Consensus Statement

Chinese expert consensus on sedation and analgesia for neurocritical

care patients
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Linlin Zhang1, Shuai Liu1, Shuya Wang1, Jianxin Zhou2, the National Center for Healthcare Quality Management in Neurological
Diseases, Chinese Society of Critical Care Medicine, Working group of the Expert Consensus on Sedation and Analgesia for
Neurocritical Care Patients
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1
Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing 100070, China;
2
Department of Critical Care Medicine, Beijing Shijitan Hospital, Capital Medical University, Beijing 100038, China.

Sedation and analgesia therapy are essential in neu- Recommendation 1: Analgesia and sedation are essential
rocritical care, but there are ongoing controversies components of neurocritical care patient management.
surrounding assessment, administration, and withdrawal. The general goals of analgesia and sedation for neuro-
With advances in neurocritical care medicine, updated critical care patients are to relieve/eliminate pain, anxiety
evidence-based medicine, considering the variability in and agitation, improve sleep, induce amnesia, reduce
knowledge and practice, the National Center for Health- stress, decrease oxygen consumption, increase comfort,
care Quality Management in Neurological Diseases and and correct patient-ventilator asynchrony (100%; 36/36).
the Chinese Society of Critical Care Medicine organized
experts in neurocritical care to form a working group Recommendation 2: The neuro-specific goals of analgesia
[Supplementary File 1, http://links.lww.com/CM9/B958] and sedation for neurocritical care patients, especially for
to update the “Expert Consensus on Sedation and Anal- patients at risk of secondary brain injuries such as intrac-
gesia for Patients with Severe Brain Injury (2013)”.[1] ranial hypertension, should consider brain protection,
This update aimed to review and summarize the literature including controlling intracranial pressure, maintaining
published since 2013 across different aspects of sedation optimal cerebral perfusion, inhibiting the sympathetic
and analgesia in neurocritical care patients and has been nervous system, controlling seizures, and preventing/
registered on http://www.guidelines-registry.org (No. alleviating secondary brain injury (100%; 36/36).
PREPARE-2023CN332). The scope of this consensus is
limited to adult patients admitted to neurocritical care Question 2: Should analgesia and sedation be administered
units because of primary and/or secondary brain injuries. for neurocritical care patients with intracranial hyperten-
Applying the modified Delphi method to collect, feedback sion?
and discuss expert opinions through three rounds of Del-
Recommendation 3: Analgesia and sedation are fun-
phi questionnaires and one round of face-to-face meeting,
damental therapy for neurocritical care patients with
this update addressed 5 domains with 18 questions
intracranial hypertension (100%; 36/36).
and formulated 31 recommendations. This consensus is
intended for use by healthcare professionals involved in Question 3: Should analgesia and sedation be adminis-
caring for neurocritical care patients.[2] Following each tered during targeted temperature management (TTM)
recommendation, we present the percentage level of agree- for neurocritical care patients?
ment followed by the rate of participants voting in favor to
the total number of participants casting their vote. Recommendation 4: Analgesia and sedation can be
administered for neurocritical care patients undergoing
Goal of Analgesia and Sedation for Neurocritical Care Patients TTM (100%; 36/36).

Question 1: What is the goal of analgesia and sedation for

neurocritical care patients?
Correspondence to: Jianxin Zhou, Department of Critical Care Medicine, Beijing
Shijitan Hospital, Capital Medical University, Beijing 100038, China
E-Mail: [email protected];
Access this article online Linlin Zhang, Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital
Medical University, Beijing 100070, China
Quick Response Code: Website: E-Mail: [email protected]
www.cmj.org Copyright © 2024 The Chinese Medical Association, produced by Wolters Kluwer, Inc. under the
CC-BY-NC-ND license. This is an open access article distributed under the terms of the Creative
Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is
DOI: permissible to download and share the work provided it is properly cited. The work cannot be
10.1097/CM9.0000000000003084 changed in any way or used commercially without permission from the journal.
Chinese Medical Journal 2024;137(XX)
Received: 01-11-2023; Online: 19-04-2024 Edited by: Jing Ni and
Xuehong Zhang

