Presentation on theme: "SEDATION IN THE ICU-SHIFTS & STRATEGIES"— Presentation transcript:
1 SEDATION IN THE ICU-SHIFTS & STRATEGIES DR. RAKESH K. CHAWLAMD,FCCP(USA)SR. CONSULTANT RESPIRATORY MEDICINE, CRITICAL CARE AND SLEEP DISORDERSJAIPUR GOLDEN HOSPITAL,SAROJ HOSPITAL & RAJIV GANDHI CANCER INSTITUTEMOBILE
2 NISO FINANCIAL GRANT FOR THIS LECTURE.PURE ACADEMIC
3 Sedation in the ICUThe ICU is a hostile environment and while pain is often the root cause of distress experienced by the patient in the unit , anxiety, dyspnoea, delirium and sleep deprivation may be additive or synergistic.
4 Everyone who works in Intensive Care Unit(I. C Everyone who works in Intensive Care Unit(I.C.U) has already faced an anxious and agitated patient requiring sedation for different goals such as management of difficult airway, improvement of mechanical ventilation or just as adjuvant therapy to commonly procedures done in Intensive Care Medicine.
5 Majority of critically ill patients experience significant distress, anxiety, and agitation during their intensive care unit stays. Numerous factors, including sleep deprivation, unfamiliar environment, delirium, adverse medication effect, pain, and extreme anxiety can contribute to ICU patient distress.
6 Intensivists often employ various sedative agents to relieve ICU associated distress and prevent secondary complications of such distress. There are a variety of pharmacologic agents used for this purpose, including benzodiazepines, propofol, antipsychotic agents, and alpha agonists.
7 Important patho-physiologic mechanisms affected by ICU – associated distress include significant increases in catecholamines, cortisol, growth hormone, vasopressin, prolactin, glucagon, fatty acids, and protein catabolism. Clinically significant sequelae of this physiologic dysregulation include fluid and electrolyte imbalances, altered wound healing , and disturbances of the sleep wake cycles.
8 ICU sedation is aimed at keeping the patient comfortable but easily arousable. Deep sedation with or without muscle relaxants is rarely indicated and is associated with a higher incidence of delirium and death. Analgo – sedation is administered to relieve pain, anxiety and discomfort and to facilitate treatment and nursing. .
9 Providing analgesia first, and adding sedation as required (“analgo - sedation”).
10 What We Know About ICU Agitation/Discomfort Prevalence50% incidence in those with length of stay > 24 hoursPrimary causes: unrelieved pain, delirium, anxiety, sleep deprivation, etc.Immediate sequelae:Patient-ventilator dyssynchronyIncreased oxygen consumptionSelf (and health care provider) injuryFamily anxietyLong-term sequelae: chronic anxiety disorders and post-traumatic stress disorder (PTSD)
11 Patient’s report pain/discomfort with common ICU procedures such as ETT suctioning and dressing changes11
12 Causes of Agitation Not to be Overlooked HypoxiaHypercarbiaHypoglycemiaEndotracheal tube malpositionPneumothoraxMyocardial ischemiaAbdominal painDrug and alcohol withdrawal
13 Correctable Causes of Agitation Full bladderUncomfortable bed positionInadequate ventilator flow ratesMental illnessUremiaDrug side effectsDisorientationSleep deprivationNoiseInability to communicate
15 Recall in the ICUSome degree of recall occurs in up to 70% of ICU patients.Anxiety, fear, pain, panic, agony, or nightmares reported in 90% of those who did have recall.Potentially cruel:Up to 36% recalled some aspect of paralysis.Associated with PTSD in ARDS?41% risk of recall of two or more traumatic experiences.Associated with PTSD in cardiac surgery
16 Goals of Sedation in ICU Patient comfort andControl of painAnxiolysis and amnesiaBlunting adverse autonomic and hemodynamic responsesFacilitate nursing managementFacilitate mechanical ventilationAvoid self-extubationReduce oxygen consumptionTreatment or Diagnostic proceduresThe specific individual goals of sedation are listed in this slide, taken from Dr Ramsay’s slide presentation on dexmedetomidine.com.
17 Characteristics of an ideal sedation agents for the ICU Lack of respiratory depressionAnalgesia, especially for surgical patientsRapid onset, titratable, with a short elimination half-timeSedation with ease of orientation and arousabilityAnxiolyticHemodynamic stabilitySpeaker’s Notes:The characteristics of an ideal agent to be used for ICU sedation are listed. The lack of respiratory depression is particularly important because most of the available agents produce respiratory depression.
