เวชบำบัดวิกฤตพื้นฐาน Fundamental in Critical Care

596 rernirUoinqnfiugru

4q1f,lnd t|sfi{fl1tfiq1s{ hypoaldosteronism6

Aldosterone def iciency
Primary

Primary adrenal insufficiency
Congenital adrenal hyperplasia, particularly 21 -hydroxylase deficiency
lsolated aldosterone synthase deficiency

Heparin and low molecular weight heparin

Hyporeninemic hypoaldosteronism
Renal disease. most often diabetic nephropathy
Volume expansion, as in acute glomerulonephritis
Angiotensin converting enzyme inhibitors (ACEI)/angiotensin ll receptor blockers (ARB)
Nonateroidal antiinflammatory drugs (NSAIDS)
Cyclosporine
HIV infection
Some cases of obstructive uropathy

Aldosterone resistance
Drugs which close the collecting tubule sodium channel

Amiloride
Spironolactone
Triamterene
Trimethoprim (usually in high doses)
Pentamidine
Tubulointerstitial disease
Pseudohypoaldosteronism
Distal chloride shunt

n'rrm: ruuattu{rhrinqn

fi-rn-r:nauauarlrirflud,ldrrfiu raqli{nldunxtJfl1 1rn1un'r:1"!f rr6rrfiu oan?rn

ir.rnr u

Tour''rhnr:liirT u f,rEE ?lnn1rfiuq;lillirlfirflo hyperkatemia firf,,Lhulilldfiflrgn'r

6u1 niu finrrv-ln?luix dxu

rioul:iildu hyperkalemia irtfludartunornnl?y "pseudohyperkalemia" l?o nm:fi

finr:nirg.:l.unor:;d'u 1tq tuiild.,: rflu cr ner n nr:d'lvi urcr6srrndoraonorn mcflu:vrjr,,:r5o

rni.rq, rrdldrfufi'rodr-r16oolrn{:-lrulrJudrcrruqdrn''rlrfiRelnnr:g6rfilrrfioRUrnfinr?fiurdrr:rir?ru

rer:16oo nrrrfirrfionl{ururiouriurvr:;o':r IK-l vioarotfloern K- oonqrn ttadtfiort6onttt

Poras$ir.rm Disorders ttfrtjgl Feuiiq 597

udi!nfinrfioa nd1,rernrfiun'rarir,,:rdaad.:"li 'lufirhuiifirnfrnr6onuiaffio16oorrro,,rlrn niu lu

{rhu leukemia t'tio myeloproliferative disorder

filrdttfrl hyperkatemia fi rfi ocrnnr:rodouzodrrtrcrfifl sano1fl rind outuro{r-ht

inqnldrrri n1:r'ro insulin rriu'lufirjru diabetic ketoacidosis, rhabdomyotysis, u16rJdflu

succinylcholine unci'l?: metabolic acidosis ([K] 'lulra'rClTrrfu 0.6 mmol/L n'o pH finono1n1

0.1 d1il5! respiratory acidosis qlfiq,rado 1x1 tunnrnrrfiouun

lurru-lfrrififirlrivrrjr{rJrufi pseudohyperkalemia l!fli potassium shifling rldl dr lfiDl

dur6o lduri nr:d uurarfiardlnoonr {i..:lvuri,:l{rflun{rlnd z nrirfio t1 n{rdfi::ou
aldoslerone aon,: udulu primary adrenal insufficiency, nrild'trn{ heparin, NSAIDS, rrn:

ACEUARB my 2) n4ufl1n1rinalduo,,,:do aldosterone niu ldur?i!flcot;nrjl K sparing diuretics,

nrr:lcrrufifi glomerular fittration rate rioun'jr 10-20 mumin viofi distal flow n'r niu tufl,rha

frfinr:aoo'nra.r etfective circulating volume (shock, heart {ailure)

O1n'lll]f,O\t (symptoms)8

{:-Jruarol;Ljr'ornrrtol n?ofiarnr:€jo!tt?,r, ftaccid paratysis, paraesthesia, :Jfrfi6ur
5rv,lfindnoo,: uocfrnmcyru'lqn'rrrn ilt,rarnr:rroi'rde:virtu{rJrudfi hyperkatemia :urrrt o.rriu

'ioXofio'rdrpfiqniunt:trluruunttinul hyperkatemia 6a otnt:uoarn"rnri, r uayndu}{flru'rh

tturto:ru-u ua:dq:rnr:tfilduro,J [K] lufl nlflr11

ECG abnormalities

m:r firuurlo.,rnfiu'b,,lflrri'rloczdufi'urfurir trl'luunrarruo;dn:1n1rrfi:rdulo{rvo'!
Tuurf, rfiuu"" tnr:r,,rd st

nrfl.rd s usq.tnrr:ftqlnfi1o,: eoc drr'lu hyperkatemia fr:;d'l 1x1 virrl rfir

Poto.ssium I MAJOR ECG CIIANGES wtrE lo morc thrm
(mmoul)

Tsll, D€al€d (knled) waves [T wovc

Prolo{scd PR iDtsvd

tfl Fba.tncd or rhr.nt P rav.s

Wldared QRS lg.atcr tlerr 0.t2 e.colds;l

Sinc save pottem 15 urd T rr eves mrrging) | HiFh rbl of
Bnrrlycanlia
f CsrdiDt srrt4t
VcrrriLrhr urh]$rdi,
)

ThaE lr lonc &gt!c ot svartio oa ECG f!!i|'tt h trrpar*abarm. 13 rc4m potaslun a|!6 .be t'|rnouL n6a drrr arE

aboottdlty firy bc pa!$'|L nF aE* oa (.rdbc aar..t locrEl!.! wlth alCrll.nrn pdltfirm rad tta Fraaic d orrlhoua Ef,G
ngt hrtlclEd r5ole.

598 rrtdrtininqnriugrl

loa{rJrudrurrn q; riurwndulilflttrlefioilnfi 6a tall peated r wave fi:rn'l [K]

> 5.5-6.5 mmol/L rfia tX.l qtfi'r 6.5-7.5 mmol/L o: littt'ttl PR interval ulxdu unv P wave MJu

n,r unvrrul nrrdrs QRS complex nirtrfia IKI odfi 7-8 mmol/L (:rJfi sa; firlrilfi5lnr:inur

QRS complex finirtdq;:rr.rn-l T wave notutflu sine wave pattern {iofinru tdut4uderrf,o

cardiac arrest (:|fi 5b)
tu{rlru\mlt:ru:riru (end stage kidney disease. ESKD) oT ee:'hiflrndu'lvlfi1fi'r'tq

n'r r!!!r[rhJu{l{d'ufi16 o1rfieo: rfiuorn{trun{rdfi hyperkatemia otirflutraruTurirtrikirfinzua
siondrlrdorido niaorco;rfioqrnfi run6itJdfinr:til6uuu:Jawot::d'r serum calcium irlrodd':u"

71fi I uaa,t Life threatening ECG changes ln hype*alemia
(a) lllustrates tented T waves, /oss of P waves and a wde QFS complex in a patient

presenting with paralysis and acute renal failure (serum K 9.3 mmol/L)

(b) lllustrates sine wave pattern in a patient with acute renal failure and digitalis intoxication

herum 9.3 mmollu.

(c) Ilustmtes a severe bradycardia at a rate of 28 beats/min in a hemodialysis patient

presenting with syncope (serum K 8-1 mmollLl

(d) lllustrates ventricular tachycardia in a hemodialysis patient presenting with generalized
weakness (serum K 9.1 mmot/L) The paper speed is 25 mm/s.

Arrhythmias associated with hyperkalqmia
Y,rrldfi orfl ::rnYr ra rtrLnairran'td

Bradycardia
fi,ilrurr.r:'troroevlrifinr:nJfiuuurin.r?o{nfiulilflry"rliurrrufl dl{du ue{orav{!dnuruy

severe bradycardia (;ilfi 5c) ir'.n:rirlfifirlqvrdeiroqoianr:inuruarr!:rnr:o-rti

Porxssium Disorder ttfivgl iautia 599

t,) riilrifi ununr:insrr'n rcu'lunrilfi calcium salt ([du calcium gtuconate] 'lunr::-nrr
bradycardia q'rn hyperkalemia lrio.:ernn'tr'lfi catcium salt fiHaut:ndaufit:ruriu66olhififi
bradycardia trn:fit1u,1lu'j'tn1ttfi catcium lufi:Jru rryperkatemia dfi nv otock rir'hifinr:udn.,r
tutflu asystole .[d

2) nlrnou6[uo\tfio atropine 'lu{ilxun{r.rrit;1il6 fiflu,:ruirnr:'ld temporary pacing 16
notirurirlfi hemocynamics 6du1u::n'jtfi:anr:rir hemodiatysis e.tn ::flurnlnilulr{ytu.tt.lra
63rrr {:-hu hyperkatemia frfi bradycardia Tu[rndxilfirJfi hyporension e;ldi!nr:inurlquld
temporary pacemaker irlfi'u nr:yth renal replacement therapy (hemodialysis fi?a CRRT) yl!

