title: Analgesia, sedation, and neuromuscular blockade during targeted temperature management after cardiac arrest.
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.
authors.affiliation: Director, Medical Critical Care, Neuroscience Institute and Department of Critical Care, Maine Medical Center, 22 Bramhall Street, Portland, ME 04102, USA. Electronic address: rriker@cmamaine.com.
authors.forename: Richard R
authors.initials: RR
authors.lastname: Riker
authors.affiliation: Clinical Pharmacist, Departments of Pharmacy and Critical Care, Maine Medical Center, 22 Bramhall Street, Portland, ME 04102, USA. Electronic address: dgagnon@mmc.org.
authors.forename: David J
authors.initials: DJ
authors.lastname: Gagnon
authors.affiliation: Assistant Director, Neurocritical Care, Maine Medical Center, 22 Bramhall Street, Portland, ME 04102, USA. Electronic address: mayt@cmamaine.com.
authors.forename: Teresa
authors.initials: T
authors.lastname: May
authors.affiliation: Director, Neurocritical Care, Maine Medical Center, 22 Bramhall Street, Portland, ME 04102, USA. Electronic address: sederd@mmc.org.
authors.forename: David B
authors.initials: DB
authors.lastname: Seder
authors.affiliation: Clinical Pharmacist, Departments of Pharmacy and Critical Care, Maine Medical Center, 22 Bramhall Street, Portland, ME 04102, USA. Electronic address: fraseg@mmc.org.
authors.forename: Gilles L
authors.initials: GL
authors.lastname: Fraser
mesh_terms: D000698:Analgesia / Q000009:adverse effects / Q000379:methods*; D001831:Body Temperature / Q000187:drug effects* / Q000502:physiology; D019468:Disease Management; D006323:Heart Arrest / Q000175:diagnosis / Q000628:therapy*; D006801:Humans; D006993:Hypnotics and Sedatives / Q000008:administration & dosage* / Q000009:adverse effects; D007036:Hypothermia, Induced / Q000009:adverse effects / Q000379:methods*; D019148:Neuromuscular Blockade / Q000009:adverse effects / Q000379:methods*
chemical_list: D006993:Hypnotics and Sedatives
keywords: analgesia; hypoxic–ischemic encephalopathy; neuromuscular blockade; sedation; targeted temperature management