3SedationRelieve pain, decrease anxiety and agitation, provide amnesia, reduce patient-ventilator dysynchrony, decrease respiratory muscle oxygen consumption, facilitate nursing care.May prolong mechanical ventilation and increase costs.
4Goals of Sedation Old- Obtundation New- Sleepy but arousable patient Almost always a combination of anxiolytics and analgesics.
5What is Agitation? Pain Anxiety Delirium Fear Sleep deprivation Patient-ventilator interactionsEncephalopathyWithdrawalDepressionICU psychosis
6BenzodiazepinesAct as sedative, hypnotic, amnestic, anticonvulsant, anxiolytic.No analgesia.Develop tolerance.Synergistic effect with opiates.Lipid soluble, metabolized in the liver, excreted in the urine.Interact with erythro, propranolol, theo
7Benzodiazepines Diazepam (Valium) Lorazepam (Ativan) Repeated dosing leads to accumulationDifficult to use in continuous infusionLorazepam (Ativan)Slowest onset, longest actingMetabolism not affected by liver diseaseMidazolam (Versed)Fast onset, short durationAccumulates when given in infusion >48 hours.
9Propofol Sedative, anesthetic, amnestic, anticonvulsant Respiratory and CV depressionHighly lipid solubleRapid onset, short durationOnset <1 min, peak 2 min, duration 4-8 minClearance not changed in liver or kidney disease.
10Propofol- Side effects Unpredictable respiratory depressionUse only in mechanically ventilated patientsHypotensionFirst described in post-op cardiac patientsIncreased triglycerides1% solution of 10% intralipidsDaily tubing changes, dedicated port
11Butyrophenones Haldol Anti-psychotic tranquilizer Slow onset (20 min) Not approved for IV use, but is probably safeNo respiratory depression or hypotension.Useful in agitated, delirious, psychotic patientsSide effects- QT prolongation, NMS, EPS
12Sedation studies Propofol vs. midazolam Similar times to sedation, faster wake-up time with propofol AJRCCM, 15:1012, 1996.Nursing implemented sedation protocol duration of mech vent, ICU stay, trach rate Crit Care Med 27:2609, 1999.Daily interruption of sedation duration of mech vent, ICU LOS, hosp LOS NEJM 342:1471, 2000.
13Monitoring Sedation Many scoring systems, none are validated. Ramsey 1: Anxious, agitated, restless2: Cooperative, oriented, tranquil3: Responds to commands4: Asleep, brisk response to loud sounds5: Asleep, slow response to loud sounds6: No response
14Pain in the ICU Pain leads to a stress response which causes: CatabolismIleusADH releaseImmune dysregulationHypercoaguable stateIncreased myocardial workloadIschemia
15Pain in the ICU What causes pain in the ICU? Lines Tubes Underlying illnessInterventionsEverything else
16Analgesics Relieve Pain Opioides Non-opiodes Can be given PRN or continuous infusionPRN avoids over sedation, but also has peaks and valleys and is more labor intensive.
17Opiodes Metabolized by the liver, excreted in the urine. Morphine- Potential for histamine release and hypotension.Fentanyl- Lipid soluble, 100X potency of MSO4, more rapid onset, no histamine release, expensive.Demerol- Not a good analgesic, potential for abuse, hallucinations, metabolites build up and can lead to seizures.
19Non-opiodesKetamineAnalog of phencyclidine, sedative and anesthetic, dissociative anesthesia.Hypertension, hypertonicity, hallucinations, nightmares.Potent bronchodilator
20Non-opiodes Ketorolac NSAID Limited efficacy (post-op ortho) Synergistic with opiodesNo respiratory depressionIncreased side effects in the critically illRenal failure, thrombocytopenia, gastritis
21Paralytics Paralyze skeletal muscle at the neuromuscular junction. They do not provide any analgesia or sedation.Prevent examination of the CNSIncrease risks of DVT, pressure ulcers, nerve compression syndromes.
