Sedation and Delirium Management Medical Surgical Nursing II Urden Chapter 9

Goals of Sedation and Delirium Management “The goal is to find a balance between providing compassionate patient care and avoiding the perils of over-sedation” (Urden, 2012, p. 95). What could cause anxiety or agitation in a critical care environment?

Sedation Scales Scoring systems to assess sedation are strongly recommended. Why Individuals do not metabolize sedative medications at the same rate. Use of a standardized scale can ensure that continuous infusions such as proprofol or lorazepam are titrated to a specific goal. Use of scales can be used for medications given prn to assess response and patient comfort. Four sedation scales – Ramsey scale, Riker Sedation – Agitation Scale (SAS), Motor Activity Assessment Scale (MASS), Richmond Agitation-Sedation Scale (RASS). Scales on pp. 96 compare them. The First step in assessing agitation is to rule out pain.

Complications of sedation “State of unintended patient unresponsiveness in which the patient resides in a state of suspended animation similar to general anesthesia” Prolonged deep sedation is associated with complications of Pressure ulcers Nosocomial pneumonia Thromboemboli Delayed weaning from Gastric ileus mechanical ventilation

Levels of Sedation Light sedation – Drug induced state in which patients respond ________ to ___________commands. Impaired function includes: Unaffected functions: What meds might be used here? What situations?

Moderate Sedation Also used as another name for: Defined: Patients respond to _______commands. Or will respond to _______ ________ Commands. No interventions are required to maintain:

Deep Sedation and Analgesia Drug induced depression of consciousness during which the patients cannot be _______ _______________. Respond purposefully after repeated or ____________stimulation. Independent ventilatory function is: Assistance is required to maintain:

General anesthesia Drug induced loss of consciousness Not arousable even w/painful stimulation Airway and ventilation are impaired Assistance is required, usually intubation is required with ventilation Total loss of protection Patient is total care

Perils of Undersedation Self extubation with complications of : Bronchospasm, aspiration, dysrhythmias, bradycardia and death related to the inability to establish a patent airway. 6% who extubate themselves have significant complications: Share the story of the patient who extubated himself, bariatric patient who was unable to be reintubated eventually died even after a tracheostomy.

Pharmacological Management with sedation Sedation must always be preceded or accompanied by analgesia if there is a mechanism of pain or suspicion of pain being experienced. Review algorithm on pp. 97 for ventilated patients. Take 5 minutes for drug cards on Benzodiazepines : diazepam, lorazepam, midazolam Sedative-Hypnotics: Propofol Neuroleptics: Haloperidol

Benzodiazepines Powerful amnesic properties Inhibit reception of new sensory information Do not give pain relief Most frequently used are: Which one is used for acute, short term agitation? All are strong amnesics, but no analgesia. All have dose related respiratory depression and hypotension as side effects. Romazicon ( flumazenil) is antidote, but careful in dependent patients (sz). Valium, versed and ativan Acute short term agitation – versed, (midazolam), onset of action is 3 minutes (active metabolites so long term sedation is prolonged) For long term sedation on ventilated patients – lorazepam infusion (but risk of increased delirium long term)

Benzodiazepines Which drug is used for long term sedation? Why is it preferred over the other? What are the major side effects of these medications? The antidote is: What must be considered before an antidote is given? Ativan is preferred over versed because metabolites are formed by versed after 24 hours which produces prolonged sedation. Hypotension and respiratory depression. Most often these patient’s are intubated, and these medications must be weaned to a degree to allow the patient the opportunity to maintain their own airway. Romazicon Long term dependence.

Sedative-Hypnotics Propofol – sedative/hypnotic and general anesthetic agent. In the critical area and in the emergency room it is used as a method to ensure sedation after intubation. Delivered as a continuous infusion at the rates of 5 to 80 mcg/kg/min. Benefit to remember: Is a sedative/hypnotic w/ rapid onset of action within 30 seconds, short half life 2 to 4 minutes with initial use. This is prolonged with continuous use. Rapid elimination from the body 30 to 60 minutes. Used in high doses in OR, lower doses of infusion on ventilated patients for deep sedation. Milky white, always a glass container and own IV line.

Propofol does not Provide amnesia Pain relief So it must be given along with other medications to provide the patient with these medication actions. Other medications to give with this drug are fentynl, morphine, versed ( amnesia).

Side effects to manage with Propofol Hypotension – How would you manage this problem Hyperlipidemia in long term use Infection related to high fat content Pancreatitis Propofol Related infusion syndrome PRIS Most common in children Metabolic acidosis Rhabodmyolysis Acute kidney failure Dysrhythymias Propofol is in a fat based emulsion, leads to the complications above from disruption of fatty acid metabolism. Monitor for hyperlipidemia, triglycerides, pancreatitis* labs Decrease inclination of the head of the bed if safe. Reassess - Hypotension – administer 250 ml normal saline fluid boluses, titrate dose to maintain sedation but maintain the blood pressure as well. Tubing must be changed every 12 hours with aseptic technique.