18 The Challenges of ICU Sedation Assessment of sedationAltered pharmacologyToleranceDelayed emergenceWithdrawalDrug interaction
20 Incidence of Inadequate Sedation QuantifyKaplan L, et al. Crit Care 2000;4(suppl 1):S110.20
21 Sedation: Background Significant issues with some current agents Opiate/benzodiazepine – tolerance, efficacyChloral hydrate - predictabilityPentobarbital – agitation, durationPropofol – limited access in some jurisdictionsKetamine – emergence reactions, tolerance2-adrenoreceptor agonistsPrototype agent is clonidineRecent applications in clinical practice- Sedation, Behavior disorders , Drug withdrawal , Hypertension
22 Complications of Under/Over Sedation Under sedationPatient recall (PTSD)Device removalIneffectual mechanical ventilationInitiation of neuromuscular blocker therapyMyocardial or cerebral ischemiaDecreased family satisfaction with careOver sedationProlonged mechanical ventilationNeed for additional diagnostic testingIncreased length of ICU and hospital stayIncreased risk of complicationsVentilator-associated pneumoniaThrombo-embolic eventsDrug withdrawalIncreased catacholamine release, metabolic stress, cardiovascular stress, impaired wound healing and immune fxn22
23 Undersedation Sedatives Causes for Agitation Agitation & anxiety Pain and discomfortCatheter displacementInadequate ventilationHypertensionTachycardiaArrhythmiasMyocardial ischemiaWound disruptionPatient injury
27 Daily Goal is Arousable, Comfortable Sedation Sedation needs to be protocolized and titrated to goal:Lighten sedation to appropriate wakefulness daily.Effect of this strategy on outcomes:One- to seven-day reduction in length of sedation and mechanical ventilation needs50% reduction in tracheostomiesThree-fold reduction in the need for diagnostic evaluation of CNS
28 Protocols and Assessment Tools SCCM practice guidelines can be used as a template for institution-specific protocols.Titration of sedatives and analgesics guided by assessment tools:Validated sedation assessment tools (Ramsay Sedation Scale [RSS], Sedation-Agitation Scale [SAS], Richmond Sedation- agitation Scale [RSAS], etc.)- No evidence that one is preferred over anotherPain assessment tools - none validated in ICU (numeric rating scale [NRS], visual analogue scale [VAS], etc.)
29 Strategies for Patient Comfort Set treatment goalQuantitate sedation and painChoose the right medicationUse combined infusionReevaluate needTreat withdrawal
39 The Riker Sedation-Agitation Scale ScoreDescriptionDefinition7Dangerous agitationPulling at endotracheal tube, trying to strike at staff, thrashing side to side6Very agitatedDoes not calm despite frequent verbal commands, biting ETT5AgitatedAnxious or mildly agitated, attempting to sit4Calm and cooperativeCalm, awakens easily, follows commands3SedatedDifficult to arouse, awakens to verbal stimuli, follows simple commands2Very sedatedArouse to physical stimuli, but does not communicate spontaneously1UnarousableMinimal or no response to noxious stimuli
40 MASS (Motor Assessment Scale ) The MASS is scored from 0 (patient unresponsive) to 6 (dangerously agitated, uncooperative patient).
41 The Motor Activity Assessment Scale ScoreDescriptionDefinition6Dangerous agitationPulling at endotracheal tube, trying to strike at staff, thrashing side to side5AgitatedDoes not calm despite frequent verbal commands, biting ETT4Restless and cooperativeAnxious or mildly agitated, attempting to sit3Calm and cooperativeCalm, awakens easily, follows commands2Responsive to touch or nameOpens eyes or raises eyebrows or turns head when touched or name is loudly spoken1Responsive only to noxious stimuliOpens eyes or raises eyebrows or turns head with noxious stimuliUnresponsiveDoes not move with noxious stimuli
42 VICS (Vancouver Interaction and Calmness Scale) The VICS consists of two separate scores, the interaction score and the calmness score. Each score is composed of five categories , with each category graded on a scale .
43 SAS (Sedation – Agitation Scale) The SAS is scored from 1 (unarousable ) to 7 (dangerous agitation).
44 LevelBehaviors7Dangerous agitation pulls at endotracheal tube, tries to remove catheter climbs over bed rail , strikes at staff, thrashes side - to – side.6Very agitated . Does not calm , despite frequent verbal reminders; requires verbal reminding of limits, physical restraints; bites endotracheal tube.5Agitated , Anxious or mildly agitated , attempts to sit up, calms down to verbal instructions.4Calm and cooperative. Calm , awakens easily, follow commands3Sedated. Difficult to arouse, awakens to verbal stimuli or gentle shaking but drifts off again, follows simple commands2Very sedated. Arouses to physical stimuli but does not communicate or follow commands, may move spontaneously1Unarousable. Minimal or no response to noxious stimuli, does not communicate or follow commands.
