Chinese expert consensus on sedation and analgesia for neurocritical care patients

Sedation and analgesia therapy are essential in neurocritical care, but there are ongoing controversies surrounding assessment, administration, and withdrawal. With advances in neurocritical care medicine, updated evidence-based medicine, considering the variability in knowledge and practice, the National Center for Healthcare Quality Management in Neurological Diseases and the Chinese Society of Critical Care Medicine organized experts in neurocritical care to form a working group [Supplementary File 1, https://links.lww.com/CM9/B958] to update the "Expert Consensus on Sedation and Analgesia for Patients with Severe Brain Injury (2013)".[1] This update aimed to review and summarize the literature published since 2013 across different aspects of sedation and analgesia in neurocritical care patients and has been registered on http://www.guidelines-registry.org (No. PREPARE-2023CN332). The scope of this consensus is limited to adult patients admitted to neurocritical care units because of primary and/or secondary brain injuries. Applying the modified Delphi method to collect, feedback and discuss expert opinions through three rounds of Delphi questionnaires and one round of face-to-face meeting, this update addressed 5 domains with 18 questions and formulated 31 recommendations. This consensus is intended for use by healthcare professionals involved in caring for neurocritical care patients.[2] Following each recommendation, we present the percentage level of agreement followed by the rate of participants voting in favor to the total number of participants casting their vote. Goal of Analgesia and Sedation for Neurocritical Care Patients Question 1: What is the goal of analgesia and sedation for neurocritical care patients? Recommendation 1: Analgesia and sedation are essential components of neurocritical care patient management. The general goals of analgesia and sedation for neurocritical care patients are to relieve/eliminate pain, anxiety and agitation, improve sleep, induce amnesia, reduce stress, decrease oxygen consumption, increase comfort, and correct patient-ventilator asynchrony (100%; 36/36). Recommendation 2: The neuro-specific goals of analgesia and sedation for neurocritical care patients, especially for patients at risk of secondary brain injuries such as intracranial hypertension, should consider brain protection, including controlling intracranial pressure, maintaining optimal cerebral perfusion, inhibiting the sympathetic nervous system, controlling seizures, and preventing/alleviating secondary brain injury (100%; 36/36). Question 2: Should analgesia and sedation be administered for neurocritical care patients with intracranial hypertension? Recommendation 3: Analgesia and sedation are fundamental therapy for neurocritical care patients with intracranial hypertension (100%; 36/36). Question 3: Should analgesia and sedation be administered during targeted temperature management (TTM) for neurocritical care patients? Recommendation 4: Analgesia and sedation can be administered for neurocritical care patients undergoing TTM (100%; 36/36). Monitoring of Neurocritical Care Patients During Analgesic and Sedative Therapy Question 4: Should pain assessment be performed for neurocritical care patients? Question 5: How should pain assessment tools be chosen for neurocritical care patients? Recommendation 5: Pain assessment should be performed for neurocritical care patients (100%; 36/36). Recommendation 6: Appropriate pain assessment tools should be chosen based on the level of consciousness and verbal ability of neurocritical care patients (97.2%; 35/36). Recommendation 7: For neurocritical care patients who can self-report pain, pain assessment tools include Numerical Rating Scale (NRS), Visual Analogue Scale (VAS), Changhai Pain Rating Scale. For patients who can not accurately self-report pain, options include Faces Pain Thermometer (FPT), Behavioral Pain Scale (BPS), Critical-care Pain Observation Tool (CPOT), the Revised Adult Nonverbal Pain Scale (NVPS-R), Pupil Light Reflex (PLR), etc, (97.2%; 35/36). Recommendation 8: Vital sign changes alone are not recommended as the sole method for pain assessment but can be used as an adjunct to the detection of underlying pain (100%; 36/36). Question 6: Should sedation assessment be performed for neurocritical care patients? Question 7: How should sedation assessment methods be chosen for neurocritical care patients? Recommendation 9: Sedation assessment should be performed for neurocritical care patients. (100%; 36/36). Recommendation 10: For neurocritical care patients, available subjective sedation assessment tools include Sedation-Agitation Scale (SAS), Richmond Agitation-Sedation Scale (RASS), etc., but their utility is limited for patients with persistent coma (100%; 36/36). Recommendation 11: Based on the characteristics of neurocritical care patients, objective assessment tools like quantitative electroencephalography (qEEG), bispectral index (BIS), etc., can be used to evaluate the level of sedation (97.2%; 35/36). Question 8: How should the depth of sedation be chosen for neurocritical care patients? Recommendation 12: For neurocritical care patients with suspected organ dysfunction like intracranial hypertension, light sedation (RASS –2 to –1, SAS 3 to 4) should be avoided. When organ function tends to be stable, transitioning from deep sedation to light sedation/no sedation can be considered (97.2%; 35/36). Question 9: Should Neurologic Wake-Up Test (NWT) be performed for neurocritical care patients? Recommendation 13: Consideration of using of NWT to assess neurological function in neurocritical care patients