't'1to Noa

s; fi:rt.rru'ir severe hyped€lemia evnol::fiTBnrvivtsrto*r temporary LLflg transvenous

pacing tfiarclnam;drirlfifinr:r$ildutB\t stimulation fithreshotd 311ru ebctrode-tissue interface

Tirlfilrjrfi q ventricular depolarizationta

4) vttl'jl hyperkatemia Lrny hypocatcemia rfluarrundrd'ryfidrlrfi{rl':afro6dd permanent

pacemaker adud'lfiorlqnr pacemaker lrinhlru [ayfi:ra.,,]ru'jrdr1firfia z:t AV btock ldr4r5

louut'rl:Jnr:lfib hyperkalomia induced severe bradycardia ddfiqo dorird'or r" oon

rrndr.rnrutfirSriiqo lrrunr:rir hemodiatysis tnudo.,rfinr:fir::i.,: EKG un: hemodynamic data

sfl ao[?d'r n:rfifi finrr;fionpuxeln bradycardia orlrior.irurld temporary pacemaker rlfl JE

n1?oa!f,u0.i?Jo{nr:1diroclfiHaflial fir hemodynamics hjruilrnrin n1fli't hemodiatysis orjl{
16urrinr;ufiltnr'::fldTnulrifio,,rld pacemaker

Asysiole lH! pulseless electrical actiyity {PEA)

druunfirJrue:rfiufiinrfio! u.:i4ruo rrn'fi':1u,,rru'jrnr:rir cardiopulmonary resusciration
(cPR) {rl'rsilrior.r1 fr'unr:rir diatysis fl'lrrrrndiu6iqfiilruur,l:ru'ld

Vertricular tachycardia [vT]

amfioorn hyperkatemia tteirrurfinorn hypokatemialdrjaan'jr lrlRfrarqru EcG nnuru:

wndlu m"xnhn.i (rate :J::lrru so-8o/min; d,o rrfiei,r ufir liu sine wave pattern rSooron:.r

dnurustflu typicat putsetess V| G:Jfi sd) fiIfi

Ventricular fi brillation (VF)

rrrjsu'j, Vr r druu o,rrrqlfl sine wave pattern tufi:Jrudfi 1K1 "lunnrnrrrrnn'i'r 8

wmmol/L"''u lroi1tt.,.1i'tu,,t1uvt:l,irft vf, tro! cardiac anest oiel nruulnjolur'ldlrnnn::u:

rftuoi{:-hudlfi tatt peaked r wave'3 o--rriu'h{rhu4nrrudiilfi Ece fioln61il.jr;:.tuuiodo,r

3dfinr:fnurodr,r:rnrfr lu{rlrrr vr rirdr cpR loulrifnurySorire-e K' oonalfli,tnnlui.r d'?u

I[rJ',U::flLjn?',1lJfi . an
1[11
t1Y n',]:fl?Ufl ?tl

600 rrnirrYninqnfrusru

Approach to hyperkalemia
rLdo,id',Juflu4fifi + fin'rnrldqo un;datnhrfluahsr''1Jllln fionlTnr?lelfiulviflT ri':10'jri

nrrvdfi o':inur rd,,r oirunislri

hyperkalemia present? Rep%t sample if risk
is high, perform EKG
Is pseudohyperkalemia

Renal failurc ? unexplained
(6FR<1o-2oml/min)
Acidosis
Potassium shift form Beb blockef
Lack of insulin
Hyperkalemic PP

oecreas€d renal K+ excretion (TTKG

< 8 or uuucreat < 15)

Adrenal insufficiency

Hypoaldo6teronism

;;;;;l;;i;:;;;."-"Rhabdomyolysis I Medication: ACEI, ARB NSAID,

l,,iiir..-""G""''t,.'.i*p.'i" I

Iw./ugfri tdmuuznNluntt aryroach n12J hyperkatemia

nt:inrnnl2! hyperkalemias
n:riid:vo'u [K-l lu plasma q.rrfiurrdnriou rrdlrifinrlr:JduurlrJnmro',rndulvlflrrhh lfi

irfioornr:*o;rriirfluor ln4 un;'hlurdruldqlfltL dt6u oontondrtntu ttiu {urosemide lt?o

cation exchange resn tu{rJrudfin'nt:lduuu awo.:nfiu}lflrlr''de u5o 1q > 6-6.5 mmo/L fio
riunmvqnriuddoddfi nr:inr*r iinr:inurfi rYld 1nr:r'':d o1

Pofasrjium Disrrrdcn nivy inutin 607

nT lNfi 6 Therapeutic agents tor the management of hyperkalemia

Th6rapy Mechanism Ons6t {minl Duration (h)

Calcium chloride '10 ml of 10% lV Antagonise 0.5-1

gluconate 10-20 rf of fOm lV AnlaOonise 0.5-1
IIlC-Inaslcuiluinm/so% glucose 10 units in 25 g lV
Shiit 15-30 46
Salbutamol 0.5 m9 lV 20 mg Shift 15-30
4-6

Nebulizer

Sodium bicarbonate 1 mmol/kg lV shift 15 30 Several
Cation exchange resin '15-30 g in 20% Fiemoves (Gl) Variable 4-6

sorbitol 50 cc PO

or 50 g in 20%

sorbitol 200 cc PR

Diuretic Furosemide lV Renal start of until diuresis
excretion diuresis end

Dialysis Hemodialysis CRRT Body removal 15 min
Peritoneal dialysis of potassaum 15 min
L-
2hr

1. aofl alait hyperkalemia sian#Ttliarie'h (membrane antagonism)

oreld'lur u:J! 1oo/o CaCl, r,ia loo/o calcium gluconate ffld'lou cacl, e;fili 1ru

!l:calcium 6-8 mmol 'lu t 0 mL fi,:lrnn'jr calcium gluconate (2.2 mmol lu 1 0 mL) 1ru 3 ryil

calcium e:'[rjd?unn::61J [K'] 'luuaralr rrde:drudo cardiac membrane excitability u9{[6tJ

ltuvuh'hiLiu'l$ calcium rfiafi EKG fintnfi 1n nju rirfi p wave fi1ul , QFS comptex nir,:ria

fi sine-wave pattern'u'' urirlodlrfufi{r6uxtlruuu;dlilnx:rirbi catcium d.rudfiilrur?ffi

tatt peaked T wave rlia.Jornlril:rx::u:[']n1u. ua lo,Jmr! 6u urJo.lndu'tv,lflrri'r'lcorn peareo

T wave 'htflu widening QRS complex vio sine wave pattern *avf'rfinxl rtnnri't.tfldu

Llgtfl:!nnflft1u

n1ltltfi1lu'ruoornrmr:r,rfi o firlrjfinrrnarauo,ralqtfid{d In"l 2-3 ulfi n1flli
catcium mnn'ir s F,itdultLLfir'lilnoufluo,r nr:fiqrrrurvri66u1 iunr:ufi'll rdu nT:ld

pacemaker tflyf1 hemodialysis tdorern 10o/o CaCl, firuroutrflu 3 ryi'ula,,i 10% calcium

gtuconate n',oriulur1,0fi n1:.Jiu6''r rr1-l;d1'h{ld catcium gtuconate lu {ilx ufrfi a Aily{fltirlo ul fi suur.ln,:
ru0iu". rjfi anhythmia dd'urr:rs M|-.VF, asystole) lrflyfi hemodynamic n,:fi dru CaCt,td'lu:lu
dfiorufiouJnfiro,r EKG uuriulnn. fi arrhythmia uay hemodynami" lrlarrii 1on:r,lii zy

