Drug dosing in the critically ill obese patient—a focus on sedation, analgesia, and delirium

Abstract

Practice guidelines provide clear evidence-based recommendations for the use of drug therapy to manage pain, agitation, and delirium associated with critical illness. Dosing recommendations however are often based on strategies used in patients with normal body habitus. Recommendations specific to critically ill patients with extreme obesity are lacking. Nonetheless, clinicians must craft dosing regimens for this population. This paper is intended to help clinicians design initial dosing regimens for medications commonly used in the management of pain, agitation, and delirium in critically ill patients with extreme obesity. A detailed literature search was conducted with an emphasis on obesity, pharmacokinetics, and dosing. Relevant manuscripts were reviewed and strategies for dosing are provided.

Serum and Erythrocyte Antioxidant Defense in Colorectal Cancer Patients during Early Postoperative Period: Potential Modifiers and Impact on Clinical Outcomes

“…This counterintuitive observation can be mostly explained by differences in the pharmacodynamics of applied anesthetic drugs. Propofol and opioid doses are adjusted to body mass [36], thus overweight/obese patients received more anesthesia and may have more elevated FRAP as a consequence. Moreover, propofol concentration in plasma is generally higher in obese than lean individuals owing to blood preferentially distributing the drug to non-adipose tissue [37].…”

“…Moreover, propofol concentration in plasma is generally higher in obese than lean individuals owing to blood preferentially distributing the drug to non-adipose tissue [37]. Furthermore, cardiometabolic diseases and age are associated with impaired hepatic metabolism [38] and disturbed renal excretion, causing decreased clearance of anesthetic drugs [36,37]. In addition, a more pronounced activation of NFkB in response to surgical trauma may occur in elderly patients or those with cardiometabolic diseases [39].…”

Resuscitative Thoracotomy for Multiple Gunshot Wounds With Cardiac Tamponade Despite Pericardial Window

“…Third, although the use of ketamine, fentanyl, and/or midazolam for procedural sedation is common practice for many procedures such as endoscopy or chest tube insertion, its use for major surgery in the traumatized patient has not been well described [ 12 , 13 ]. This combination of medications is ideal for the traumatized patient with their lack of cardiovascular depressant effects and minimal concern for medication-induced respiratory depression since these patients are already mechanically ventilated.…”

Drug dosing in the critically ill obese patient: a focus on medications for hemodynamic support and prophylaxis

“…Antimicrobials were not included given the overarching theme of this manuscript coupled with the availability of other manuscripts providing dosing recommendations in this area [ 13 – 15 ]. Furthermore, thorough reviews providing recommendations for medications used for pain, agitation, delirium and neuromuscular blockade are also available and the reader is referred to these texts [ 16 , 17 ]. Thus, the remaining areas included were medications for hemodynamic support in shock (i.e., vasopressors and corticosteroids), stress ulcer prophylaxis and venous thromboembolism.…”