0. ABCDE implementation at BHCS
Susan Smith, MS, RN, ACNS-BC
Clinical Nurse Specialist
Baylor University Medical Center
Critical Care Services

3. Sedation vacation and Spontaneous Breathing Trials

6. Awakening Trial Safety Screen (BUMC criteria)
NO FiO2 ≥ 0.6
NO PEEP > 7.5 cm
NO neurosurgical pts.
NO ICP > 10 cm H2O
NO HR > 140 bpm
NO neuromuscular blocker
NO open surgical abdomen/chest
NO active seizures
NO active ETOH withdrawal
NO active agitation
NO myocardial ischemia within the past 24 hours
Hold analgesic / sedation for continuous infusion 2 times daily. May supplement with prn analgesic / sedative if ordered.

7. Sedation Restarting Criteria
If patient develops any of the symptoms below, resume infusion at HALF of the previous rate prior to sedation vacation
Agitated or combative
O2 saturation falls below 90%
Respiratory Rate is 40 or above
Worsening dyspnea
If these symptoms persist, contact the physician
Be sure to have prn bolus orders for pain and sedation before beginning SAT/sedation vacation

8. Spontaneous Breathing Trial Safety Screen (BUMC)
No vasopressors, HD stable
No active agitation
No FiO2 ≥ 0.6
No RR ≥ 40
No worsening dyspnea
If these symptoms present contact physician
Breathing Trial
Patient awake and able to follow 3 of 4 commands:
Opens eyes with verbal command
Points 2 fingers upon instruction
Tracks caregiver
Sticks tongue out on command
Place patient on
CPAP cm H2O

9. Spontaneous Breathing Trial
Discontinue SBT and resume prior vent settings for:
RR > 35 or < 8 x 5 minutes or longer
SpO2 < 90% x 5 minutes or longer
Acute cardiac arrhythmia
HR > 130 or < 60
Accessory muscle use
Abdominal paradoxical breathing
Diaphoresis
Marked dyspnea

10. Spontaneous Breathing Trial
If SBT successful measure:
RR and TV (more parameters may be requested)
Call physician after 30 minutes of the trial

11. Critical Care Flowsheet

12. Patient Care Viewer

13. Improvement Strategies
People
RN, RT, MD
Others: Pharmacist
Process
Adult Ventilator Orderset
Multidisciplinary Rounds
Daily Vent Mortality Data collection
How do we get this data to match up with our documentation?
Technology
EHR
DART reports

14. Choice of Sedative

15. Treatment of Pain Opiate IV PO IV Onset (min) Half-life (hours)
Fentanyl
0.1 --
1-2
2-4
Hydromorphone
1.5
7.5
5-15
2-3
Morphine 10 30
5-10
3-4

16. Treatment of pain with IV medications
Opiate
Intermittent dosing
IV infusion rate
Other information
Fentanyl
mcg/kg
25-100mcg
mcg/kg/hr
25-250mcg/hr
Most lipophillic, accumulation w/ liver dysfunction
Hydromorphone mg
0.5-3 mg/hr
May be better in patients tolerant to other agents
Morphine
2-4 mg
2-30 mg/hr
Active metabolites, histamine release

17. Opioid related side effects
Sedation
Muscle rigidity
Respiratory depression
Decrease GI mucus secretion and increase fluid absorption
Nausea, vomiting
Pruritus
CONSTIPATION

18. Adjunctive pain agents
Local and regional anesthetics
Ketamine
Acetaminophen
NSAIDS
Gabapentin or pregabalin
Carbamazepine
Non-pharmacological management strategies

19. Indications for sedation
Treat agitation
Promptly identify underlying causes
Delirium, pain, hypoxemia, hypoglycemia, hypotension, alcohol withdrawal
Titration of sedation to light and arousable
Sedation scales and protocols have reduced the amount of sedation patients receive and improve outcomes

20. Benzodiazepines Activate GABA-A receptors in the brain
Anxiolytic, amnestic, sedating, hypnotic, and anticonvulsant effects
Potency: Lorazepam > Midazolam > Diazepam
Lipophilicity: Midazolam and Diazepam > Lorazepam
All BDZs are metabolized hepatically
Caution in elderly patients
Lorazepam, oxazepam, and temazepam are renally cleared

21. Benzodiazepines Agent Onset (min) Half life (hours) Active metabolites
IV infusion rate
Midazolam
2-3
3-11
Yes
1-7 mg/hr
Lorazepam
15-20
8-15 No
1-10 mg/hr
Diazepam
2-5
20-120
Not used

22. Propofol Exact mechanism is not known
Binds to GABA-A, glycine, nicotinic, and muscarinic receptors
Sedative, hypnotic, anxiolytic, amnestic, antiemetic, and anticonvulsant
No analgesic properties
Highly lipid soluble
Best for patients who need frequent awakenings
Caution with egg and soybean allergies