602 rrtrirtininqndugru

ionfi:c{.l

- lu{rlrufi,ildir digitalis a?:lfi calcium atirtdrl niu acr to% ca gluconate 10

mL'lu o.g% Nact i00 mL fiuewr,ivnoo t6aoo"rtunn'r go urfr

- nr:'ifi catclum tflu{afilr1u{rtrufildiunr:ifiedu'jrfi hyperkalemia q'ln digitalis

intoxication rdo{qrnnrr'htr catcium rir'tfi digitalis tlluv.: Na-K ATPase pump rurndu ril'lfilfia
hyperkalemia ;urr:':du 1nr:r'lii z1

e. nrrinrt{io&iinrttn6ouls.rtuuuariuilrf,tsad (transcellular shift}

2.1 lnsulin-glucose
rflun, rinurdldrunur.iuoudqalunr:aor:n'r [K'l loue:nnld 0.651 mmol/L tr']utu
rrnr oo u'rfivd'.rldirur {rJrufifr::d'lrhslrn tnn'j't 300 mg/dL are'hi insulin arjrt tdurlunr:

insr rra: da': fi nr:fi ntrr :: n--!dr nr n4 n t rirTr.l

9'Yr1{.fi-.7t'nD[|U311M'1!:3fl',r5d1141!n']llnU1 hyperkalemia ll.lnlxJqnlou

ECG changes or serum Calcium gluconate (10%) Besponse lasts only 20 to 30
K>7 mmol/L 10 mL lV over 3 minutes: minutes. Do not give bicarbonate
can repeat in 5 minutes after calcium-
I AV block refractory to
calcium treatment Circulatory compromise Calcium chloride (10%)
'10 mL lV over 3 minutes Calcium chloride
I contains 3 times more
calcium than calcium gluconate.
Disitalis cardiotoxicity
j 1. 10 U regular insulin in 500 mL lnsulin-dextrose treatmenl should
of 20% dextrose : infuse oYer drop the serum K by 1 mmol/L for
After acute phase or 1 to 2 hours.
when no ECG changes t hour

I 2. Transvenous pacemaker
l
1. Magesium sullate:2 gas lV bolus Do not use calcium for the

2. Digitalis specitic antibodies
of necessary

Kayexalate : oral dose of 30 g in
50 mL of 20% sorbitol, or rectal dose
of 50 g in 200 mL 20% soricitol as a
retention enema

Potassium Disorclers ttftwgl iau:ia 603

ionT :r:iir
- hypoglycemla

- nr:irl gtucose oti'rrrdar'trildrua rdo{ern,:yriL.t endogenous insulin fi rlirJrtruq;

lrjnialilafrc:lfiinu1m?J hyperkatemia'u uo;a'nrirhlfi osmotatity'lu16onar un:fi hyperkalemia

Q'tn water shift il1nflsu16

2.2 Sodium bicarbonate (NaHCO") nujrlririouldora lnuralrr:1u{ilru1"tlur{ur'o

irdldirnr:rianrdon flo1fuliluwrfrlfitd mriulun:fivrori rufinrr: metabolic acidosis dru'n

2,3 Albuterol (B, selection adrenergic agonist artldflu1n 0.5 mg yrryaaqrfionoi

(on K"[d 0.87-1.4 mmol/L) fl5a 20 mg t4't{ neubutizer (nn K ld 0.53-0.98 mmot/L} io6xt
:yi{60 rirtrifitof,u (tachycardia) rLd; tremor -ld

3. nrttrr-nlnungtisroanqrnjrrnlu (potassium removal)
3.1 Diuretics: iurosemide'ldl6'lun:fifinrirno11nu",td ue ;drnolauarriou'rriuflnorr;

3.2 Cation exchange resin

3.3 Kayexalate (sodium polystyrene sulfonate) 1 gm fla,r resin eylc'gT |ryrcria!

:;aancrndr, 6 1nr 't mmot lnuRflnrTilrrdarnri'l rflrddt',:nru:l:;rrru 1-2 mmot 6tnr::;it

lu{ilrofifinrrv rdurdo ri:hrrrniafi volume overtoad arjudr

3.4 Kalimate (calcium polystyrene sulfcnate) tflu resin fild catcium rran r duu
fi' r,rure 16ur.r rurovr"biuno,rri",ror:rrfi o

4. Dialysis

4.'1 H emod iatysis rfl ui6n'6fr qo tu nr:f i'eTr ura 16uilaoncrnir,lnr u'h rro'r o'urr n rf r
ln ratn:otd'o1vr uyrd ri uildfit 25-40 mmot darirfu .: aur:nrfi rnr:sinlnurar6uuoancrn
dr{nru ldTouliirnrultr{uro,rJu uyolfiurJ'luflur diatysate lfin'rna qniu 0. r rio z mmot/

oay1, rfirom:rnrrlrnriuur6on (btood ftow) y5ouijrcrrurdrd!?ra{ Hco3'lurirur diatysate'

4.2 Continuous renal replacement therapy (CRR! rfluiifiddniBnfitlunr:tdo

lflurotiu oane'rnironrer lnu ralrr;ourrEirtuflr-hufifi hemodynamic 'lrin.:d orir,:'l:fifiril

:.1:sfi finrnc;dounil hemodialysis

4.3 fi:rs.:'tunr:1d peritoneal oialysis tunrtintl hyperkalemia ttn'nrnlrjuriuou

ruaroonqnf,drfir z rjr1r,: i,r'lriuusrjrlfitd

604 rrtrirfnlnqnfrugru

10nf1501{to{
1. Tannen RL. Dyskalemias. In : Shaul G. Massry, Richard J. Glassock eds. Massry and Glassock's Textbook od

Nephrology 4s ed. Philadelphia Lippincott Williarns & Wilkins, 2001:295-307

2. Wngo CS. Weiner lD. Disorders of potassium balance. ln: Barry M. Brenner eds. Brenner & Rec'tor's The Kidney 6n

ed.: WB. Saunders, 2000:998-1035.

g. Tannen BL. Potassium disorders. In: Kokko JP, Tannen RL eds. Fluids and electrolytes.2- ed. Philadelphia: WB

Saunders. 19961 1 1-99.

4. Brown BS. Extrafenal potassium homeostasis. Kidney lnt 1986:30:116-27
5, Halperin ['1L Karnel KS. Potassium. Lancet 1gS8:352: 135-40.
6. Rose BD. Post TW Potassium homeostasis. In: Clinical physiology ol acidbase and electrolyte disorde|s. 5'" ed.

New York Mccraw-Hill. 2001 :372-402.

7. Adams. PC. Woodhouse, KW. Adela, M. Parnham, A Exaggerated hypokalaemia in acute myeloid leukaemia Br Med

J (Clin Res Ed) 1981:282i1034.

L Alfonzo AVM, lsles C, Geddes C. et al. Potassium disorders-clinic€l spectrum and emergency management.

Resuscitation 2006:70:10-25.

L Cohn JN, Kowey PB. Whelton PK. et al. New guidelines for potassium replacement in clinical practice. Arch lntern

Med 2000:160:2429-36.

'10. Un SH, Lin YF, Chen DT. et al. Laboratory Tests to Determine the Cause of Hypokalemia and Paralysis. Arch Intem
Med 2004:16411561 -6.

\'11. Groeneveld JHM, Sijpkens /VJ, Lin SH- et al. An approach to the palient with severe hypokaiaemia: the potassium

quiz. Q J Med 2005;98:305-16.
'12. Ahmed J, Weisberg LS. Hype*alaemia in dialysis patients, Semin Dial 2001114:348-56.

13. Aslam S, Freidman EA. lfudu O. Electrocardiography is unreliable in detecting potentially lethal hyp€rkalaem ia in

haemodialvsis oatients. Neohrol Dial Transplant 2002:17:1639-42.

14. ortega-Camiecer J. Benezet J, Benezet-Mazuecos J. Hyperkalaemia causing loss of atrial capture and extremely
wide QHS complex during DDD pacing. Resuscitation 2004:62:119-20.

15. Barold SS. Loss of atrial capture during DDD pacing: what is the mechanism? Pacing Clin Electrophysiol 1998:21:

1988-9.

'16. An advisory statement on mnditions which may require modifcations in resuscitation proo€dures or techniques.
Prepared by Members of the Inlemalional Liaison Committee on Resuscitation. Special resuscitation situations.
Resuscitation 1 997:341 29-49.

17. irahoney BA Smith WAD, Lo DS. Emergency intervention tor hyperkalaemia. Cochrane Database System Rev

2005:2(lssue). Art. No.: C0003235.pub2. DOI: '10.1002/14651858. CD003235. pub2.

18. Fraley DS. Adler S. Correction of hyperkalemia despite constant blood pH. Kidney Int 19S712:254-60.
'19. Greenberg A. Hyperkalemiar Treatment options. Semin Nephrol1998i46-57.

