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The Art of Sedation in ICU Yasser Zaghloul MD PhD, FCARCSI (Ireland)

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Presentation on theme: "The Art of Sedation in ICU Yasser Zaghloul MD PhD, FCARCSI (Ireland)"— Presentation transcript:

1 The Art of Sedation in ICU Yasser Zaghloul MD PhD, FCARCSI (Ireland)

2 Hypnosis ± Muscle Relaxation Analgesia Sedation comes from the Latin word sedare. Sedare = to calm or to allay fear

3 Hypnosis ± Muscle Relaxation Analgesia Sedation comes from the Latin word sedare. Sedare = to calm or to allay fear

4 Why sedation is necessary? To improve patient comfort. Reduce stress. Facilitate interventions. Allow effective ventilation. Encourage sleep. ?? Prevent post-ICU psychosis.


6 Inadequate Sedation All ICU patients suffer from severe sleep deprivation. REM sleep is 6% ( Normal 25 %). Stress neuroendocrine response ( ACTH, GH, Aldosterone, Adrenaline,.....) Release of cytokines inflammatory response.

7 Non-pharmacological interventions Good nursing. Psychological: - Explanation. - Reassurance. Physical: - Touching & message. - Environment - Prevent constipation - Physiotherapy. - Tracheostomy.

8 Sedation-Analgesia Medications IV Anaesthetics: - Prpofol - Thiopentone. - Ketamine - Etomidate. Benzodiazepines: - Midazolam. - Lorazepam

9 Sedation-Analgesia Medications Opiodis: - Morphine - Fentanyl. - Remifentanil α- 2 receptors agonists: –Clonidine. –Dexmedetomidine.

10 Sedation-Analgesia Medications Others: - Inhalation anaesthetics (Sevoflurane). - Phenothiazines. - Butyrophenones (Haloperidol). - Local Anaesthetics.

11 Choice of the sedative drug Short-term Vs long-term sedation. Pain & painful Procedures. Organ problems (Renal, hepatic, brain, CVS). Drug withdrawal (Alcohol, heroin,.....) Prescriber & Prescription.

12 Which Medication? Soliman et al, Brit J Anaesth 2001;87:186-92

13 IV Anaesthetics; Thiopentone Acts on the GABA A. Zero order kinetics (accumulation). Provides a cerebral protection effect. Main uses in ICU: - High ICP. - Status epilepticus

14 IV Anaesthetics; Propofol (CH 3 ) 2 CH CH(CH 3 ) 2 OH 2,6 di-isopropyl phenol Short-term sedation (< 48 h)

15 IV Anaesthetics; Propofol Mechanisms of actions: - Acts on GABA A receptors in the hippocampus. - Inhibits of NMDA. IOP, ICP & CMRO 2.

16 IV Anaesthetics; Propofol Decreases (10 – 30%): - HR. - SBP, DBP & MAP. - SVR. - CI. - SV.

17 Diprifusor TCI Subsystem Recognition software/electronics Diprifusor TCI Software/ 2 microprocessors Pump software Pump hardware Finger grip Tag = PMR (Programmaable Magnetic Resonance*) Full Diprivan PFS is loaded correctly Aerial Target concentrations with Diprifusor TCI

18 Time (hours) Infusion rate (ml/h) Blood concentration (µg/ml) Calculated concentration (automatic calculation and display by system) Target concentration (selected by anaesthetist, displayed) Start; 6µg/ml Titration End 4 6 Age Wt. Tc

19 IV Anaesthetics; Propofol Propofol infusion syndrome: - Rare but fatal. - 1 st described in children. - Infusion 5 mg/kg/hr or 48 hours.

20 Propofol Infusion Syndrome Clinical features: - Cardiomyopathy with acute cardiac failure. - Myopathy. - Metabolic acidosis, K + - Hepatomegaly. Inhibition of FFA entry into mitochondria failure of its metabolism.

21 IV Anaesthetics - Ketamine

22 Phencyclidine derivative. High lipid solubility (5–10 times > thiopental) crosses BBB faster. Non-competitive antagonism at NMDA receptor

23 IV Anaesthetics - Ketamine HR, BP. CBF, ICP & CMRO 2. Bronchial smooth muscle relaxant. Excellent analgesic. Dose: 5-30 µg/kg/min.

24 Opioids; Morphine Isolated in 1803 by the German pharmacist Friedrich Adam. Named it 'morphium' after Morpheus, the Greek god of dreams.

25 Opioids - Morphine Plasma levels do not correlate with clinical effect. Low lipid solubility causes slow equilibration across BBB. Metabolized in the liver by conjugation. Morphine-6-glucuronide (active).

26 Remifentanil Piperidine derivative. Selective mu-receptor agonist. Potency similar to fentanyl. Terminal half-life < 10 min. Rapid blood-brain equilibrium. Metabolised by non-specific esterases.

27 Remfentnil Acid 95% 1.5%

28 Sufentanil 34 min Alfentanil 59 min Duration of infusion (minutes) Time to 50% drop in concentration at effect site (minutes) Fentanyl 262 min Remifentanil 3.7 min Plasma concentration after long term infusion After 240 min Context –sensitive half-time

29 Unwanted side-effects of opioids Respiratory depression Confusion Vasodilation Gut motility depression Opioids

30 Benzodiazepines

31 Benzodiazepines; Midazolam Water-soluble lipid soluble in the body. Produces sedation, anxiolysis and amensia. Withdrawal agitation.

32 α 2 -Adrenergic agonists Clonidine Dexmedetomidine

33 α 2 – agonists Sedation-hypnosis: by an action on α 2 -receptors in the locus ceruleus. Analgesia: by an action on α 2 -receptors within the locus ceruleus and the spinal cord

34 α 2 – agonists; Dexmedetomidine 94% protein bound. Narrow therapeutic range ( ng/mL) It undergoes conjugation & N-methylation. Approved only for sedation 24 h.

35 α 2 – agonists Haemodynamics Effects: - heart rate. - Initial then BP. - SVR. - CO No respiratory depression

36 Unwanted side-effects of sedative agents Propofol Hypertriglyceridemia CVS depression Hypotension 2 -agonists Hypotension Bradycardia Benzodiazepines Hypotension Respiratory depression Agitation/Confusion Ketamine Hypertension Secretions Dysphoria General Over sedation Delayed awakening/extubation

37 DrugElimination h 1/2 (h) Prpofol4 – 7 Dexmedetomidine2 - 3 Ketamine2.5 – 2.8 Midazolam1.7 – 2.6

38 Assessment of Sedation Ramsay Sedation Score. Motor Activity Assessment Scale Richmond Agitation–Sedation Scale. Sedation – Agitation Score. Modified Glasgow Coma Score.

39 Ramsay Sedation Score Level 1 Awake, anxious, agitated, restlessness Level 2 Awake, cooperative, tranquil. Level 3 Respond to commands. Level 4 Asleep, brisk response to stimuli. Level 5 Asleep, sluggish response to stimuli. Level 6 Asleep, no response

40 Bispectral Index

41 Is any place for neuro- muscular Blockers in ICU?

42 Mehta S et al. Crit Care Med 2006; 34: 374


44 The Art of Sedation * Under sedation: Fighting the ventilator. V/Q mismatch. Accidental extubation. Catheter displacement. CV stress ischemia. Anxiety, awareness. Post-traumatic stress disorder. * Over sedation: Tolerance, tachyphylaxis. Withdrawal syndrome. Delirium. Prolonged ventilation. CV depression. neuro testing. Sleep disturbance.

45 Thank You Yasser Zaghloul

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