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 Chinese Medical Journal 2024;137(XX) www.cmj.org

Monitoring of Neurocritical Care Patients During Analgesic Recommendation 13: Consideration of using of NWT to
and Sedative Therapy assess neurological function in neurocritical care patients
is warranted, but the timing of NWT should be balanced
Question 4: Should pain assessment be performed for against risks and benefits (100%; 36/36).
neurocritical care patients?
Recommendation 14: In neurocritical care patients with
Question 5: How should pain assessment tools be chosen suspected severe conditions like intracranial hypertension,
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for neurocritical care patients? routine NWT should be avoided (100%; 36/36).
Recommendation 5: Pain assessment should be performed Question 10: Should neurological examination be
for neurocritical care patients (100%; 36/36). performed during analgesic and sedative therapy for neu-
rocritical care patients?
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Recommendation 6: Appropriate pain assessment tools

should be chosen based on the level of consciousness and Recommendation 15: Neurological examination should be
verbal ability of neurocritical care patients (97.2%; 35/36). performed during analgesic and sedative therapy for neuro-
critical care patients. Examinations should include level of
Recommendation 7: For neurocritical care patients
consciousness, pupil reactions, neurological examination
who can self-report pain, pain assessment tools include
(cranial nerves, motor, sensory, respiratory pattern, brain-
Numerical Rating Scale (NRS), Visual Analogue Scale
stem reflexes, etc.), laboratory, and imaging (100%; 36/36).
(VAS), Changhai Pain Rating Scale. For patients who
can not accurately self-report pain, options include Faces Question 11: Should one or more multimodal neuro-
Pain Thermometer (FPT), Behavioral Pain Scale (BPS), monitoring techniques be used for objective monitoring
Critical-care Pain Observation Tool (CPOT), the Revised
during analgesic and sedative therapy for neurocritical
Adult Nonverbal Pain Scale (NVPS-R), Pupil Light Reflex
care patients?
(PLR), etc, (97.2%; 35/36).
Recommendation 16: Multimodal monitoring can dynamically
Recommendation 8: Vital sign changes alone are not
evaluate the safety and efficacy of analgesic and sedative
recommended as the sole method for pain assessment but
therapy from different dimensions (100%; 36/36).
can be used as an adjunct to the detection of underlying
pain (100%; 36/36). Question 12: Should delirium assessment be performed
for neurocritical care patients?
Question 6: Should sedation assessment be performed for
neurocritical care patients? Question 13: How should delirium assessment tools be
chosen for neurocritical care patients?
Question 7: How should sedation assessment methods be
chosen for neurocritical care patients? Recommendation 17: Delirium assessment should be
performed for neurocritical care patients and should not
Recommendation 9: Sedation assessment should be per-
be overlooked even with existing/potential neurological
formed for neurocritical care patients. (100%; 36/36).
deficits (100%; 36/36).
Recommendation 10: For neurocritical care patients,
Recommendation 18: The confusion assessment method
available subjective sedation assessment tools include
for the intensive care unit (CAM-ICU) or intensive care
Sedation-Agitation Scale (SAS), Richmond Agitation-Se-
delirium screening checklist (ICDSC) are commonly
dation Scale (RASS), etc., but their utility is limited for
patients with persistent coma (100%; 36/36). used tools for delirium assessment in neurocritical care
patients. Quick screening tools such as 4A’s test (4AT) can
Recommendation 11: Based on the characteristics of help identify delirium early (97.2%; 35/36).
neurocritical care patients, objective assessment tools like
quantitative electroencephalography (qEEG), bispectral Recommendation 19: For patients with severe neuro-
index (BIS), etc., can be used to evaluate the level of seda- logical conditions such as impaired consciousness and
tion (97.2%; 35/36). aphasia, appropriate assessment tools should be chosen,
and the results of the assessment should be interpreted
Question 8: How should the depth of sedation be chosen cautiously. For patients with aphasia, ICDSC may be
for neurocritical care patients? more valuable than CAM-ICU (97.2%; 35/36).