32

Sedation, Analgesia and

Neuromuscular Blockade in ICU

ntn1{wri ntw*tfru

Sedation and Analgesia
Tnrrirll{uuiirdrirnr:inurtulodgusurinfinrrillilqlloururfisduldqrnraruoru.rn rdu

nrrr16r rnd,roro lfiorern uflnii'reTo nt:a"n rfluolor-ur;rir.:1 nr:laiviotirufiru'lq nr:'l6i o:;!ru
ornrirrvr:r:anuiafl"tu caiherer oirtl r,rionr:ddoluauadluyirlorviufi,,rurul nr:gnroru:ii.l

oredrtfifiilruloilrnld nrryru'lehidrJr{u6'rYillnio.rdrufiru'le nr:'hjolrJr:nfionr:nir{6u1dnu
da.onr: yionr:'l*jn:rrnrtvnrurilrhu:ro.lnuror yisnr:ad'luonruurerdolfilri{urna rirhlrfio
Ri'rrnn"?rrncnlr n-.rrn'lfi uonerndfirhuoreuouva-tllrirfiu.:raqrn6ll rrrofio vt':r.rnru rdu rdur
o",:s'rfl atarm ra.: rniortiruyrule rLooo.ir.,i'lufio.l nr:lirffinnr:sir,Jr tunaunottFu d.:nr:uau

u dl'hirfi a,rn adn'ru nyri'hirfi onm: det irium ld

fleo'urir.,:1 unrirddrufi!'ra:!nrufitrurf.,rnr,rd'rudrrnruuo:6n'h or.rriu6,,rn.::lfinr:gun
{rJ':rludruoir,rl rysjrddru niofre:druhi{r]rufinruarLalrtu.ndu nr:lduruaufiniuyiour
::.lurhnrflurfiu,inr:inurdrur,rfirrrirriufie:ilr,rirurair nr:quati.:u rrfialuri'ru6u1 frti,:finru
rirri'rprtjurTu rrju nr:o"od.:u:ordartfirjroqj nr:e'olia,rr'fififirdrrfiuR,,:lrno::rmh rirlfir{:huf;.:r

riunnr,:iuyionnri6u ii.le:drfllfifinr:uauvn'rd6rsu nnnr:rfionrry detirium nlrloqufillfi ru
rr'o}intrri'.010 n'r:aBr.rruua:hidaradofi:haorirr lyrur:ar yfinrdurnr:oi :rrLdolalrratirrdr,l

16u,:firhu6rorefrHan'oonrvrintera,rrfirhuld niu nr: urn:niT:nd'lrjd nr:irila's.l'rrflut:nryr5.r

nr:ouninurnrlyyn,lnrufiui}irfisrn.luhiqlc::ru rtiu n:yrylrtilnct:Iil.r fio,:6a fi;ao1n1?
n'umtrfiryf,: nr:l"nyirarjr.,:ruuryaruo: r dtruvirfi:Jruorjr,rar'rrdralourarr:tufirhrdlriffinri'r
nr:q"nria,,r'lfiriuuun:lrifi*a.:R'ir,rtrnrfiu}J nr:fr.l atarm rallnio,,rrirlfirBlolfirfirrryoil lrilfi

606 rrniliarinqnfrugru

iorn-':rrnrfiunrrrdrrflu ur,rni,rarofio,rlfirn{a'rqogniofiriinnr et rqzdrutli{fimouvn'r.ilrfi6du
fi',niurioudq:riiltriuruouv6r'rr?aur:ciu rq o;do,ri,finr:qunfirJru'ludrudrtl rnoirddrulcra

nr:tturiu{ilrufi 2 urrfio
1. Sedation nlrufl.r nrrrirtrt{ilrrfia, rlf;finfi"rnontuiovdt"u ltrunr:tduruoura''!

(Sedatives fi €o Hypnotics) rrindrrl rdoli{r-t, ua.ouarrioRor unrufiirn
2. Analgesia rJ'rufir ntu::rrrntrlr6:Lilro lsunrddur:;.fu rnlAnalgesics) tfiodl'r1

dturr:,r'u ra:fttfin niu nair opioids fiqrd sedation deuniunu

nr:q; 16on'ldulrrdo:fira{ffuikuvruo;n':uq'rrfluror{rhuuria;:ru'fi nT :q:16iuur
uourn-rtiour:;ir:Jraniofr'raoootir{drilrYu usu fir{rJrufinrurSrrJra finr:l$ur::.r"rrJrnldo
lJ:l1r'r0rn'n lrier, rtfiuruauna'urr:rvhjfiqvrd:ri:r:.Jto uonorndnr:rior:rurfitonrl,rro,r{dru

runcT:adrrr dr ulunr: r6on'tfi ar

1o:j.oruaro,:nr:'ldu16o rdau::rvrrntrr lir:ho un;artrrT.:rn tjrubiuounri'r:rrnsfi

qrfnonr:nrulo rfiairfi4rJru.nuto drrTr rnlo,:rjruvrulolfid nn work of breathing ualnoornr:lo
tu{:Jrudldviotjruvralo tufidc;lonoirrfiuaur:n{rarfitdrjoaun:filfi'lud::Ms'hu

s1uauilffu (sedatives)
Benzodiazepines rfiuniirlurfirjruaqnttrn'rto (anxiotytic) un;rir}iuaur,rolldd rro:

r-lrirtfifi amnesia iardru6on,rtfilriarrr:oo'ruqnr:nirvr.r'jr,ildfiurld uld""nqndI"u'ltJ{,
ni:.j gamma aminobutyric acid (GABA) receptor dr'lfinnnr:n:vdu limbic system urtun{ dfi
qrf,nnnr:rirmura{:rruv''rle ua;nr:nrutq uoncrndti,:tdrfluurinurnrrrr'nld {anr::yir6o
orcfi n'rr: detirium rfi ndu uriunsiriifi ldriau lduri

1. Midazolam (Dormicum@) lflu sedatives frgntdlrnfrqotulafig fiqruomifi lipophilic
{roiru btood brain barrier ldd drtfifi onset r5r :cu: r'rornr:ornordotu fi elimination hatl-tife

z rirl .,rudorcuflndrdiuf,r-lrr critica[y itt urdfi r"t"boti"r rilu cYP450 isoenzyme 3A4 lu

d'rluncfi active metabotite {i.,:eya:a unrrclnrTu d,rriunr:tfiarlufifiudfiflrynrralnlniofi
nr'::lrrluoyrirbiuroonqnf,urunirrJn6ld danr:::i.rlunT rtdur6o rirbifi tachyphytaxis uo:
rfi o wnhdrawat symptom .ldlrinr:lfi ur rfl unnrurun'ir ae-zz drlrJ.t

tU1aU1: lV bolus 0.02-0.08 mg/kg q 0.5-2 hr (Ui: 1ru 1-5 mg). Intusion rate 0.04-
0.2 mg/kgth( (Jr: lru 2-10 mg/hr)

2. Diazepam Ualium@) liluurfifi onset tfr*oifi active metabolites 6,:fi etiminaiion
half-life r.l'ru rir'lfiaanqrfiflurrntutu otqlrrt:n-r tong-term sedation 'ld:;.1'Uo'rnr:d'n-ld

alnnsl: lV bolus 0.03-0.1 mg/kg q 0.5-6 hr ( ry lru 2-10 mg). lrjn'l:ldru:t

continuous lV Infusion dio.,rernd1tfirflq thrombophlebitis dluttr,l

Sedation. Analgesia and lVeuromuscular blockade ir\ ICL n1ryiNrt nxw?u 607

arfiruqldlo,l benzodiazepines fl54 Benzodiazepine antagonist ddrr{'a!60 flumazenil

ili.,rrulqua'unTuur benzodiazepine lousE,'r Ljld{ufil benzodiazepine receptor ri{fi6[1!']1n

rufiltnrlc sedation 160d1\:?ror5r lrjnr:td'lu{:-trudlislur benzodiazepine rrrflurrnruru
rn:'xl;rir1fifi withdrawat symptoms uiad'nld fi natf-lite l:rJlru 60 uT fi turou, Gr.rdud
0,2-1 mg lV tto; titrate aufil'!umar:nuo.r lrietrr'ldtu{ilrudfinrrrrdt{donrrfnyiol' intracranial

