation with the Propofol was found to be more effective in attaining the patient-ventilator synchrony as compared to Midazolam after first hour of the treatment (Kapp & Punjabi, 2019). Patient when sedated with this Propofol awoke more instantly and rapidly, along with less variability in comparison to when patient was under the medication of Midazolam. Besides this, there were generally no biochemical changes that were detected with the patient when the patient was under Propofol. The doctors found that Propofol is more efficient and effective, as well as safe alternative in sedation, as it generally requires a short period of action as well as have high effectiveness. The main reason behind shifting from Midazolam to Propofol is that the patient was not responding. When the patient was given Midazolam for several months, no sign of recovery was seen in the patient, but when Propofol was encountered together with Fentanyl, this sedative rapidly distributed within the peripheral tissue of the brain in the patient and thus increased the blood flow to the brain (Nagaraj et al., 2017). Due to this, the mental recovery occurred fast and rapidly. Besides this, another reason for changing to Propofol was that Midazolam was highly expensive for the hospital and was not cost-effective, as even after the months it was not showing any positive sign. On the other hand, Propofol is generally cost-effective; even 0.1 mg of its administration stimulates central nervous system and thus has some neuroprotective effects on the brain.

Importance of Dexmedetomidine

After the administration of Propofol and Fentanyl, Dexmedetomidine was administered to the patient for the purpose of extubation. It mainly helps in managing the sedation without the cardiovascular instability as well as facilitates the weaning along with extubation within trauma ICU patients that have generally failed in the previous attempts (Mehta, Spies, & Shehabi (2018)). Dexmedetomidine is generally the sedative α2-adrenoceptor agonist that has vast array and range of properties, thus making it highly suitable for the purpose of sedation within clinical scenarios. Dexmedetomidine generally works by inhibiting the noradrenaline that is released within the locus ceruleus. Thus, at the end, it produces the state and sense similar to the natural sleep, wherein patients can thus be aroused with the help of external stimulus. The primary mechanism of this sedative is the stimulation as well as cessation of the parasympathetic along with sympathetic outflows. As the patient was elated, thus, the administration of Dexmedetomidine was highly essential for the activation of the reactors and post-synaptic receptors.

The main rationale behind its administration was that it prevents and overcomes hypoxia through the proper maintenance of airways, thus enabling spontaneous respiration (Shehabi 2018). When Midazolam and Propofol sedatives are administered to patients, then somewhere the respiratory functions got hindered as the central nervous system functioned in different way and the blood passage that goes from capillaries to the peripheral side of brain somewhat got hindered. Thus, in order to preserve the carbon di oxide and maintain the proper flow, patient is usually administered with Dexmedetomidine.

CONCLUSION

It has been summarized that sedation is basically the process where the patient is administered with some sedative drug for the purpose of producing a state of sleep and calm. Nursing essay help can provide further insight into such medical procedures. It becomes highly necessary to stabilize the patient's mind so that procedures can be performed effectively. Sedation is mainly used in minor surgical methodologies like endoscopy, vasectomy, etc. It is primarily utilized by doctors in intensive care units to help patients tolerate the high amount of pain during surgery. Various sedative drugs are administered to patients, such as fentanyl and midazolam. These two are the first sedatives given to reduce discomfort and minimize respiratory depression. Although Fentanyl is an effective sedative, sometimes Midazolam is replaced with Propofol as it is more effective and cost-efficient.

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