Propofol Infusion Things to remember Dedicated line Do not mix with other drugs if possible otherwise check compatibility Certain IV fluids cannot be given with proprofol Monitor serum triglyceride levels Calories from propofol are calculated into daily calorie counts. MUST have protected airway prior to giving it, why?

Central Alpha Agonists Dexmedetomidine or Precedex Approved for continuous infusion for less than 24 hours in mechanically ventilated patients. Confers sedation and analgesic effects without respiratory depression. Loading dose is 1.0 mcg/kg over 10 minutes Continuous infusion is range 0.2 to 0.7 mcg/kg/hour. 24 hours

Central Alpha Agonists Precedex Onset of action: Elimination from the body: What condition decreases Precedex elimination from the body? Onset of action – give over 10 minutes In a normal patient 2 hours In the setting of liver failure, elimination is delayed significantly

Things to Remember Choice of sedative is highly specific to the patient and the situation Short term sedation - < 24 hours most frequently used sedatives are _______ & Propofol. Both drugs should or may be combined with a short-acting opiod analgesic which is ____________ or ______________.

Things to remember For long term sedation the recommended agent is? Precedex Versed Lorazepam Morphine Fentynl Lorazepam – long term sedation has no active metabolites. Versed is for short term sedation, but it does have have problems with long term use due to active metabolites. Precedex is recommended for short term sedation, it has an advantage of having analgesic effects.

Preventing sedative dependence and withdrawal Why this occurs? Critically ill patients are often sedated and mechanically ventilated are seriously ill for weeks or months. With time physical and psychological dependence occurs. What are the symptoms of sedative dependence and withdrawal? Agitation, tachycardia, increased blood pressure, and respiratory rate. Lack of self awareness, unawareness of surroundings, short term memory only, irritability, anxiety, confusion, delirium and even seizures. Patients may pull at tubes, attempt to climb out of bed, represent a danger to themselves.

Sedation vacation Strategy to avoid the pitfalls of sedative dependence and withdrawal is a planned strategy to turn off the sedation infusion once a day. Shortens time to extubation Back up plan is needed for patients who do not tolerate the procedure. The goal is to allow the stable patient to regain consciousness for clinical assessment – what would you use? May shorten time to extubation, patient must be hemodynamically stable to try this. Each hospital will have a protocol including which drugs stopped and order to restart sedation.

Nursing Care Responsibility Ongoing assessment of the patient’s level of consciousness to avert complications. If the patient is severely agitated, consult with the physician it is vital to consult with the physician and pharmacist to establish and effective treatment plan. Often the sedation is restarted at 50% of the previous morning dose and titrated upward for patient comfort.

Delirium Global impairment of cognitive processes Sudden onset Coupled with disorientation Impaired short-term memory Altered sensory perception(manifests as?) Inappropriate behavior Estimated 60-85% of ventilated patients have delirium at some point. Increases hospital stay and mortality rates. Caused by acute brain dysfunction from sepsis, organ dysfunction or critical illness.

Delirium Occurs in 60% to 85% among mechanically ventilated patients. Delirium is often identified in the patient who is agitated and pulling at tubes. Delirium can occur in patients who are physically calm. Provision of adequate _________is an essential component of delirium prevention. Specific scoring tools for delirium, used in conjunction with RASS, can be used verbal or nonverbal.

Management of Delirium with Medication Priority – medication selection of drugs that provide sedation without withdrawal associated agitation. Which drug is discussed by Urden as a plausible choice? What type of delirium is this medication used for? Haldol for hyperactive delirium

Monitoring Requirements Use of this drug requires _____ monitoring due to the prolongation of the QT interval which increases the risk of ventricular dysrhythmias. Stabilizes cerebral function by blocking transmission of ______mediated neurotransmitters at the cerebral synapses and in the basal ganglia. ECG Dopamine. Extrapyramidal symptoms can occur w/Haldol, use anticholinergic to treat.

Nonpharmacological interventions to prevent delirium These methods are similar to those used to relieve pain Back massage Music therapy Noise reduction Decreasing lights at night Clustering nursing care interventions Uninterrupted rest Speaking in a calm and gentle voice.

AWS & Delirium Tremens Patients w/alcohol dependency & critically ill are at risk for alcohol withdrawal syndrome and DT’s. AWS assoc w/increased risk of delirium, hallucinations, seizures, need for mechanical ventilation and death Delirium Tremens- when hyperactive agitated delirium is caused by alcohol withdrawal As an alcohol dependent patient blood alcohol level falls, AWS symptoms appear in 50%.. But less than 5% experience DT’s or severe complications. Alcohol withdrawal must be managed – observe for agitation, use benzos (Valium or Ativan). Because valium is lipid soluble it passes through blood-brain barrier quickly, enters the CNS and produces sedation faster. Multivitamins (banana bag) administered. ** Delirium related to alcohol withdrawal is tx differently than delirium from other causes** Benzos are not used in tx of delirium from other causes (Haldol/neuroleptic). Review table pp. 103