hypertension

Propofol oonqvrdnlru GABA receptor 6{fi nraTounr,'reioolo,: fi qnrRrl-fi rflu tipophitic
ri{fioiru blood-brain banier ldadrl:ror5r do66a rir.roanqnf,r5r (rfluiurfifi,rurfi) unyrro
qrf,rSrrn-rornvanudrlfifi:-huf frnn"rr5r propofot 'ldo-rrira;n'rurflu6lrtfifi6ern soya bean 6,:

rflu lipid emulsion nn metabolized deulrndfiunaruliiu inactive metabolites uonernd,i,,rtd

propofol 1unr:inE1R'r'r: refractory seizure (status epilepticus) 16 rfluuriifi neuroprotective

effect tunrrr brain ischemia n''.rriu propofol 6ttflu {irst-line sedative agent tu{ ru traumatic

mbrain injury guideline na{ Brain Trauma Foundation' tfio,tltntirunq intracranial pressure

vrfl'o 16

fiaar::vir: lu{il?o hypothermia }130fi sphnchnic hypoperfusion ayritfi metabotism

frdlonar finra ni:.r:co':rurhr6oalfr iu{ilrudldi tnotjr{siorda.:rtrdur6oon':rnrrefioerr

i:vn'uro,r triglyceride na'lcrnlfiur 2 uaJ1n g-z iu |,ra;d,1'jirJlruuldtd ln'ru?ru1ra"n\r'lu
1firu (propofol n, tfir{a"n,t'tu 1,1 kcal)

lil$l1nu1: lV bolus 1-2 mg/kg. Infusion rate 5-80 mg/kg/min 'lrjrfiu +-s mg/kg/hr

nxrldurururfi +e {i'r1u.:

rfii1.rr6s{: nfl nrflrh{rulo.:rcuurir'lc Iavnr:fi rule drtfi fi nrrild'uTnfi srrirldornnr:

fl6n,Jra{ tone rdurfionun: cardiac outout rirlfifiornr:rjrnrirr fiurfioofilfiur1dTou ra r:

nr:lrtar rru:r lv bolus

Propofol infusion syndrome (PRls) 14:Jliouhfln14 il::*nu t % usitflunrr v uvr:ndou

idluu:.: ruriaS:ivrurfl. rrlt"errqu rrrioreldurda.:nillntrrfior nfitol mitochondrial respiratory

chain ua:t]o{urt.ntTuqn::r o'rR1r1ro{ PBIS ldllri hyperlactatemia with metabolic acidosis,
rhabdomyolysis, hyperkalemia, myoglobinuria. hyperlipemia drhlfi bradycardia, cardiac failure
un:fi asystote.[d laura rclu:rud'ldiuurlutu'roq.ulflu!']n1url

Ketamine aanqr6'lnunr:n::q! N-methyFD-aspartate (NMDA) |."""ptol. arfi'fi1f'rqvrd

sedation !!fl; anatgesia rirtrlfinr:no",,r catechotamines 6orirtfio-o:rnr:rdura.rn-thuo;nt*t

d'uTnfingodul{ Ketamine rtfu cerebral blocd flow ua: metabotism rir'lfi intracranial pressure
g.rdu uono''ndu-olflu bronchodilator rirr.rrlfilunr:inu1 severe acute asthma Id

608 retri'rrininqnfrugru

lu1fiul: lV bolus 25-50 mg, Infusion rate 10-30 mg/hr
flnifitfia.t: nightmares, hallucination d"orilitar:ldfiln''u benzodiazepine rf,rto

Thiopentat rflutrrnajr barbiturate oonqfldij,ilml\t GABA receptor ldriu induction

agent'lunr:nruran![fra,,ie1noonqrf#urrnn.l:fifi redistribution lu fatty tissue s1fi clearance
Tnu heoatic metabolism nr:'hiuruuu infusion tflu:vu: ttoruruoronvoltudr{nruli1tfifrud'r
lddrloarayrr:{rJradfi:lrpnrnr:rivruta'tfi'rfinrJnfi uonorndarrfinonn::r.ru4fi{rniu fiaT :rur
tfiurdlufifirrfitdrndo,rrirufirute unv sedate drsur6ulrilde{n tStflu second line treatment lu

{rhu retractory intracranial hypertension rra;tilrfluurildinul status epilepticus ld
n 1nu1: lV bolus 25-100 mg, Infusion rate 2-5 mg/kg/hr

radlsr6u.r: rirbinmld'r.rlafi qdrldlsraron, vnr:lfi uutl lv bolus

Neuroleptics {Antipsychotic drug) frd1n''ru60 Haloperidol rflulrnejl neuroleptics d
gnriT lr'ld seoare {rJruldldufiulouronrv{rJrudfi o"li,lur lula6gloooonqnfuiuu",,r copamine
receptor'ludra.rt;r:rtot'lunr:aanqvrf, l-e rirTm

nnul: lv/lM 0.03-0.15 mg/kg q 0.5-6 hr ( ?Y 1ru 2.5-5 mg), Infusion rate 0.04-0.15

mg/kg/h r

greir{r6rrn: extrapyramidal symptoms, prolong QT interval, Torsades de pointes,

cardiorespiratory depression ($uilau), neuroleptic malignant syndrome (NMS). cardiac anest
(v.r!fiou)

ulic{'rJilln (Ana I gesics)

opioios oonqriloonr:n::{u m-opioid recepror tt to:tltti,taruu6u:Jroiir:lu:J:vorl

nnr,: uoncrndciofiqvf, seoative irldru wndr,rrda,lntafrfiq6o respiratory depression, hypotension

flnararrrr; morphine dtfinr:nn"',1 histamine). gastric.and intestinal hypomotility Tia iteus r{rtfi
fio,,r4n'[d uri,laanrfiu z nrjrdo natural opioids !!aJ synthetic opioids

Natural opioids
Morphine 0n metabolized drultnfic':.r1ou enzyme uridinosine diphosphate (UDP)

glucuronylirans{erase system fi active metabolites 6omorphine-3-glucuronide (lV-3-G) !!av
morphine-6-glucuronide (M-6-G) lnu tvt-g-e o1a tflu anti-analgesic deu M-6-G tflu potent

analgesic do metabolites oT qtlrnriudl,rn, Utunrrc'lnrrudrhlfi prolonged secation lfi urdfi

onset daudr.o$rtm:aannrdurun'ir ooioid nrdu

!u19U1: lV bolus 0,01-0,15 mg/kg q 1-2 hr ( r;tJ1ru 1-5 mg), Infusion rate 0.07-0.5

mg/kgltrr (r.hv 'rru 1-10 mg/hr)

rafirsrfi !r\t: n'r1iln''uTnfi nnie1fl fl 'r?fi flr.J histamine riltfifi vasodilation

Sedation, ,laalgesia and \euromuscular blockade in ICU nnliwi nffistiu 609

Synthetic opioids

Pethidine (Meperidinel rfll synthetic opioid fi'eu:nfinnrj,ltJ*fi fi active metabotite

6o norpethidine (normeperidine) fi.rorlrir'lfifnldloulovt.]J fifl{o.tulrn;{rtr uiifi-lcrra {.ilri

uutJ tg tutogu

!u10rn: lv bolus 10-50 mg

Fentanyl rflu potent synthetic opioiO d,:fiqndu:{n.j1 morphine 75-200 ryir fi onset
t5':uay::ut nnrnlioanqild#tr rda.rornmrflu tipophitic rir'lfifinr:cvolurlu adipose tissue
er'',rdufiltfiurrr!:r in{usion rflu:;ucrrnlu'ruoradl'lfiu'rf,:fl hi.r,,rn1fl firudo;nqourufiruriqrdro,r
urorlri.rlrirrJn rir'tfifi recovery druoyfi wirhdrawat symproms 16 .il0n'6o hjdr}irfionr:nott
histamine 6,r uu:rirtfild fentanyt rfluu'mriuilrntu{r-trudfiunsran5nr:lunriuu16oelrjn.ld
nio'lunrrvdlnrir.:rurnnia.r

sulau'r: lV bolus 0.35-1.5 Fgikg q 0,5-1 hr ( ?;rJ1fu 20-100 pg). Infusion rate 0.5-3
pg/kg/hr ( rYr,lru 20-200 Fg/hd