is warranted, but the timing of NWT should be balanced against risks and benefits (100%; 36/36). Recommendation 14: In neurocritical care patients with suspected severe conditions like intracranial hypertension, routine NWT should be avoided (100%; 36/36). Question 10: Should neurological examination be performed during analgesic and sedative therapy for neurocritical care patients? Recommendation 15: Neurological examination should be performed during analgesic and sedative therapy for neurocritical care patients. Examinations should include level of consciousness, pupil reactions, neurological examination (cranial nerves, motor, sensory, respiratory pattern, brainstem reflexes, etc.), laboratory, and imaging (100%; 36/36). Question 11: Should one or more multimodal neuromonitoring techniques be used for objective monitoring during analgesic and sedative therapy for neurocritical care patients? Recommendation 16: Multimodal monitoring can dynamically evaluate the safety and efficacy of analgesic and sedative therapy from different dimensions (100%; 36/36). Question 12: Should delirium assessment be performed for neurocritical care patients? Question 13: How should delirium assessment tools be chosen for neurocritical care patients? Recommendation 17: Delirium assessment should be performed for neurocritical care patients and should not be overlooked even with existing/potential neurological deficits (100%; 36/36). Recommendation 18: The confusion assessment method for the intensive care unit (CAM-ICU) or intensive care delirium screening checklist (ICDSC) are commonly used tools for delirium assessment in neurocritical care patients. Quick screening tools such as 4A's test (4AT) can help identify delirium early (97.2%; 35/36). Recommendation 19: For patients with severe neurological conditions such as impaired consciousness and aphasia, appropriate assessment tools should be chosen, and the results of the assessment should be interpreted cautiously. For patients with aphasia, ICDSC may be more valuable than CAM-ICU (97.2%; 35/36). Recommendation 20: Risk factors for delirium in neurocritical care patients include age, mechanical ventilation, sepsis, aphasia, sleep deprivation, physical restraints, and frontal lobe lesions (100%; 36/36). Analgesic and Sedative Medications Selection Question 14: How should analgesic and sedative agents be selected for neurocritical care patients? Recommendation 21: There is currently no superior strategy for the selection of analgesic and sedative agents in neurocritical care patients. Opioids, midazolam, and propofol were the most commonly prescribed agents (100%; 36/36). Recommendation 22: Selection should be based on patient characteristics, treatment needs, and pharmacological properties of the agents. Caution is needed for the adverse effects of analgesic/sedative agents (especially opioids), such as respiratory depression, hypotension, effects on consciousness, tolerance, withdrawal, etc., particularly in special populations (hemodynamic instability, hepatic/renal insufficiency, elderly, and obesity) (100%; 36/36). Recommendation 23: Short-acting or ultra-short-acting agents may be more appropriate when accurate and rapid assessment of neurological function is required in neurocritical care patients (100%; 36/36). Recommendation 24: The use of ketamine should be cautious in neurocritical care patients (94.4%; 34/36). Recommendation 25: The efficacy of dexmedetomidine in the prevention and treatment of delirium in neurocritical care patients needs to be further confirmed (94.4%; 34/36). Role of Analgesic and Sedative Therapy in Refractory Intracranial Hypertension Question 15: Should analgesic and sedative therapy be increased for neurocritical care patients with refractory intracranial hypertension? Recommendation 26: Analgesic and sedative therapy should be increased for neurocritical care patients with refractory intracranial hypertension (97.2%; 35/36). Recommendation 27: Adverse effects like propofol infusion syndrome (PRIS) should be monitored with high-dose sedative therapy (100%; 36/36). Question 16: Is barbiturate coma treatment recommended for the treatment of refractory intracranial hypertension? Recommendation 28: Barbiturate can be titrated to intracranial pressure control for refractory intracranial hypertension unresponsive to other conservative management (91.7%; 33/36). Application of Analgesic and Sedative Therapy in TTM Question 17: How should analgesic and sedative agents be selected for neurocritical care patients undergoing TTM? Question 18: Is the adjunctive use of neuromuscular blockade recommended for TTM in neurocritical care patients? Recommendation 29: The selection of analgesic and sedative agents for TTM should be based on patient characteristics, treatment needs, and pharmacological properties of the agents. Hypothermia can result in slower drug metabolism and elimination and prolonged action duration, so that short-acting agents may be more appropriate (97.2%; 35/36). Recommendation 30: There is currently no evidence on the optimal analgesic and sedative agents for neurocritical care patients undergoing TTM. Fentanyl, midazolam, and propofol were the most commonly prescribed agents (100%; 36/36). Recommendation 31: The routine use of neuromuscular blockade should be avoided for TTM in neurocritical care patients (100%; 36/36). Funding The work was supported by grants from the Beijing Municipal Science and Technology Commission (No. Z201100005520050), and Beijing Municipal Health Commission (No. BHTPP2022026). Conflicts of interest None. Acknowledgments This article is based on the mandarin version of consensus first reported in the Journal of Chinese Critical Care Medicine 2023;35: 897–918.