title: Sedation options for the morbidly obese intensive care unit patient: a concise survey and an agenda for development.
abstract: BACKGROUND
  We offer some perspectives and commentary on the sedation of obese patients in the intensive care unit (ICU).
  
  
  CONCLUSIONS
  Sedation in morbidly obese patients should conform to the same broad principles now current in ICU practice. These include a general presumption against benzodiazepines as first-line agents. Opioids should be avoided in any situation where spontaneous breathing is required. Remifentanil is the preferred agent where continuous stable opioid levels using an infusion are required, because of its lack of context-sensitive accumulation. Volatile anaesthetics may be an option for the same reason but there are no substantial, controlled demonstrations of effectiveness/safety in short-term use in the ICU setting. Propofol is a valuable resource in the morbidly obese patients but the duration of continuous sedation should not exceed 6 days, in order to avoid propofol infusion syndrome. Alpha-2 agonists offer a range of theoretically positive features for the sedation of morbidly obese patients, but at present there is a lack of pharmacokinetic data and a critical mass of high-grade clinical data. Dexmedetomidine has the attraction of not causing respiratory depression or obstructive breathing during sedation and its sympatholytic effects should help deliver stable blood pressure and heart rate. Ketamine has a poor tolerability profile in adults so its use in the ICU context is largely confined to paediatrics.
  
  
  CONCLUSIONS
  None of the agents currently available is ideal for every situation encountered in the management of morbidly obese patients. This article identifies additional research needed to place sedation practice of obese patients on a more systematic footing.
authors.affiliation: Division of Perioperative Services, Intensive Care, Emergency Care and Pain Medicine, University of Turku, Turku, Finland.
authors.forename: Riku
authors.initials: R
authors.lastname: Aantaa
authors.affiliation: Department of Anaesthesiology and Intensive Care Medicine, Emergency Medicine Hospital Links der Weser GmbH, Bremen, Germany.
authors.forename: Peter
authors.initials: P
authors.lastname: Tonner
authors.affiliation: Department of Intensive Care and Anaesthesiology, Università Cattolica del Sacro Cuore, Rome, Italy.
authors.forename: Giorgio
authors.initials: G
authors.lastname: Conti
authors.affiliation: Université Paris-Diderot, Hôpitaux Universitaires Paris Nord Val de Seine, Département d'Anesthésie Réanimation Chirurgicale, Hôpital Bichat-Claude Bernard, Paris, France.
authors.forename: Dan
authors.initials: D
authors.lastname: Longrois
authors.affiliation: Anaesthesiology Department, Beaujon Hospital, AP-HP, Université Paris-Diderot, Paris, France.
authors.forename: Jean
authors.initials: J
authors.lastname: Mantz
authors.affiliation: Department of Anaesthesiology, Intensive and Emergency Care, Sint Jan Brugge-Oostende, Ruddershove 10, Brugge, 8000 Belgium.
authors.forename: Jan P
authors.initials: JP
authors.lastname: Mulier
keywords: Benzodiazepines; Clonidine; Dexmedetomidine; Intensive care; Ketamine; Obesity; Opioids; Propofol; Sedation; Volatile anaesthetics