Opioid antagonists: Naloxone

aonquilnruo-rnil m-receptor rirhi opioid nrnorf,adrmrorSr i.:'lrinr:ld'lu:rudldfi

flltJrurutu:'t;dr'1fifi withdrawal symptoms Ifi orofi nypertension. tachycardia. anhythmia

ttn: seizure ld nr:lfirnnr: titrate ad't{dtl

1u'lnul: 0.1 mg lV n 3-4 !1fr

nr::J:vfi u:'6uno\: analgesia

nr::J:; rfiu::fl'1jerrIri'l rn llli.ioonrflu 2 rluu

t. 'lufirhsfidoar:ld lfi{rJrurJ::riunrur6u:Jrndrunuro,:lnt'ld Numeric pain scate

(rues1 d,rfin;uuuns.rud oJ0 Toirn:uuu 10 rtrun'r riuJrorrnn'anrvird rns :youlr n;!!uu 0
rrrufit lrifi n':'u16l!'ro

z 'lu{ilrufilriatn:ndoar:ld.[riaurrnlan::ornrrrliurJ'rolddrunura.r tfi:J::rfiu

lnutd behavior uac physiologic parametersld'uri nr:rrcnrfiyfir nr:rndoulvraord't.in'ta yilrfi

nr:nrahdur{ufrTlroio,rri?afiru'lo vitat signs ldrlri nlr.rd'ulnfin fi c: *oydn:rnr:1ara'h

nr, rJ:v tfiufigiuto\t sedation
nt{tiar sedation riourfiulil (under-sedation) raialrnrfiulillover-sedation) rirlfifina

rfiuoia{ilruld l',rnr:finr: :lrfiu:to'lnar sedation }ioglu::ri'!fiu4 rcnrJTntnr:'ld scate oir.l1
dfiudfilirrri Ramsay Sedation Scale (FSS) r.ria Fichmond Agitation-Sedation Scate (RASS)

lnal'rll nr:t{ RSS score trirJrru B-4

610 r'ndrrioinqndlSru

Ramsay Sedation Scale
1 Patient anxious and agitated or restless or both
2 Patient cooperative, oriented and tranquil
3 Fatient responds to commands only
4 Asleep A brisk response to a light glabellar tap or loud auditory stimulus
5 A sluggish response to a light glabellar tap or loud auditory stimulus
6 No response to a light glabellar tap or loud auditory stimulus

Richmond Agitation-Sedation Scale

+4 Combative Overtly combative or violentt immediate danger to staff

+3 Very agitated Pulls on or removes tube(s) or catheter(s) or has aggressive

behavior toward staff

Frequenl nonpurposeful movement or patient-ventilator
dyssynchrony

Anxious or apprehensive but movements not aggressive or
vigorous

Alert and calm

Drowsy Not fully alert, but has sustained (more than 10 s)
awakening. with eye contact in response to voice

Light sedation Briefly (less than 10 s) awakens.../ith eye contact in
1o voice

[,4oderate sedation Any movement (but no eye contact) in response to voice

Deep sedation No response to voice. but any movement in response to

physical stimulation

Unarousable No response lo voice or physical stimulation

tnEJr"xl:J RAss score lriarrn'rn'ir -z ust'tu:.t't.::rEJdfio,lnit deeo sedation arq'lfi score
fi.: -g unv -q 16

uunornr*firo:un:nl o-ufafinorqfinr:rilduu!!ila.ildstr ::oi!ral sedation lunl?c

under-sedation oTrirbifi hypertension lio tachycardia drunrrv over-sedation olofilfii

hypotension ria bradycardia .[d otir.rl:finlrarlfir]du6ur fifinnriofnmun;nrrlri'u1nfinld

Sedation, Analgesia and Neu()muscular blockade in ICU n1filiwi n7fiH?u 67L

ttu?ynr'tilnl?tf;m sedatives/ analgesics 1ulo6g

ruuryn.r rdo.rdulunr:'[fi ur6a

. :J:: u.r'unru r{l:Jrn ri oulo uifi nr:oirt 1 n",:dnrir r'h rda,l du
. dT {rjrafinrurir.r:Jranrrricrrrurlfi anatgesics dou uriildrioufio morphine nio

tentanyt drfiqrfrY.: anatgesia LLn: sedation rLeililfllfifi amnesia :clio:ct-,rnrr'[{ morphine'lu
{:-hudfi fl rgurlnmurSafi nmrri'ulnfi nn'r

. :J:: lfiuryriutro\: sedation lrny analgesia zYrriaul un::Jilnurour'lfity ryotJ fi't

{r-hutilfi agitation n5oti,ilri1d:yniulo.r sedation fidalnr:niou".,:fiilqnr niu nrllclritrlvriuf
fii rnia..rtiruuru'[r fier:rurlfi sedatives irrdru lfio'lfiosnqvrdrairriu rtir bi morpnine drlrTr-r

midazolam

. fir{rha'lilfinrlr rSulhousifinrtJrY':rnr5ou'':fi agitation axflie1trurlfi sedatives ur

fifiultdflo midazotam uio propofot :rrTnr;r"lnrr'l$ midazotam tu{:Jrul:neilriafilorlu

nn'n rfiu'rnr:ld propotot 1l{:-hufifial:.rd'uInfinq'r urifirdo,rnrrtfifiilran'urirna".oornrqnurnr:

tfi propofol

. fir{ilrufinrrv delirium nt:'H antipsychotics rdu haloperidol

Ioruri"illtnliliurlu dose urnnr:'hirflu tv borus rirlLriaurfiolfildNoro,,rurorirt:rnrfu
usjfiar:vt-rrundr,rrfiu.Jcrn::n":JEJrfi riirduarir,r:rn r5r rtiu hypotension orntiur','tr.l:rrfiuflaso.t
ulirldoromr.rfifiasnr:vialriuo:fi::a:rrnrlunr:oonnrf,ururfia.r'ln nrrr:n'hisruul tv botus
rtrldfirtirfiornr: usi(irdo$'iur N borus frrnrunY.rn'r:fiqr:rurlfiursiardo',:druii continuous
tv infusionloadoul titrate urrul6:rn''uifio,:nr: {o66odrbl{rhuld:"lurarir.:cr'rror.ro fi::ri'urhi

fluauate rurfiul udfifianT :::i,,rfio oron"rt{u'ro:on'tuir{nruld'Insrav{rvfirfiicgrrtunrrriroou,

rdu 1:nsiut,t5o1:nlo dr'h4fi0',rmn?flour udrfi:Jruore R'r.Jv5o'hiifinri'rrflu:cu:rrnru'ru'ld

Sedative and analgesic withdrawal

lu{rl'rufildftlur opioid ria sedatives lulurn4.lnialdiurrn'ords.,lrflurrnrurun'jl 1

d:Jnrfi arrriarl flolu'rou'rfltqlrrqour bjnr:nqourriufiur:ryqvdrlfifi withdrawat symptoms

ld ludr.,ru:norennuln{ 20-40% rialJi.rnodnniln; 10% 4n tz-z+ rirllr

a1n1l?o{ opioid withdrawat ldrrri pupils dilaiation, sweaiing, lacrimation, rhinorrhea,
piloerection, tachycardia. vomiling, diarrhea, hypertension, yawning. fever. tachypnea.
restlessness, irritability, increased sensitivity to pain, cramps, muscle aches ttny anxiety

a1fl1llto.t benzodiazepine withdrawal ldllri dysphoria, tremor, headache. nausea,

sweating, {atigue, anxiety. agitation, increased sensilivity to lighl and sound. paresthesias,

muscle cramps, myoclonus, sleep disturbances, delirium [[Ry seizures

612 rrtri'rtioinqodugru

Sedation protocol/ algorithm

nr:'ld sedation protocol rfiatiluturrrorJirj6tunr:'tfi sedatives rio analgesics tiu

tirunrrl4rnr:tsurlrilfimnrfiuhJviaurueutflul d.:orqdr'hilfioflnrfiuld rdu:vuvrrornr:'td
rnCo,rrjruvru'lou'rus*u nrrn"r tracheostomy xrnl'u {rJruldfin'rtn:rlr.n,:atjrtdlridr rflu rrju

cr scan fi:r; ::u:narnr:uoululofigur#iu finr:finurrarunr:6nsrrran.:'hirfiu'jr nrrld

sedation protocot rituner::uvutntnl:'lfirn{o'rtjruvrulq ttatRn?;utLlflln1:uoululaig uonorn
df.rtiruti sedationldnurirrlralrndu ann, :'tdurrrn:rir:-nur ao patient-ventilator asynchrony

ttovnnnr:tfi a ventilator-associated pneumonia

n-radroto.t sedation algorithm

I !* sedation ;tle+,, fl1llu
9r,rL!1fi311Ui4,0 t1{ 0 t14 4u1rrflfl

l:l

rrdrru4uolttfilanrittqfi reversible .| uurlrrfllfi lutD,r sedation nn{1r'ld

ti.rfiorrll qanrru- sedation score

\fi:a agitaton-,/ . rjrTrruroarlfld sedation fi1lrihr 1u

un:l'fi ruroarlfi T iotrfi qe u{rfi l'r lilu

. fierrfurlfifi daily interruption of sedation
. -fYirlfiartruu continuous infusion

rios.l nonrr a ur drldilr urrurog.: riu rrnruru
]ouno infusion rate Ty!1ru 10-25% giaxiu

i:rf, fi2rxrixl1n Hemodynamic unstable

. Fentanyl 25J00 ttg lV q 5-15 min

Hemqdynamic stable

. Morphine 2-5 mg lV q 5-15 min

lrtirlHcrsr rrnnrunrorlrr6u rel
un3n1T10t1{llntarcv"jtuu1fzl]

