Presentation on theme: "Sedation & Paralytic Therapy in the ICU"— Presentation transcript:
1 Sedation & Paralytic Therapy in the ICU Leanna R. Miller, RN, MN, CCRN-CSC, PCCN-CMC, CEN, CNRN, NPEducation SpecialistLRM ConsultingNashville, TN
2 ObjectivesIdentify the purpose for pain, sedation, & paralysis management in the ICU patientAnalyze and compare assessment methods for determining appropriate pain, sedation & paralysis management.Recognize and apply the different pharmacotherapeutics used in the ICU for pain, sedation, & paralysis.
3 Goals of Critical Care Management Save the salvageable and relieve sufferingPeaceful & dignified death without prolonging lifeCurative therapy should not supplant palliation of painUse of state-of-the-art interventionsAggressive & fast paced therapy according to needQuality pain management mandatory for all patients
4 Consciousness/Sedation The Balance of Analgesia, Sedation, and Paralytics to promote comfort
5 What is Sedation? Several Clinical Definitions: process of establishing a state of calmpromoting a sense of well-beingreduction of anxiety and agitation through the use of pharmacotherapySedation is NOT analgesia80% of Doctors and 40% of ICU nurses answered that benzodiazepines provided analgesia (1990s)
6 Pathophysiology Response of Stress and Anxiety CardiovascularRelease of systemic epinephrine and norepinephrineElevated HR and BPIncreased cardiac O2 demandDecrease end-organ perfusionEndocrineRelease of Cortisol, Glucagon, GlucoseHyperglycemia
7 Pathophysiology Response of Stress and Anxiety NeurologicalIncreased response and activation of peripheral pain fibersIncreased sensation to painRelease of neurotransmitters in the brainPainAgitationDelirium
8 Pathophysiology Response of Stress and Anxiety ImmuneIncreased levels of prostaglandins, cortisol, glucose, cytokines,Increase anti-inflammatory responseDecrease wound healingSIGNIFICANT STRESS IN THE ICU PATIENT OVERALL CAUSES ORGAN ISCHEMIA AND DECREASED HEALING
9 Analgesia Clinical Definition: The absence of pain through the use of pharmacotherapyAcute and chronic pain in the ICU activates the stress responsePatients with analgesia can still experience anxiety
10 Its essentially a maintenance therapy” PAIN THERAPY - Myth“One size fits all orSet and forget therapy.Its essentially a maintenance therapy”
11 Truths Majority of ICU patents suffer moderate/severe pain 40% are delirious & cannot communicate50% are either physically/emotionally distressed10-20% have no hopes of cure --- end-of-life in ICUBalance between pain relief & maintaining alertnessMultidisciplinary team for multimodal therapies.
12 Pain in ICU Repeated episodes of acute pain localized Surgery/tissue inflammation immobilitycatheter/ apparatus discomfort/ nasogastric & orogastric tubesendotracheal intubation/ suctioning/ chest tubesphlebotomy/vascular access/physiotherapyroutine turning & positioning the patient
13 Types of pain in ICU Somatic – most common –localized opiates Visceral – cramping & colicky anticholinergicsNeuropathic – burning / shooting antidepressantsMixed type combination therapySustained or chronic pain of varying degrees
14 Inherent Problemsdifficult to differentiate due to lack of communicationuntreated pain affects all body systemssynergistic effect of pain on anxiety, depression, sleepall modalities are unpredictable & have adverse effectspain therapy to be tailored to individual needs.
