11Sedation: Current Issues Without a means toobjectively titratethe level of sedation,patients may be:Over-sedatedincreased drug costsdelayed weaningincreased ICU length of stayincreased testingUnder-sedatedanxiety and agitationawareness and recallpost-traumatic stress disorderincreased adverse eventsincreased use of paralyticsThe majority of patients will receive some form of sedation during their stay in an intensive care unit, and for many, this is a critical component of their care regime. However ICU patients are very complex and their needs for sedatives are unpredictable and complicated, and often highly variable.Sedation challenges in the ICU are well documented and recognized, and even more so in recent years. It is clear that the problems associated with sedation are indeed bipolar, branching into 2 extreme conditions of over sedation and under-sedation -- each with their important consequences.Over-sedationCan result in unnecessary costs of sedative drugs, which in some cases can range into hundreds of dollars per patient per day.When patients are over-sedated, they often experience delayed weaning from mechanical ventilation (MV), which can impose additional costs. Even more importantly, extended and unnecessary time on MV can lead to complications such as ventilator associated pneumonias and the need for tracheostomies.Extension of MV and other complications can result in increased length of stay (LOS) in the ICU and hospital.Additionally, when patients do not show signs of waking up when sedation is weaned or discontinued, many of them will be subjected to expensive and unnecessary diagnostic tests to rule out the incidence of a neurological event.Under-sedationCan result in patients who are anxious and agitated, and increase the risk of awareness and recall of unpleasant events, even in patients who are receiving neuromuscular blocking agents (NMBAs). These occurrences are far more common than they are in the OR setting. They may also result in long-term sequelae such as Post-Traumatic Stress Disorder (PTSD)In addition, patients who do not have adequate sedation may receive other classes of drugs, such as NMBAs.
12Daily interruption of sedative infusion in critically ill patients undergoing mechanical ventilation Kress. NEJM 2000.
13Effect of nurse-implemented sedation protocol on the incidence of ventilator-associated pneumonia Quenot. CCM 2007.
14Effect of nurse-implemented sedation protocol on the incidence of ventilator-associated pneumonia Quenot. CCM 2007.
15Sedation Use Recommendations Lorazepam is recommended for sedation of most patients via intermittant IV or continuous infusion (Grade=B)Triglyceride levels should be monitored after two days of propofol infusion (Grade=B)Use of sedation guidelines, an algorithm or a protocol is recommended. (Grade=B)Jacobi J. Crit Care Med 2002; 30(1):
16Sedation protocol production intensivistCritical care nurse
17Morphine and Midazolam (M&M) combination AgentsMixtureDosagePrecautionMorphine and Midazolam (M&M) combination(First line agent)Morphine 60 mg + Midazolam 30 mg + NSS 60 mlloading 2-3 ml iv then continuous drip 1-20 ml/hr and 1-3 ml iv prn.prolonged effect in renal dysfunctionbeware of seizure in renal dysfunction due to accumulation of active metabolite of MorphineMorphineMorphine 60 mg + NSS 60 mlcontinuous drip 1-5 ml/hr and 1-3 m iv prn.for pain control onlyas aboveMidazolamMidazolam 30 mg + NSS 60 mlcontinuous drip 1-20 ml/hronly for sedationFentanylFentanyl 500 mcg + NSS 50 mlcontinuous drip 0.5 – 5 ml/hrsecond line agent for pain control in renal failure patientsProprofolProprofol 200 mgcontinuous drip ml/hr and mg iv prn.second line agent for sedationcheck CPK and Triglyceride level if use longer than 5 daysno analgesic effect at all
18Score Description Definition 7 Dangerous agitation 6 Very agitated 5 Pulling at ET tube, trying to remove catheters, climbing over bedrail, striking to staff, thrashing side by side6Very agitatedDoes not clam despite frequent verbal reminding of limit, require physical restraints, biting ETT5AgitatedAnxious or mildly agitated, attempt to sit up, calm down to verbal instruction4LightSedation(Default)Calm and cooperativeCalm, awakening easily, follows command3SedatedDifficult to arouse, awake or eye open to verbal stimuli or gentle shaking but drift off again, follow simple command2Moderate sedationVery sedatedArouses to physical stimuli but does not communicate of follow commands, may move spontaneously, eye close1HeavysedationUnrousableMinimal or no response to noxious stimuli, does not communicate or follow commands, weak cough on suction
24LearningSedation protocol is effective to prevent self extubation in medical ICU.Sedation protocol did not increase ventilator day and risk of VAP.The collaborate of critical care nurse and intensivist is the key of success.The incidence of extubation could possible reach to ZERO.
25LearningWe should be increase awareness and alertness in isolated room patients.During period of sedation interruption, critical care nurse must pay more attention to the patients in order to prevent self extubation.This protocol should be implemented in all ventilator care unit.
26Patient Safety in cancer patients Oncology nurse driven chemotherapy
28Number of cancer patients in medicine department: 2550
29Medical error in chemotherapeutic patients Inaccurate dose and drugWrong patientsLeakage of chemotherapy during injectionNo medical advice postchemotherapy
30Why chemotherapy error is important? life threatening complicationMorbidityIneffective of treatmentPoor treatment outcome
31Safety in chemotherapy injection Check drug and dosageCheck patient labelChemo thera peutic unitNo error in chemotherapy givenOncology nurseAmended injection technique
32Oncology nurse: job description Give chemotherapy to hospitalized medical oncology patientsGive medical advice for cancer patientsInstruction and sharing the knowledge of caring in cancer patient to ward nurses