Midazolam 2-5 mg lV q 5-15 min
Propofol 5 pg4(g/min titrate q 5
min until at goal

d:s!fiur'rx: delirium Haloperidol 2-10 mg lV q 20-30 min
thtrt 25% ot loading dose q 6 hr

lclSedation. Analgesia and Neurcmuscular bl<rckade ir\ nnliui MnHAu 613

Daily interruption of sedation (DIS)
tufl n.g.2000 Kress trnyn.uydrn']tilnul u'j1 n1iflqau1 sedatives (midazotam or

propofol) LLd: analgesics infusion (morphinel ri'ln:'nou{rjruyiayth'l'rrdn"[d g-+ arjr',rriarirfi
agitate dltJrrnoo::uc r?nrnr:ldrniatrjxufi1u19 r:urr?a1nruoul laf u uavnnnrrn:rrrfin

rfi unr:rralnmo,0otn't:r niuutt n,rnrtrf 6tnm"r'

luflcllirifiiauuvrirtirft ots iunyniofirlilfi{artrrl niu {rJrufi pain uio distress rr'tn

fi intracranial pressure g'i il?ofinlild neuromuscular blockade a{ 1ur;ni'r.:dtqnurfil

{inure:dor rilrn ua{rJraadr.rtndfiolilr'l:dd?uaiefi distress nio agitation oleii hypertension

tlio tachycardia fi50fi ventitator asynchrony ld {itfinr:ro?urniaildcvriiltfiultydldniu r.:fi
lou'hiurrflu tV botus lilriau rsion':uqrarnr: unvlfirflu intusion dolnsnoturnnrniwd.,r
crntlurntd uncdou'l titrate urrfj ducufi,t:so-Lllo\: sedation fidornr: nr:rir ots drlnil

spontaneous brealhing trial ti?unn:yUc[?nT nr:ldrniatriruTlu'tald3

Neuromuscular blockade

'{finr:ldurudoundutda (muscte relaxant, neuromuscular blockers. ttMBs) rflunr:

{:JruLjnur:nrndaulrrdrueirrl 1o\rd1.0n'ru (paratysis) rnylrifi1x1?0141ulqr0,ild n',tfirriau
dodfil, nrjoundrlrdo {rtrue:da.,rldiilnr:ldrio,riruura'hun;tsrniashurnuhuur conirot mode
rufir unr{ulun:rf,fiecldurvEioundl rdodiadrulunr:ldviotirutalun:rfideyfioruni!rlo nrnflu
nrr'ldri atir utcliu ia r rioudr Crtrur {ljr u

nr:ifi t tlrles cyda,J'lfifin',rcrnrir!:-hu1dfuur sedation u6o anatgesia ou{rJrulrif frnfi'r

lrdlrililli NMBS rfiu,,:0ri1rr6urToud1rild sedatives uia anatgesics dau ril:r:firtfiurdtu
t ru: d {:h u li.rf fi n fi'r o:drtrl{:-h uf fi nrr 1 rr1 fl qrnfl 1 :fi1rj nr rr:mu"rdronr ald

fiori.rftlnr:liur

. fiil'rsdda.flSrnto,rrirufirutour.t setting niu l'fi peep lurn4.rria inverse l:E ratio

dtororirlfi{rJrrlriorrr:nvu1fi niolun:n1d{rtrunrutehjfrlfiu6fi:laia.:tirun'ralc
(ventilator dysynchrony) lunrfirr".,lnshmCd Fttvtgs vfl'rcrniilim sedation nio
anatgesia atjr.rrfrrf irl.trYild:Jf!rnia'rtiruilrulcodr,r rvrr'r;NrJrLfiru',t-hi'ldt{n

. drlrudfi intracraniat pressure {,r nr:hi ruuB" rfioflauYuld'tri{rlegloiliani,tdidr'h{

intracranial pressure q-rfi"u dru cerebral protection

. firltu refractory muscle spasms tdu telanus uio status epilepticus

urndsundtldarnj.raanrilu z n{lfi o

1. Depolarizing Hlrles fiIo:'rgtr'rtfifiol,l acetylcholine 6':{lltn:nr;{u acetylcholine

ireceptor rirlfifi persistent depolarization flaJ membrane muscle fib€rs rinoucualrdanr:

614 rrtdrrininqodlgru

nri{t.t1nu acetylcholine urlun4uftdrrd Succinylcholine

2. Nondepola zing NMBs fi-rfiu acetylcholine receptors niurdurn'uurdlrioonqvrfn::{u

rflu competitive antagonist ril acetylcholine ttt-iloontflu z nejr'ilriuri
2.1 Aminosteroid ldtn Pancuronium. vecuronium l!flJ Rocuronium rffurndfiairu

:cna:Jro.i steroid oreli{firfion'l'l: critical illness neuromyopatny ld:jouT9!a

[otI']! Pancuronium ttfl ; Vecuronium

2,2 Benryliloquinolinium ldtLri Atracurium !!oc Cisatracurium iids66o uroarud'r

1dto,,:lqun:: run'l? ester hydrolysis (Hoffman degradation) ridficur:nlfi ur

'l61ufi:-hudfiT:nn':rv5o}nln dio.rrrnarfi nar-lite du6.:nr:'hlulrL!! infusion ori'r\:

riorfio.,,:

Succinylcholine (Suxamethonium)

riu short-acting depotarizing agent d'r'ldtJlnlunr:ldviodrunrfl'le rflu rapid sequence
Inufi:yu: nnrtunr:arnnyrf rrurru g u1fi uo:tdolcrnilrdti{firna depolarization d n.rro-

muscutar junction rirlfrfi muscte fasciculation rioufiectflonr: ntoct< d.tdr'lfifinrrndl potassium
oanx'nrnranf lnurt'ilil::d'uso.J potassium o:nir.rn*urfiru6nrlau (0.5-1.0 mEq/L) unliulu

{rhurr,:n{rdarlLfionrxs hyperkalemia lull:t lduri spinal fracture, neuromuscular diseases,
paraplegia 1:udr critical illness neuromyopany drorofi muscle atrophy ornnr:uoulula6g
rlat:,:r,'rurrrnuru,i) nl?c burns $'lilld acute phase), rhabdomyolysis yia renal failure'lu
{ilrtrnrjldfiuld succinytchotine drchrfludaflt NMBs nrrt$urfi'rduuvulfiud rocuronium 6.,t

tflu non-depolarizing agent doonqvrdrirniu16arrTu

rulnm: lv bolus 75-100 mg

{onrrrciio: rinrdu,:nr:l{urhf,:Jrufifi intracranial pressure q{rdonrtnnt:rfie fascicu-
tations arqir'tfifi intracranial pressure fltdu uono, ndti,'rorrr'rtfitfin malignant hyperthermia

lfi

Pancuronium

?1n clinical practice guideline fl a.a. ZOOZ' lnu American College of Critical Care

lVledicine 1nccvl uu;rirtfi'ld pancuronium rfluartdoundr rdor-tu:n unr{utufiilrudfin'rru
rdu.:rio vagolgic effect niu acute coronary syndrome finr::vr".ilrjlifuq:rdurSr rro;lrinli
tdlu fi:-h aT:n6'wioT:n'ln uu:r: orqri'r'tfi u'r o :su uo: oonnrfurun'ir:Jnfi

ru1ns1: lV bolus dose 0.1 mg/kg (oanqTf,ldurufu t rirTu.r), Infusion rate 4-10 mg/hr
fleirrt;iut: tachycardia

Vecuronium

fi active metabotire l'.oola:al'tunrr:lorlu drliii prolonged paralysis 16 tadsorar