15 Assessment of pain in ICU Pain as the 5th vital sign- requires frequent evaluationCognitive impairment/delirium markersBehavioral (facial, FACS)Physiological (BP, HR, RR)Creative assessments (teaching hand movements, blinkingSubjective quantification (numeric/graphic scales –W-B faces)
18 Treatment of Paintreatment of perceived & prevention of anticipated painOpiates – principal agents in ICU- potent / lack ceiling effects- mild anxiolytic & sedative- relieves air hunger & suppresses cough inrespiratory failure- improved patient – ventilator synchrony- effective antagonist – naloxonelack amnesic effects /additional sedatives required
19 Treatment of Painadjuvant / non-pharmacological / multimodal therapiesSimple Relaxation – must begin preoperativelyJaw relaxationProgressive muscle relaxationSimple imageryMusic (either patient – preferred or “easy listening” are effective in reducing mild to moderate painComplex Relaxation – must begin preoperativelyBiofeedbackimagery
20 Causes of Pain in the ICU? Routine care: Suctioning, turning,Surgical IncisionsLines/Chest tubes
21 The Messengers of Pain Bradykinin, Prostaglandins, Cytokines Histamine Direct tissue damage stimulates pain fibersLocal Inflammatory mediatorsBradykinin, Prostaglandins, CytokinesTissue InjuryHistamineSerotoninTNF
24 A Focus on Morphine First narcotic to be used Narcotic standard Relies on good kidney function for excretionStimulates mast cells to release histamineItchingRashHypotensionAcute Asthma episodeNo longer used frequently due to newer drugs
25 A Focus on Fentanyl 100x stronger then Morphine Fastest metabolizing narcotic used in the CVICUChest Wall Rigiditycan cause shortness of breath and difficulty weaningoccurs most often with high IV bolus dosesDecreases BP and HR
26 A Focus on Remifentanil Newest synthetic narcotic derived from FentanylEliminated by plasma esterasesMetabolism not dependent on liver or kidney functionElimination not dose dependentAdvantagesOrgan independent metabolismLack of accumulationProvides analgesia and sedation in ventilated patientDisadvantagesExpensiveSevere withdrawalRebound hyperalgesia
27 A Focus on Toradol Is a potent IV/IM NSAID Decreases sternal incision pain and inflammationLike many NSAIDs can be nephrotoxicKnow your patients BNP and CreatinineCan cause GI bleedingUsually not given if the patient is…Age >75Elevated creatinineChest tube bleedingLow platelets
28 Sedation in ICUused in the agitated, ventilated & for procedure discomfortto avoid self extubation & removal of cathetersNM blockade mandates analgesia & sedationcontrol of pain before sedationall have side effects – dose dependentanalgesics are not sedatives/ Sedatives are not analgesics
29 Common Sedatives in the ICU DrugDoseOnsetPeakDurationAtivanLiver.5 - 2mg5 min.60-90 min6 - 8 hrsVersed1 - 2mgminRapid2 - 6 hrsPropofolLiver*Starts at 25 mcg/kg/min<40 sec.3-5 minminPrecedexPlasma.2-.7 mcg/kg/hr (3mcg/kg/hr)min30 minminKetamine2 – 7 mcg/kg/min30 s1 minmin
30 A Focus on PrecedexOnly sedative used that does not cause respiratory depressionPatients can be weaned and extubated while on PrecedexUsual titration range 0.2 – 0.7mcg/kg/hrMD order >0.7mcg/kg/hrTitrate by mcg/kg/hr q30-45minCan cause SEVERE bradycardia and hypotensionVery expensive!
31 A Focus on Ketamine dissociative anesthetic light sedation & amnesia used as an adjunct for patients with uncontrolled pain or inadequately sedatedrarely used in the CVICU due to myocardial depressant propertiesmonitor for hallucinations and vivid dreams
33 Sedation scoring systems Assess levels to vary according to course of ICU stayObservational scales - 4 levels – min, mod, deep, GAAddenbrooke sedation scale 0-7 (vocal, tracheal suction)Ramsay sedation scale 1-6 (vocal, glabellar tap)--aim for 3-4Direct information- ideal to assess analgesia & sedationBIS – for deep sedated & paralyzed
34 RASS ASSESSMENT +4 Combative, violent, danger to self/staff +3 Very agitated, pulls lines, tubes, aggressive+2 Agitated frequent non-purposeful movement, fights the vent+1 Restless / Anxious but not aggressive or vigorous0 Alert and calm-1 Drowsy, not fully alert but can stay awake, eyes open to voice for >10sec-2 Light sedation, wake and makes eye contact for < 10 sec-3 Moderate sedation, moves/opens eyes to voice but no eye contact-4 Deep sedation, no response to voice but moves or opens eyes to physical stimulation-5 Unarousable, no response to stimuli
37 BIS Monitor BIS monitor utilizes EEG waveforms. reading is monitored from the patient’s forehead.excessive muscle activity can interfere with EEG detection
38 Bispectral IndexBIS – an attempt to objectively monitor patients sedationprocessed EEG measurement that gives a score to help determine the patient’s response to sedationuseful to help titrate medicationproper sensor placement is key to accurate monitoring
39 Sensor Application Apply sensor on forehead at angle Circle #1: Centered, 2 inches above noseCircle #4: Directly above eyebrowCircle #3: On temple, between corner of eyeand hairlinePress around the edges of each circle to assure adhesionPress each circle for 5 seconds
40 BIS Placement Make sure the forehead is clean and dry! Label the sensor with date/timeReplace sensor every 24 hours and PRN
41 BIS Monitorimplement BIS monitoring on all patients with paralytic drips infusingpurpose of BIS monitor is to provide a direct measurement of the SEDATIVE effects on the brain.goal for BIS Monitoring will be 40 – 60.studies have indicated that this is a safe range for no memory recall.