45 AVRIPASThis scale consists of four components : (a) agitation; (b) alertness; (c) heart rate; (d) respiration.Agitation, alertness , and respiration are measured on a 5 point scoring system. Heart rate is measured on a 4 point scale . The overall sedation score for this system is a sum of each component , with scores ranging from 1 (sedated) to 19 (need for more sedation).
46 BloomsburyAlso known as the University College London Hospitals sedation protocol, this scale spans from -3 (unarousable) to +3 (agitated and restless). There is also categorization for natural sleep. The bloomsbury scale appears to have a high association with the Ramsay Sedation Scale.
47 Sedation Analgesia Propofol Benzodiazepines Opioids Patient Comfort Choose the Right DrugSedationAnalgesiaAmnesiaHypnosisAnxiolysisPropofolBenzodiazepinesOpioidsPatient Comfort-2 agonists
48 Sedation Options: Benzodiazepines (Midazolam and Lorazepam) Pharmacokinetics/dynamicsLorazepam: onset minutes, half-life 10 hours, glucuronidatedMidazolam: onset minutes, half-life 3 hours, metabolized by cytochrome P450, active metabolite (1-OH) accumulates in renal diseaseBenefitsAnxiolyticAmnesticSedatingRisksDeliriumNO analgesiaExcessive sedation: especially after long-term sustained usePropylene glycol toxicity (parenteral lorazepam): significance uncertain- Evaluate when a patient has unexplained acidosis- Particularly problematic in alcoholics (due to doses used) and renal failureRespiratory failure (especially with concurrent opiate use)Withdrawal
49 Benzodiazepines Onset Peaks Duration Diazepam 2-5 min 5-30 min >20 hrMidazolam2-3 min5-10 minminLorazepam5-20 min30 min10-20 hr
50 Sedation Options: Propofol Pharmacology: GABA agonistPharmacokinetics/dynamics: onset minutes, terminal half-life 6 hours, duration 10 minutes, hepatic metabolismBenefitsRapid onset and offset and easily titratedHypnotic and antiemeticCan be used for intractable seizures and elevated intracranial pressureRisksNot reliably amnestic, especially at low dosesNO analgesia!HypotensionHypertriglyceridemia; lipid source (1.1 kcal/ml)Respiratory depressionPropofol Infusion Syndrome- Cardiac failure, rhabdomyolysis, severe metabolic acidosis, and renal failure- Caution should be exercised at doses > 80 mcg/kg/min for more than 48 hours- Particularly problematic when used simultaneously in patient receiving catecholamines and/or steroids
53 Problems with Current Sedative Agents MidazolamPropofolOpioidsProlonged weaningX-Respiratory depressionSevere hypotensionToleranceHyperlipidemiaIncreased infectionConstipationLack of orientation and cooperation
54 Opiate and Benzodiazepine Withdrawal Frequency related to dose and duration32% if receiving high doses for longer than a weekOnset depends on the half-lives of the parent drug and its active metabolitesClinical signs and symptoms are common among agentsCNS activation: seizures, hallucinations,GI disturbances: nausea, vomiting, diarrheaSympathetic hyperactivity: tachycardia, hypertension, tachypnea, sweating, feverNo prospectively evaluated weaning protocols available% daily decrease in dose% initial decrease in dose with additional daily reductions of %Consider conversion to longer acting agent or transdermal delivery form
55 Withdrawal Withdrawal from preoperative drugs Sudden cessation of sedationReturn of underlying agitationHyperadrenergic syndromeHypertension, tachycardia,sweatingOpioid withdrawalSalivation, yawning, diarrhea
57 Sedation Options: Dexmedetomidine Alpha-2-adrenergic agonist like clonidine but with much less imidazole activityHas been shown to decrease the need for other sedation in postoperative ICU patientsPotentially useful while decreasing other sedatives to prevent withdrawalBenefitsDoes not cause respiratory depressionShort-actingProduces sympatholysis which may be advantageous in certain patients such as postop cardiac surgeryRisksNo amnesiaSmall number of patients reported distress upon recollection of ICU period despite good sedation scores due to excessive awarenessBradycardia and hypotension can be excessive, necessitating drug cessation and other intervention
58 Dosage Route of Administration and Dosage IV infusion parenteral injection, 100 mcg/mL in a 2 mL vial Sodium Chloride 0.9%AdministrationDiluted in 0.9% sodium chloride solution to achieve required concentration (4 mcg /mL) prior to administration. To prepare the infusion, withdraw 2 mL of Dexmedetomidine and add to 48 mL of 0.9% sodium chloride injection to a total of 50 mL.Intensive Care Unit SedationInitiation- Loading infusion of up to 1 mcg/kg over 10 to 20 minutes, if needed.Maintenance- Adults generally require a maintenance infusion of mcg/kg/hr.Conscious SedationClinically effective onset of sedation 10 to 15 minutes after start of infusionInitiation- Loading infusion of 1 mcg/kg over 10 minutes. For patients over 65 years of age or those undergoing less invasive procedures, a loading infusion of 0.5 mcg/kg over 10 minutes may be suitableMaintenance- Generally initiated at 0.6 mcg /kg/hr and titrated from 0.2 to 1 mcg/kg/hrFollowing the load in AFI, a fixed maintenance dose of 0.7 mcg/kg/hr is recommended until the ETT is secured.
