Analgesia, sedation, and neuromuscular blockade during targeted temperature management after cardiac arrest

Richard R Riker; David J Gagnon; Teresa May; David B Seder; Gilles L Fraser

doi:10.1016/j.bpa.2015.09.006

Analgesia, sedation, and neuromuscular blockade during targeted temperature management after cardiac arrest

Best Pract Res Clin Anaesthesiol. 2015 Dec;29(4):435-50. doi: 10.1016/j.bpa.2015.09.006.

Authors

Richard R Riker¹, David J Gagnon², Teresa May³, David B Seder⁴, Gilles L Fraser⁵

Affiliations

¹ Director, Medical Critical Care, Neuroscience Institute and Department of Critical Care, Maine Medical Center, 22 Bramhall Street, Portland, ME 04102, USA. Electronic address: [email protected].
² Clinical Pharmacist, Departments of Pharmacy and Critical Care, Maine Medical Center, 22 Bramhall Street, Portland, ME 04102, USA. Electronic address: [email protected].
³ Assistant Director, Neurocritical Care, Maine Medical Center, 22 Bramhall Street, Portland, ME 04102, USA. Electronic address: [email protected].
⁴ Director, Neurocritical Care, Maine Medical Center, 22 Bramhall Street, Portland, ME 04102, USA. Electronic address: [email protected].
⁵ Clinical Pharmacist, Departments of Pharmacy and Critical Care, Maine Medical Center, 22 Bramhall Street, Portland, ME 04102, USA. Electronic address: [email protected].

PMID: 26670815
DOI: 10.1016/j.bpa.2015.09.006

Abstract

The approach to sedation, analgesia, and neuromuscular blockade during targeted temperature management (TTM) remains largely unstudied, forcing clinicians to adapt previous research from other patient environments. During TTM, very little data guide drug selection, doses, and specific therapeutic goals. Sedation should be deep enough to prevent awareness during neuromuscular blockade, but titration is complex as metabolism and clearance are delayed for almost all drugs during hypothermia. Deeper sedation is associated with prolonged intensive care unit (ICU) and ventilator therapy, increased delirium and infection, and delayed wakening which can confound early critical neurological assessments, potentially resulting in erroneous prognostication and inappropriate withdrawal of life support. We review the potential therapeutic goals for sedation, analgesia, and neuromuscular blockade during TTM; the adverse events associated with that treatment; data suggesting that TTM and organ dysfunction impair drug metabolism; and controversies and potential benefits of specific monitoring. We also highlight the areas needing better research to guide our therapy.

Keywords: analgesia; hypoxic–ischemic encephalopathy; neuromuscular blockade; sedation; targeted temperature management.

Publication types

Review

MeSH terms

Analgesia / adverse effects
Analgesia / methods*
Body Temperature / drug effects*
Body Temperature / physiology
Disease Management*
Heart Arrest / diagnosis
Heart Arrest / therapy*
Humans
Hypnotics and Sedatives / administration & dosage*
Hypnotics and Sedatives / adverse effects
Hypothermia, Induced / adverse effects
Hypothermia, Induced / methods*
Neuromuscular Blockade / adverse effects
Neuromuscular Blockade / methods*

Substances

Hypnotics and Sedatives