Sedation, Analgesia and Neuromuscular blockade in lClI nlwia$ nfi4e6u 615

dfit oonq#,5rblfioraoiovrnarcnfnr:bnrfurr6anrrnu-nrir}fifir,rq:yioerlud'ulofiouJn'uuurjns
rinfiau'r:u;rrarlunT i0anqrfflrn'j'r pancuronium

ru1nu1: lv bolus 0-1 mg/kg (oonlilftdilrufi.,r +s urfi1. Intusion rate 0.8-2.0 ug/kg/
min r?o s-to mg/nr

Rocuronium

{o6fi0 hifirnrio::rLufr'lounyynoordan rfluurdoonnniirfr c'tfit::Iutrilun:riddor
ldviotirunrutcfiilruadr,,r:rn lStun;iidorirruhnr:ldar succinytchotine

rulam: lv bolus 35 mg (o0nqu6 'tu :: 1 45 u1fi). tv Infusion 60-100 mg/hr

Atracurium flracriumt
ul1ilqnfrlvr1,tsr'!lrignrilnr,rlm trdfi metaoolism laui6 esrer hydrotysis firiun.jr Hofmann

degradaiion

ttiofi6o nr:duro,l neuromuscular transmission *nqstsrrnrfioun'ir r?r1r.r.rya'.rtrn

nqourlnulridufi'm;u:rrorlunr:ttiu, fiol'6nr:nftraln1?J criticat illness neuromyopathy riou
n'j'r t'tvtBs ri'rdu nrnflr,l6u.J6o drlfifiarrrri'uTnfimoirlfrornnr:fifinrryn'r histamine lLo:alqfi
tachyphylaxis fir'hiur rflu:;u;rrnruru

1u1nsl: 0.5 mg/kg for tracheal intubation. lV Infusion 0.5 mg/kg/hr

Gisatracurium {Nimbex@)

lflu slereoisomerr q"rmd.,ttar atracurium lqutiu 15yo aan isomers ri.ryunrroifi activity
rrnfir oo% dodn'0'hifilfifinr:r6',r histamine 6,ohifiarnriollnflranSnr:'[ynriuu16or unrurdfi
metabotism leui6 Hotmann degradation rrfi ou atracurium 6raur:n1d1d1ufirJxuL a n-tl uny
l:nlsr urd6,rrflu NMes dfiuilld

au19u't: lV bolus 0.1-0.2 mg/kg, lV Infusion maintenance dose 0.'18 mg/kglhr

nfl
. urfrkifi r.rnrdo hemodynamic ldrrri Cisatracurium, Vecuronium, Rocuronium
' uT fi nrrr:o'ld1u1:nn"r nial:nln'lduri Atracurium. cisarracunum

iilaae::;i.::cn'ir.rdtf NMes

. ::rian:i.rdalirun, ulqv5a tracheostomy tuoe atir'lfi disconnect lrnfiJra r1,|:r;

q:ilhlfifi nypoxia :uu:u1drd o,tor n {:-hue :1rJfi respiratory ef fort

NMBs tflud'rMn0dr,t fi{toonmc critical illness neuromyopathy drhlfi protongeO

neuromuscular weakness floUtQytlJulnq, y!at steroid [n!tn pancuronium lfny

!nvecuronr.u1m,4 !U0utJ1nTfin

616 rrtrirrintnqodugru

nr:tJoruJfionnr{rJ'tufi1u eye patches trnv uondlnltfiul rfroflotrTu corneal abrasion

ttnY keratitis

NMBS 1i1'l{fi0n1tvur:ndauctn immobility ld ttiu deep vein thrombosis, muscle

wasting !La: peripheral nerve iniury

. firl.rld muscle relaxant tu{rhudtd Bird ventilator rdamrnlrifi::u-rfr4ru1{ul6ou

(alarm) loutavlrtlfr oviorirutru'levqooonq'1fl ventilator

. n:nin'l'fi muscle relaxant 'lu:rldrflu patient-ventilator dyssynchrony rijofi:-hun.:r-r

rufir orovih'Ifi tidal volume flefl,t 01ef1'hi e"co, g',rduld e'ofio.riliurniaodruvrutl
lfiniarrirflryvrrddru

n1,r:J?vfiu;gfruflo{t neuromuscular blockade
nrrlfiurntioundurdournrfiulj oT rriT'lfifiarnrfiuldniu rirlfifindtrrdoeiaur:.:tiu::u;

rrnrlru nrrfinntr::d'ltatnr:'lfiu, dtfiorudr6'ry arlr:n :;tfiu1nuqe1noln1:r1.rnafirl fi34

'ldrnio.lfia oerioheral nerve stimulator ni?a train of four stimutarion 'lut:ia.rdun?l titrate url.l
{:-hulriotr:ntu-rirrnruldun:finr:vruhffirYu6'fiirnCs.rdruvrulcd#fli lout{eLrluaurnd

Irr:.rvOr.rl1jrrnysorioumrfiuI:J lu{rJ'tu critically illl}idrrfludo':lfiurqufi complete neuromuscular
btockade rnfioulu{rhunirn-o uo:nr:tqcurTouriedqorfro'lriohrfrudootdrfiondnrdEi'rntv
rur:ndau lu:tv'jr'rldurn'l:finr:vunuT lu!r,td't'i:ir,1rdo:lotrYulritfifiornr:dautt:ttflunaruru

dfl

{rhuillofigrYufinfi nrulilqt arruldqtnvnr s dt trn tdu ntu tSlrJro n':rr.rd.:rn via
dlrrrndordam:unru{ ra nr:ouninurnr:ti drui6nr:fililldur rrfillorucrmqfi rflu!]ldrrju
nrrded'rurodou'lfiturr:Rr nr:4oqutfirir6'ttc rta;fiqr:rurtdur sedation uia analgesia tfia

finrrmhrflu niu {tJrlr".,,:fierut6u rn fi distress fiia agitation lrn{irarqtfiao"usnrunl{rJru1fi
rdr nr:fitviorirst'rutrfiionru catheter oirtl v5o{rJruifinr:rru1o'lridl.:niudrrl lniatdruh nrr
rdan'ldurnr:rfian'lfitnrr:flltir-ranm:rotfidrutllurnd tvur:sr.r rra;nifi'tfr',:no'flrltdu.'tlolur
do'terfindulfi flfr.rqrnlfiurnr:6on1r.t:;cl'uto't sedation ttfi: analgesia tfittlrvalunvnr:d.l
trir'lfifi sedation protocol unJ 'l daily intenuption of sedation lurlntu dru neuromuscular

btockade nr:trirdo{rtruldilu'l sedation nio analgesia atirt16rufrlul fdnoTrrrdrri'rfif,rynr
rrjurrutqdrurnio{tiru ruh ua;n1:vuau'r rfi oLi.ir tflu

Sedadon, Analgesia and Neuromuscular blockade in ICU nxUfefii ffinufru 677

[on6t't?d1.t6''
1. Bratton SL, Chestnut RM. Ghajar J. et al- Guidelin€o tor the management of severe traumatic brain injury. Xl.

Anesthetics. analgesics. and sedatives. J Neurotrauma 2007:24 Suppt '1;571-76.

2. KI€ss JP, Fohlman AS, O'Connor MF, Hall JB. Daily intenuption of sedatile inlusions in critically ill patients

undergoing m€chanical !€ntilation. N Engl J Med 2000;342120\.1471-7.

3. Girard TD, Kress JP. Fuchs BD. st al. Etficacy and safoty of a paired sedatiofi and \€ntilator weaning protocol lor

mechanically ventilated patients in intensive care (awakening and breathing controlled trial): a randomised

controlled trial. Lancet 2008t371i126-34.

4. Murray MJ, Cov,en J, DeBlock H. et al. Clinical practice guidelines for sustained neummuscular blockade in the

adult critically ill patient. Crit Care Med 2002;30(1)1142-56.

5. Oddo M. S€dation and analgesia : Skill and techniques. Updale 2010. Patient-C€ntrod Acute Care Training. European

Society of Int€nsive Care Medicine.

6. Patel SB. Kre$ JP. Sedation and Analgesia in the M€chanically Ventilated Patient. Am J Bespir Cdi Care Med 2012;

1 85(5):48&97.

7. Jacobi J, Fraser GL, CouIsin DB, et al. Clinical practice guideline3 for the suskjned use of sedatives and analgesics

in th€ critically ill adult. Crit Carc Med 200a30(11t 19-36.

8. Honiden S. Siegel tulD. Managjng ths Agitated Patient in the lCtJ: SBdation, Analgesia, and Neuromuscular Blockade.

fntensive Care Med 2010:251A7 -200.

618

33

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