43 Troubleshooting the BIS If the BIS increases suddenly or is higher than expected:Consider:Is the sedative dose sufficient?Is there an increase in stimulation?When was the last analgesic given?Is the patient adequately paralyzed? TOF?Is the patient having a seizure
44 Troubleshooting the BIS If the BIS decreases suddenly or is lower than expected:Consider:Has there been a decrease in stimulation or increase in sedation/analgesia?Is the patient significantly hypothermic?Has there been a sudden significant drop in BP?
45 BIS Monitoring Always consider the overall picture of the patient Ex: if nothing significant has changed with patient and BIS number suddenly reflects very different readings then fall back to your overall assessment of the patient
46 REMEMBER!Look at the BIG PICTURE! Do Not Forget You are treating a patient not just the number
51 “Sedation Vacation” SBT Termination Criteria RR > 35/min for > 5 minutesSpO2 < 90% for > 2 minutesNew ectopyHR change 20% from baselineBP change 20% from baselineAccessory muscle useIncreased anxiety/diaphoresis
52 “Sedation Vacation” Conduct SBT for 1 minute Mode CPAP PEEP = 0 least 5 – 10FiO2 unchanged
53 Paralytics in the ICUParalysis – the loss of voluntary muscular function due to the administration of a paralyticNeuromuscular Blockade Agent (NMB) – Drugs that obstruct transmission of nerve impulses to the muscleNeuromuscular Blockade agents DO NOT BLOCK THE TRANSMISSION OF PAIN!!!!
54 Paralytics in the CVICU Sedation and Analgesics must always be given FIRSTMust use sedatives with an Amnesic affectBenzodiazepines (VERSED)High dose PropofolParalytics are always given LAST
55 Why Do We Paralyze? Decreases O2 demand ARDSPrevent Patient-Ventilator dysynchronyVDR ventilatorsBiVentPrevents Shivering in hypothermia patientsShivering increases O2 demandRaises patients temperatureOpen chest
56 Checklist for chemical paralysis Must be adequately sedated first before paralytic administeredMust have anxiolytic drip that has amnesic propertiesMust have analgesic drip infusingMust have lubrication for eyes/eye bubbles
57 Common CVICU Paralytics DrugDoseOnsetPeakDurationVecuroniummg/kg1 min3-5 min15-25 minPancuroniummg/kg30-45 sec3-4 min35-65 minSuccinylcholine.6 mg/kg30-60 sec1-2 min4-10minNimbex3 mcg/kg/min2-5 min25-44 min
58 A Focus on Vecuronium A non-depolarizing NMB Will NOT increase K+ Full recovery from paralytic 25-40minFrequently used in the CVICU for intubation or as a bolus drug before NimbexRarely used as a drip in the absence of Nimbexmck/kg/min
59 A Focus on Succinylcholine A depolarizing NMBCan increase K+ ~ 0.5-1mEq/LKNOW YOUR PATIENTS K+ before administeringDoes your patient have any renal disease?Metabolized by plasma cholinesteraseVery rapid metabolism ~5minDoes not rely on kidney or liver function
60 A Focus on Nimbex Is our primary titrating NMB used in the CVICU Is also metabolized in the bloodStandard dose is 3mcg/kg/minTitrate range: 0.5-5mcg/kg/minMetabolism ~45minChanges with hypothermia?
61 Successful Paralysis: How do we know? AssessmentMovementSpontaneous BreathsPeripheral Nerve Stimulator
62 Peripheral Nerve Stimulators Peripheral Nerve Stimulator – A device that delivers a determine electrical current to create a muscular contractionUsed to determine the amount of neuromuscular blockade a patient hasAn increase in NMB will show a decrease response to a peripheral nerve stimulator at a set current
63 Train of FourTrain of Four – 4 consecutive impulses generated from the peripheral nerve stimulator resulting in 4 muscular twitches# of twitches seen = degree of NMBNo blockade – 4 twitchesTotal blockade – 0 twitchesGOAL IS 1-2 TWITCHESIncrease drip by 10% if >2 twitchesDecrease drip by 10% if <1 twitch
64 Train of Four: Facial Nerve Place one electrode on the face at the outer canthus of the eye (positive/red electrode)Place the second electrode 2 cm below and parallel with the tragus of the ear (negative/black electrode)Watch and feel for facial nerve contraction
66 Train of Four Must have 2x baseline TOFs before starting NMBs Ulnar nerve is more preferred but facial nerve is easier to see/assessUse alcohol pad to wipe clean and dry the skin before applying electrodeElectrodes must be changed 24 hrsPossibly inaccurate in hypothermia patients…
67 Helpful tips for TOFIf checking the thumb – ensure the leads are placed on the ulnar side of the arm(this is where the nerve lies)Be careful with applying maximum MA’s when leads are placed on the face – this can lead to burns/scarringCheck your batteryChange your electrodes q24h
68 Putting it all Together start BIS Monitoringget a Baseline TOF on two locationsstart Sedation and Analgesic Dripstitrate medication up until BIS 40-60bolus paralyticstart paralytic dripcheck TOF q30min until 1-2 twitchesmonitor TOF and BIS and titrate drips to endpoints
69 ***** CRUCIAL POINT ****** Prior to the administration of any paralytic agent - sedation MUST be administered first. If paralytic will be continued as an infusion, sedation MUST also be continued.Sedation MUST be a drug that has amnesic properties.
