A METHOD TO PRODUCE SEDATION IN CRITICALLY ILL PATIENTS

OBJECTIVE: TO evaluate a protocol based on continuous infusion of a be nzodiazepine and morphine to produce apnea/decreased respiratory effor t as an adjunct to complex mechanical ventilation in patients with res piratory failure. DESIGN: Observational report of consecutive patients . SETTING: University medical intensive care unit. PATIENTS: Seventeen consecutive patients with acute respiratory failure requiring high le vels of sedation and/or paralysis to facilitate mechanical ventilation were studied. INTERVENTIONS: Patients were started on a continuous in fusion of a benzodiazepine and morphine soon after mechanical ventilat ion was instituted. The dosages of the benzodiazepine and morphine wer e increased to the end point of diminished respiratory effort or apnea depending on the clinical status of the patient and ventilatory mode. This regimen was supplemented with single doses of neuromuscular bloc king agents (NMBAs) only as the dosages of benzodiazepine/narcotic wer e being titrated. The benzodiazepine/narcotic agents were then gradual ly reduced as the patient's condition improved, often using an oral ro ute of administration. MEASUREMENTS AND RESULTS: The benzodiazepine/mo rphine combination produced apnea and diminished respiratory effort in patients requiring sedation from 2 to 50 days, including those with h emodynamic instability, hepatic dysfunction, renal dysfunction, and se psis. The combination allowed the use of NMBAs to be minimized. There was no evidence of worsened hemodynamic instability as a result of the administration of these agents. The gastrointestinal tract could be u sed for nutrition in 8 of the 17 patients. CONCLUSIONS: Continuous inf usion of a benzodiazepine and morphine controlled the respiratory rate in patients with severe respiratory failure requiring complex mechani cal ventilatory support.