Special ICU Populations: Opioids in Neurocritical Care

Abstract

Sedation and analgesia are used in the neurocritically ill patient to treat discomfort associated with routine ICU care and to minimize ICP elevations. Particularly important in this critically ill population is the use of short-acting agents to allow for frequent neurologic assessments. Pharmacologic coma is reserved for limited indications such as refractory intracranial hypertension and status epilepticus. The BPS and CPOT assessment scores have received limited validation in small studies, and are recommended for the assessment of pain in patients with neurologic injury who cannot self-report pain; the Nociception-Coma Scale-Revised may be useful in patients with prolonged comatose states. Opioids, including meperidine, have particular indications in the prevention and treatment of shivering in patients undergoing targeted temperature management (TTM). In patients undergoing TTM after cardiac arrest, impaired metabolism and clearance of medications – including fentanyl, morphine, and remifentanil – is proportional to the depth of hypothermia and may significantly increase serum drug levels. Accumulation of sedative doses received during TTM must be accounted for, and sufficient time allowed for awakening before accurate prognostication in patients who do not regain consciousness. Morphine and alternative opioids are also specifically indicated in the treatment of paroxysmal sympathetic hyperactivity to treat and reduce recurrence of storming episodes.