A 50th BIRTHDAY PARTY BY THE RIVER

I did another full on day. NA meeting in Urunga and then NH’s 50th birthday at Yellow Rock Road. My favourite road. I was actually able to serve my own food from the BBQ table and carry it across and sit down and eat. First time in 2 years.

I have a bit of nosebleeding going on but very low level pain and everything else working quite well. Including networking and getting out there amongst people. I have some very good shots of some very good people but i do not know whether or not they would want their images on a blog so I won’t be posting them I shall look at the Studio this week and think about it.  Suffice to say. We travelled. We talked. We laughed and hugged.

In the meantime – BED and this extract below.

Good Night, Voyager.

http://www.learnicu.org/…/…/Attachments/9419/Chapter%208.pdf
Although current guidelines recommend that most patients admitted to the ICU be maintained in a painfree
and wakeful state, a number of observational studies suggest that these end points are often not attained
in clinical practice.3,12,13 Patients who become comatose cannot self-report pain, be screened for delirium, be
evaluated for readiness to wean and extubate, or participate in early mobilization efforts; they form fewer
factual memories that may help prevent posttraumatic stress disorder and are more likely to die.3,4 Coma that
results from the administration of sedative or opioid medications usually stems from 2 main factors: (1) failure
to use strategies that have been shown to reduce oversedation and coma, such as sedation protocolization and
daily interruption, and (2) failure to consider the numerous pharmacokinetic, pharmacodynamic, and pharmacogenetic
factors that influence analgesic and sedative response, recovery, and safety in the critically ill.14-19
Compared with propofol or dexmedetomidine, the benzodiazepines, particularly when administered as a
continuous infusion, are more likely to result in excessive sedation and coma because of the important pharmacokinetic
and pharmacodynamic differences between these classes of medications. For example, patients
administered a prolonged (>72 hours) infusion of midazolam are at a particularly high risk for protracted
sedation and should therefore receive lower doses of midazolam and management with a daily sedation interruption
protocol or down-titration protocol.15,16,20 Benzodiazepine dosing requirements are generally lower in
the elderly, given the greater volume of distribution and lower clearance seen in this population. One of the
metabolites of midazolam, 1-hydroxymidazolam, has central nervous system (CNS) depressant effects and may
accumulate in the critically ill patient, especially in the presence of kidney failure.21,22
Compared with the benzodiazepines, propofol and dexmedetomidine are usually associated with faster neurological
recovery after discontinuation.23-25 For example, lorazepam administered continuously without daily interruptions
or down-titration led to a greater incidence of coma and less time within the desired sedation range
than continuously infused dexmedetomidine.24 Even when administered intermittently, lorazepam can lead to
a longer duration of mechanical ventilation than propofol.23 Similarly, continuous midazolam infusions led to a
longer duration of mechanical ventilation than continuous dexmedetomidine.25

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