Pain, Agitation/Sedation, Delirium, Immobility, Sleep Disruption, and Neuromuscular Blockade

Pregabalin (Lyrica)

50 mg three times daily; may be increased in 1 week depending on tolerability and effect;

maximum dose: 100 mg three times daily.

ii.

Pharmacokinetics: 90% excretion in urine

iii.

Adverse effects: Peripheral edema, dizziness, drowsiness, headache, fatigue, weight gain,

xerostomia, visual field loss, and blurred vision

Analgosedation Method in the ICU: This method of sedation advocates the use of opiate medications before

prescribing an anxiolytic/hypnotic medication to provide patient comfort in the ICU unless anxiolytics

are otherwise indicated. The PADIS guidelines recommend analgosedation (analgesia is used before a

sedative to reach the sedative goal) or analgesia-based sedation (an opioid is used instead of a sedative to

reach the sedative goal). Providing pain relief early in the ICU stay may decrease the agitation associated

with pain and/or general discomfort while minimizing the use of alternative medications commonly used

for agitation (e.g., benzodiazepines). The guidelines recognize that current data using analgosedation are

primarily limited to open-label trials, using remifentanil as the analgesic, and mostly conducted in Europe,

where critical care staffing and management practices differ from those in the United States. Despite these

limitations, it remains notable that studies using the analgosedation method found a significant decrease in

benzodiazepine dosage requirements when opiates were the primary medications used for discomfort and

agitation. This is a positive step in decreasing the untoward adverse effects of the benzodiazepine class

of sedatives. There is a potential for high cumulative doses of opiates with the analgosedation method,

necessitating daily monitoring of their adverse effects (e.g., respiratory depression, altered mental status, GI

slowing). Opioid use in the ICU also increases the daily risk of delirium development in a dose dependent

manner.

sedation (bolus doses of morphine) and light sedation (propofol for 48 hours then midazolam titrated to a

RASS of −2 to −3). There was no difference in 90-day mortality between groups (no sedation 148 [42.4%]

vs. light sedation 130 [37%]; 95% CI −2.2 to 12.2; p=0.65). However, 27% of the no-sedation group crossed

over to receive sedation during the first 24 hours after randomization.