Recommendation 12: For neurocritical care patients with Recommendation 20: Risk factors for delirium in neuro-
suspected organ dysfunction like intracranial hyperten- critical care patients include age, mechanical ventilation,
sion, light sedation (RASS –2 to –1, SAS 3 to 4) should be sepsis, aphasia, sleep deprivation, physical restraints, and
avoided. When organ function tends to be stable, transi- frontal lobe lesions (100%; 36/36).
tioning from deep sedation to light sedation/no sedation
can be considered (97.2%; 35/36). Analgesic and Sedative Medications Selection
Question 9: Should Neurologic Wake-Up Test (NWT) be Question 14: How should analgesic and sedative agents
performed for neurocritical care patients? be selected for neurocritical care patients?

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Recommendation 21: There is currently no superior Question 18: Is the adjunctive use of neuromuscular
strategy for the selection of analgesic and sedative agents blockade recommended for TTM in neurocritical care
in neurocritical care patients. Opioids, midazolam, and patients?
propofol were the most commonly prescribed agents
(100%; 36/36). Recommendation 29: The selection of analgesic and
sedative agents for TTM should be based on patient
Recommendation 22: Selection should be based on characteristics, treatment needs, and pharmacological
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patient characteristics, treatment needs, and pharmaco- properties of the agents. Hypothermia can result in slower
logical properties of the agents. Caution is needed for drug metabolism and elimination and prolonged action
the adverse effects of analgesic/sedative agents (especially duration, so that short-acting agents may be more appro-
opioids), such as respiratory depression, hypotension, priate (97.2%; 35/36).
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effects on consciousness, tolerance, withdrawal, etc., par-

ticularly in special populations (hemodynamic instability, Recommendation 30: There is currently no evidence on
the optimal analgesic and sedative agents for neurocriti-
hepatic/renal insufficiency, elderly, and obesity) (100%;
cal care patients undergoing TTM. Fentanyl, midazolam,
36/36).
and propofol were the most commonly prescribed agents
Recommendation 23: Short-acting or ultra-short-acting (100%; 36/36).
agents may be more appropriate when accurate and rapid Recommendation 31: The routine use of neuromuscular
assessment of neurological function is required in neuro- blockade should be avoided for TTM in neurocritical care
critical care patients (100%; 36/36). patients (100%; 36/36).
Recommendation 24: The use of ketamine should be cau-
tious in neurocritical care patients (94.4%; 34/36). Funding

Recommendation 25: The efficacy of dexmedetomidine in The work was supported by grants from the Beijing
the prevention and treatment of delirium in neurocriti- Municipal Science and Technology Commission (No.
cal care patients needs to be further confirmed (94.4%; Z201100005520050), and Beijing Municipal Health
Commission (No. BHTPP2022026).
34/36).

Conflicts of interest
Role of Analgesic and Sedative Therapy in Refractory
Intracranial Hypertension None.
Question 15: Should analgesic and sedative therapy be
increased for neurocritical care patients with refractory Acknowledgments
intracranial hypertension? This article is based on the mandarin version of consensus
first reported in the Journal of Chinese Critical Care Medi-
Recommendation 26: Analgesic and sedative therapy
cine 2023;35: 897–918.
should be increased for neurocritical care patients with
refractory intracranial hypertension (97.2%; 35/36).
References
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How to cite this article: Zhang LL, Liu S, Wang SY, Zhou JX, the
Application of Analgesic and Sedative Therapy in TTM National Center for Healthcare Quality Management in Neurological
Diseases, Chinese Society of Critical Care Medicine, Working group
Question 17: How should analgesic and sedative agents of the Expert Consensus on Sedation and Analgesia for Neurocritical
Care Patients. Chinese expert consensus on sedation and analgesia for
be selected for neurocritical care patients undergoing neurocritical care patients. Chin Med J 2024;XXX:1–3. doi: 10.1097/
TTM? CM9.0000000000003084