22Use of Paralytics Intubation Facilitation of mechanical ventilation Preventing increases in ICPDecreasing metabolic demands (shivering)Decreasing lactic acidosis in tetanus, NMS.
26Complications of Paralysis Persistent neuromuscular blockadeDrug accumulation in critically ill patientsRenal failure and >48 hr infusions raise riskIn patients given neuromuscular blockers for >24 hours, there is a 5-10% incidence of prolonged muscle weakness (post-paralytic syndrome).
27Post-paralytic syndrome Acute myopathy that persists after NMB is goneFlaccid paralysis, decreased DTRs, normal sensation, increased CPKs.May happen with any of the paralyticsCombining NMB with high dose steroids may raise the risk.
28Monitoring Paralysis Observe for movement Twitch monitoring, train of four, peripheral nerve stimulation.
29Shock Hypoperfusion of multiple organ systems. May present as tachycardia, tachypnea, altered mental status, decreased urine output, lactic acidosis.Not all hypotension is shock and not all shock has hypotension.
30Shock Rapidity of diagnosis is key. The types: Hypovolemic/ hemorrhagicCardiogenicHigh outputFluid bolus is almost always the correct initial therapy.
34Dopamine“Renal dose” dopamine probably only transiently increases u/o without changing clearance.There are better b and a agents.Adverse effects- tachyarrhythmias .
35Dobutamine (Dobutrex) Primarily b1, mild b2.Dose dependent increase in stroke volume, accompanied by decreased filling pressures.SVR may decrease, baroreceptor mediated in response to SV.BP may or may not change, depending on disease state.
37Dobutamine Useful in right and left heart failure. May be useful in septic shock.Dose mcg/kg/min.Adverse effects- tachyarrhythmias.
38Isoproteronol (Isuprel) Mainly a positive chronotrope.Increases heart rate and myocardial oxygen consumption.May worse ischemia.
39PDE Inhibitors Amrinone, Milrinone Positive ionotrope and vasodilator. Little effect on heart rate.Uses- CHFAE- arrhythmogenic, thrombocytopeniaMilrinone dosing- 50mcg/kg bolus, mcg/kg/min infusion.
40Epinephrine b at very low doses, a at higher doses. Very potent agent. Some effects on metabolic rate, inflammation.Useful in anaphylaxis.AE- Arrhythmogenic, coronary ischemia, renal vasoconstriction, metabolic rate.
41Norepinephrine (Levophed) Potent a agent, some bVasoconstriction (that tends to spare the brain and heart).Good agent to SVR in high output shock.Dose 1-12 mcg/minCan cause reflex bradycardia (vagal).
42Phenylephrine (Neosynephrine) Strong, pure a agent.Vasoconstriction with minimal in heart rate or contractility.Does not spare the heart or brain.BP at the expense of perfusion.
43Ephedrine Releases tissue stores of epinephrine. Longer lasting, less potent than epi.Used mostly by anesthesiologists.5-25 mg IVP.
44Vasopressin Vasoconstrictor that may be useful in septic shock. Use evolving to parallel hormone replacement therapy.0.4 units/min
45Nitroglycerine Venodilator at low doses (<40mcg/min) Arteriolar dilation at high doses (>200 mcg/min).Rapid onset, short duration, tolerance.AE- inhibits platelet aggregation, ICP, headache.
46Nitroprusside (Nipride) Balanced vasodilatorRapid onset, short elimination timeUseful in hypertensive emergency, severe CHF, aortic dissectionAccumulates in renal and liver dysfunction.Toxicity= CN poisoning (decreased CO, lactic acidosis, seizures).
48Labetolol (Normodyne) a1 and non-selective b blocker.Dose related decrease in SVR and BP without tachycardia.Does not ICPUseful in the treatment of hypertensive emergencies, aortic dissection.Bolus= 20mg, infusion= 2mg/min.