1. LOGO Sedation in the ICU Prof. Bahaa Ewees Ain Shams University

2. Contents Definition of Sedation 1 Importance of Sedation in the ICU 2 Monitoring of Sedation 3 Mode of Sedation 4 Examples of Sedation Protocol 5 Delivery of Sedation 5

3.  Sedation: depression of awareness and reduction of the response to external stimuli Definition of Sedation 1

4.  Plays a vital role in the care of critically-ill patients and encompasses wide spectrum of symptom management.  Heavy sedation is used to facilitate ETT insertion and M.V. (replacing NMBA) Importance of Sedation 2

5. Monitoring of Sedation 3 Done Hourly To avoid: Under- Sedation Heavy Sedation ↑ catecholamines  Coagulopathy and Immune Suppression * ↑ duration of ICU stay and M.V. * Side Effects of sedationdrug

6. Monitoring of Sedation 3 1. Scoring Systems 2. Instrumental BIS EEG

7. Mode of Sedation 4 Non Pharmacological Pharmacological

8. Mode of Sedation 4 Non Pharmacological 1.Continuous communication with the patient 2.Good Hydration 3.Good Nutritional Support 4.Physiotherapy Ve………..ry Important

9. Mode of Sedation 4 Pharmacological A.Drugs used for Induction of Anaesthesia B.Benzodiazepines C.Neuroleptic Agents D.Opioids E.Clonidine and Dexmedetomedine

10. Pharmacological A.Drugs used for Induction of Anaesthesia A.Propofol  Widely used due to high clearance and metabolism.  Dose: 0.5 – 4 mg/kg/h.  Problems  ↓ HR  ↓ BP  Propofol Infusion Syndrome

11. Pharmacological  Rare  Manifestations  ↓ pH  Arrhythmias  Cardiovacular collapse  Acute renal Failure  Hyperkalaemia  Risk factors  Sepsis  Severe Cerebrovascular Stroke  High propofol doses (> 5 mg/kg/h.)

12. Pharmacological  Propofol Infusion Syndrome (cont.)  Recommendations  Once suspected, stop infusion  Dose should be < 4mg/kg/h.  Duration should be less than 24 h.  Daily monitoring of triglyceride levels and renal function.

13. Pharmacological A.Drugs used for Induction of Anaesthesia B. Thiopental  used by infusion (for status epilepticus to control convulsions)  Problems:  Low clearance  Metabolized by redistribution  Myocardial depression  Accumulation

14. Pharmacological A.Drugs used for Induction of Anaesthesia C. Etomidate  Infusion OnlyBUT, ↓↓↓↓ adrenocortical function

15. Pharmacological A.Drugs used for Induction of Anaesthesia D. Ketamine  Can be used for intubation in the ICU  Sedation especially in asthmatic patient  BUT, ↑↑ CMRO 2, Delirium, and hallucination

16. Pharmacological B.Benzodiazepines  Acting on GABA receptors (the main inhibitory neurotransmitter in CNS) 1.Midazolam  Metabolized in liver to active metabolite  Highest clearance among BZs  Suitable for infusion (0.04 – 0.2 mg/kg/h.) 2.Diazepam  Metabolized to active metabolite by liver  Lowest clearance among BZs  Suitable for oral use or bolus injection (2- 10 mg)

17. Pharmacological C.Neuroleptic Agents  Haloperidol or Chloropromazine  Used for delirium and psychosis in the ICU  Can cause:  Respiratory depression  Prolonged QT interval  Arrhythmias

18. Pharmacological D.Opioids  Provide analgesia and anxiolysis  Better used by infusion  Remifentanil (ultrashort acting opioid)  0.1 – 0.15 ug/kg/min.

19. Pharmacological E.Clonidine and Dexmedetomedine  Alpha 2 Agonists  Can be used for sedation in both spontaneous and mechanically ventilated patients.  Dexmedetomedine is  more potent than clonidine  Shorter elimination t 1/2  So, it is widely used nowadays for sedation

20. Delivery of Sedation 5 Intermittent Injection Bolus Injection Infusion Constant Level of sedation 1 Less chance Of Intermittent agitation 2

21. Delivery of Sedation 5 Sedation Holiday  Stopping the sedation infusion and allowing the patient to awake.  Restarted once:  Patient fully awake and obeying commands, or  Patient becoming agitated or uncomfortable  Should be done on a daily basis!  This strategy  ↓ duration of MV and Length of stay in ICU.

22. Example of Sedation Protocols 6 Short term therapy < 72 h. Hemodynamically stable?YES * Propofol infusion * Opioid - Remifentanil - Fentanil NO * Alfentanil infusion If necessary consider propofol infusion.

23. Example of Sedation Protocols 6 Long-term therapy > 72 h. CONSIDER 1. Opioid - morphine infusion - Alfentanil infsion (if Renal failure) 2. Benzodiazepine

24. LOGO