59 Indications Intensive Care Unit Sedation Sedation of initially intubated and mechanically ventilated postsurgical patients during treatment in an intensive care setting by continuous intravenous infusion.It has been continuously infused in mechanically ventilated patients prior to extubation, during extubation, and post- extubation. It is not necessary to discontinue the drug prior to extubation.Conscious SedationSedation of non-intubated patients prior to and/or during surgical and other procedures by continuous intravenous infusion for the following procedures:Monitored Anaesthesia Care (MAC)Awake Fibreoptic Intubation (AFI)
60 Clinical Effects RESPIRATORY EFFECTS Minimal respiratory depressing effects0.17% incidence on monogramMost data suggests SaO2 and PaCO2 unaffected , Numerous reports during spont ventNON-CNS EFFECTSHypertension: peripheral 1-agonismBradycardia/hypotension: Sympathetic inhibition - medullary VMC shivering, Diuresis: renin, vasopressin; ANPPERIOPERATIVE OBSERVATIONS hypotension vs propofolBlunted tachycardia during controlled hypotension PACU analgesia requirementsBlunted catecholamine response: Potential importance with vascular procedures
61 Clinical Uses of Dex . Sedation in CT and MRI imaging studies Mason K, Ped Anesth 2008Koroglu A, Anesth Analg 2006Outpatient third molar surgeryUstin Y, J Oral Maxilfac Surg 2006Cheung C, Anaesthesia 2007Cataract surgeryAlhashemi J, Br J Anaest 2006Cardiac catheterizationTosun Z, J Card Vasc Anesth 2006Mester R, Am J Therap 2008GI ProceduresDemiraran Y, Can J Gastroenter 2007Dex may be a good alternative to midazolam for upper endoscopy61
62 Dex: Use in Sleep Apnea, Gastric Bypass Sleep Apnea PatientsAnesthesia considerationsMorbid obesity, at risk for aspirationDifficult IV accessSystemic + pulm HTN, cor pulmonalePostop airway obstruction + ventilatory arrest with anesthetic drugsDex: Anesthetic adjunct to minimize opioid + sedative useOgan OU, Plevak DJ: Mayo Clinic;Gastric Bypass Surgery PatientsMorbidly obese patients, Prone to hypoxemiaSleep apnea is common, Respiratory depression w opioidsDexmedetomidine, 0.1 to 0.7 ug/kg/hr, prospectively studied in 32 pts opioid use in dex group, pts more normotensiveCraig MG et al: IARS abstract, Baylor
63 Drug interactions Anesthetics, sedatives, hypnotics, opioids Co-administration of Dexmedetomidine with anesthetics, sedatives, hypnotics, and opioids is likely to lead to an enhancement of effects. Specific studies have confirmed these effects with sevoflurane, isoflurane, propofol, alfentanil, and midazolam.No pharmacokinetic interactions with isoflurane, propofol, alfentanil and midazolam have been demonstrated. However, a reduction in dosage of Dex or the concomitant anesthetic, sedative, hypnotic or opioid may be required.Neuromuscular Blockers- no clinically meaningful increases in the magnitudeCytochrome P-450- No evidence of cytochrome P450 mediated drug interactionsVagal effects- can be counteracted by atropine / glycoContraindicationsPatients who are hypersensitive to drug or to any ingredientCaution in pts with advanced heart block, severe ventricular dysfunction, shock
64 Adverse Reactions Adverse Drug Reaction Overview Serious adverse reactions: Hypotension, bradycardia and sinus arrest, Transient hypertensionMost common treatment-emergent adverse reactions, occurring in greater than 2% of patients include hypotension, bradycardia and dry mouth.Clinical Trial Adverse Drug ReactionsIntensive Care Unit Sedation: Hypotension, Hypertension, Nausea, Bradycardia, Fever, Vomiting, Atrial Fibrillation, Hypoxia, Tachycardia, Hemorrhage, Anemia, Dry Mouth, Rigors, Agitation, Hyperpyrexia, Pain, Hyperglycemia , Acidosis , Pleural Effusion, Oliguria , ThirstConscious Sedation: Hypotension , Hypertension , Respiratory depression, Hypoxia, Bradypnea, Bradycardia , Tachycardia , Nausea , Dry mouthPost-Market Adverse Drug ReactionsHypotension and bradycardia were the most common adverse reactions associated with the use during post approval use of the drug.