70 Drugs that have amnesic effects Benzodiazepine classExamples:VersedPropofol (in high doses) dose will be individual to patient
71 Intravenous Medicines commonly used in CVICU SEDATIONAtivan *Versed *Propofol **Precedex **** Amnesic properties** Amnesic in high doses only*** DOES NOT have amnesic propertiesANALGESIAMorphineFentanylDilaudidToradol
72 Case StudyYou are caring for a patient that has an open chest, they are on a Nimbex, Fentanyl & Versed gtts:VS’s:BP 160/90HR 128Vent Settings: SIMV 12, TV 450, PEEP 5, PS 10, Spontaneous RR 12, 02 saturation 98%, TOF 2/4Is anything wrong here?
73 Case Study Patient has open chest, Nimbex, Fentanyl & Versed gtts: VS’s105/68HR 80 PacedVent settings: SIMV 12, TV 600, PEEP 5, PS 10, Spontaneous RR 16TOF 2/4Is anything wrong here?
74 Case StudyPatient has open chest, has experienced excessive blood loss through chest tubes, Nimbex & Propofol gtts(5 mcg/kg/hr)VS’sBP labile 70’s to 100’s systolicHR 80’s pacedVent settings: SIMV 12, TV 400, PEEP 5, PS 5, Spontaneous RR 14, 02 saturation 98%TOF 0/4Is anything wrong here?
75 SCCM task force recommendations Benzodiazepines most popular for sedationShort term sedationMidazolam <3h (amnesic/ hypotension)propofol – infusion syndrome/ pancreatitisLong term – lorazepam <20h /diazepam>96h (not for infusion)Delirium – haloperidol - neuroleptic syndrome/ torsade pointesAntagonist- flumazenil 0.2mg-1mg (withdrawal seizures)
76 ReCap of Key Points Sedation: Analgesia: Paralytics: Patient may still experience pain, goal is anti-anxiety/ – relaxation, goal is usually to give amnesiaAnalgesia:Used to treat pain, no anti-anxiety propertiesParalytics:Used to decrease skeletal muscle movement, imperative that amnesic drugs be used in combination with analgesic meds, MUST sedate before paralyzing
77 ReCap of Key Points BIS Monitor: Peripheral Nerve Stimulator: Used to strictly assess patient’s sedation levelGoal is 40-60Peripheral Nerve Stimulator:Used to strictly assess patients paralytic stateTOF goal is 1-2/4
78 Putting it all Together start BIS Monitoringget a Baseline TOF on two locationsstart Sedation and Analgesic Dripstitrate medication up until BIS 40-60bolus paralyticstart paralytic dripcheck TOF q30min until 1-2 twitchesmonitor TOF and BIS and titrate drips to endpoints
79 Final Thoughts give sedation/analgesia before paralytics BIS assess for sedationTOF assess for adequate NMBIf in doubt it never hurts to ask!
80 ReferencesGelinas C. Management of pain in cardiac surgery ICU patients: have we improved over time? Intensive Crit Care Nurs. 2007;23(5):Girard TD, Shintani AK, Jackson JC, et al. Risk factors for post-traumatic stress disorder symptoms following critical illness requiring mechanical ventilation: a prospective cohort study. Crit Care. 2007;11(1):R28.Jacobi J, Fraser GL, Coursin DB, et al. Clinical practice guidelines for the sustained use of sedatives and analgesics in the critically ill adult. Crit Care Med. 2002;30(1):Pandharipande PP, Pun BT, Herr DL, et al. Effect of sedation with dexmedetomidine vs lorazepam on acute brain dysfunction in mechanically ventilated patients: the MENDS randomized controlled trial. JAMA. 2007;298(22):