65 Patient Focused Sedation: Key Points Non-pharmacological measuresMinimize:Blood draws, X-raysBlood pressure measurements, Blood glucose measurementsDimming lights at night (sleep-wake cycle)Massage, therapeutic touch and music therapySelection of SedativesBenzodiazepines- Diazepam, Lorazepam, MidazolamPropofolDexmedetomidineHaloperidol, other neuroleptics
66 Patient Focused Sedation: Key Points Choose medications best suited to the patient’s characteristicsOrgan function and Drug metabolismRisk of side effectsSedation needs differ among patients and vary over timeTips to minimize sedationUse a sedation protocolIncorporate Daily Interruption of Sedation (DIS)Provide Analgesia Management FirstUse Newer Medications With Different PropertiesUse Other Non pharmacologic Interventions
67 Overview of SCCM Algorithm 1234Jacobi J, Fraser GL, Coursin D, et al. Crit Care Med. 2002;30:
69 Acute onset of mental status changes or a fluctuating course DeliriumAcute onset of mental status changes or a fluctuating course&2. Inattention3. DisorganizedThinkingor4. Altered level ofconsciousnessCourtesy of W Ely, MD
70 Risk Factors for Delirium Primary CNS DxInfectionMetabolic derangementPainSleep deprivationAgeSubstances including tobacco (withdrawal as well as direct effect)
71 Significance of ICU Delirium Seen in > 50% of ICU patientsThree times higher risk of death by six monthsFive fewer ventilator free days (days alive and off vent.), adjusted P = 0.03Four times greater frequency of medical device removalNine times higher incidence of cognitive impairment at hospital discharge
72 Treatment of DeliriumCorrect inciting factor, but as for pain…relief need not be delayed while identifying causative factorControl symptoms?No evidence that treatment reduces duration and severity of symptomsTypical and atypical antipsychotic agentsSedatives?Particularly in combination with antipsychotic and for drug/alcohol withdrawal deliriumNo treatment FDA approved
73 Case Scenario #122-year-old male with isolated closed head injury who was intubated for GCS of 7He received 5 mg of morphine, 40 mg of etomidate, and 100 mg of succinylcholine for his intubation.He is covered in blood spurting from an arterial catheter that was just removed, and he appears to be reaching for his endotracheal tube.What sedative would you use and why?What are the particular advantages in this situation?How could you avoid the disadvantages of this drug?
74 Case Scenario #1 - Answer Propofol will rapidly calm a patient who is displaying dangerous behavior without need for paralysis.Titratable and can be weaned quickly to allow for neurologic examCan treat seizures and elevated ICP which may be present in a head trauma with GCS of eight or lessMinimizing dose and duration will avoid side effects.
75 Case Scenario #254-year-old alcoholic who has been admitted for Staph sepsisIntubated in the ICU for seven days and is currently on midazolam at 10 mg/hourHis nurse was told in report that he was a “madman” on the evening shift.Currently, he opens his eyes occasionally to voice but does not follow commands nor does he move his extremities to deep painful stimulation.Is this appropriate sedation?What would you like to do?How would you institute your plan of action?
76 Case Scenario #362-year-old, 65-kg woman with ARDS from aspiration pneumoniaHer ventilator settings are PRVC 400, RR 18, PEEP 8, and FIO2 100%. She is dyssynchronous with the ventilator and her plateau pressure is 37 mm Hg.She is on propofol at 50 mcg/kg/min, which has been ongoing since admit four days ago.She is also on norepinephrine 0.1 mcg/kg/min and she was just started on steroids.What do you want to do next?Do you want to continue the propofol?Why or why not?What two iatrogenic problems is she likely at risk for?
77 Case Scenario #3 - Answer This patient needs optimization of her sedatives, and potentially chemical paralysis to avoid complications of ventilator dyssynchrony and high airway pressures.If you continue to use propofol, higher doses are required and the patient is already on norepinephrine. In addition, if paralysis is used, you do not have reliable amnesia.She is at risk for propofol infusion syndrome and critical illness polyneuropathy.