23. Propofol
Agent
Onset (min)
Half life (hours)
Active metabolites
IV infusion rate
Propofol
1-2
3-12 No
5-50 mcg/kg/min
Adverse effects: hypertriglyceridemia, acute pancreatitis, myoclonus, hypotension
Propofol infusion syndrome: metabolic acidosis, hypertriglyceridemia, hypotension with vasopressor use, arrhythmias, acute kidney injury, hyperkalemia, rhadbomyolysis

24. Dexmedetomidine Selective alpha 2 receptor agonist
Sedative, sympatholytic, and questionable analgesic properties
Generally patients are more easily arousable with minimal respiratory depression
Hepatically cleared
Adverse effects: hypotension, bradycardia
Agent
Onset (min)
Half life (hours)
Active metabolites
IV infusion rate
Dexmedetomidine
5-10
1-3 No
mcg/kg/min

25. What should I do to prepare for a sedation vacation?
Evaluate your flowsheet checklist
If patient doesn’t meet requirement, ask for clarification on multidisciplinary rounds
The most important tool you can have for a sedation vacation is PRN pain and sedative agents. Why???
If a patient fails vacation and patient isn’t going to be extubated you will need PRN agents to get them under control and to prevent dose titrations beyond their requirements.

26. What about precedex?
This agent is typically ordered when preparing for extubation
Purpose of precedex is to allow the pt to remain calm and compliant with the ventilator without lowering respiratory drive
Allow the patient to prove that he/she needs the agent when the other sedatives are stopped

27. How do I handle a sedation vacation when the patient is already on precedex?
90 percent of the time, it is appropriate to keep this agent going
If the patient is only on precedex and they are overly drowsy, they may not require this agent to remain calm for extubation, consider stopping
It is not wrong to pause this agent, in fact, the ideal patient would remain calm with no agent on board.
If patient has had a h/o agitation and this was the reason for starting the agent, another appropriate method would be to titrate down to minimal requirements during the “sedation vacation”
Once the patient is extubated, stop the agent.
If agitation occurs after extubation, clarify with MD what agent to use. In general we will use other agents after extubation to assist the patient in remaining calm

28. The patient failed the trial, how do I proceed
Is the patient acutely in pain?
Give PRN Pain agent (fentanyl, dilaudid, morphine, norco, etc)
Is the patient acutely agitated?
Give PRN Sedative agent (ativan, versed)
If patient was on propofol gtt
What rate to I set my drips at?
Regardless of agitation or not, restart at half the rate!
Utilize PRN pushes to support the patient through the agitation/pain period
If more than one push is required, then titrate up the agent
Let the patient prove they need more agent
Always titrate to calmness, while trying to maintain the highest level of alertness unless MD order specifies otherwise

29. What if my patient is fully alert on their sedation?
Stop the agent and do a sedation vacation.
Let them prove they need the agent to remain calm
The agent may be frivolous at that point…why give something they do not need?
It is never wrong to ask for clarification, but the majority of the time your answer will be to stop the agent
Remember, the ideal patient is the one tolerating the ventilator without any continuous infusion on board. Ideally we would have no gtts and utilize PRN agents to support them through acute pain and agitation

30. What if my patient is complaining of pain, should I stop the agent?
If your pt is alert and complaining of pain, then get a clarification from the MD.
We do not want to cause pain that would increase respirations and thus negatively impact their ability to be extubated.
The patient may qualify for a transition to longer acting oral agents to control pain
If they aren’t alert and unable to verbalize their pain, then stop the agent.
Let them prove to you they need the pain medication

31. HF is a 60 yoF on a ventilator now for 3 days
HF is a 60 yoF on a ventilator now for 3 days. Her current regimen is Fentanyl 3mcg/kg/hour and Versed 5mg/hour. She qualifies for a sedation vacation so Sally stops the Versed.
Has she done the correct thing?
What recommendations would you make?

32. HF is a 60 yoF on a ventilator now for 3 days
HF is a 60 yoF on a ventilator now for 3 days. Her current regimen is Fentanyl 3mcg/kg/hour and Versed 5mg/hour. She qualifies for a sedation vacation. After your brilliant education, Sally stops both the fentanyl and versed. However an hour later the patient starts fighting the ventilator and requires reinitiating the patient’s pain and sedation regimen.
How should she proceed with reinitiating the pain and sedation on this patient?

33. MM is a 50 yoM on a ventilator for 7 days
MM is a 50 yoM on a ventilator for 7 days. He was initiated on precedex 0.5mcg/kg/hour yesterday after his propofol was stopped and he became agitated. He is also on fentanyl at 1mcg/kg/hr. He meets requirements for a sedation vacation.
What other information do you need before deciding how to proceed?
If he is in pain how would you proceed?
If he is drowsy how would you proceed

34. Improvement Strategies
Provide more in depth drug information to super trainers to be able to better support staff nurses during the SAT/SBT process
Encourage use of pharmacists to help with guidance
Encourage good communication
Daily multidisciplinary rounds to discuss patient progress
Review of documentation daily
Daily vent mortality data collection
Does this match your documentation?

35. Delirium screening and management

36. …seems like it was in a huge, empty gray space, sort of like a monstrous underground parking garage with no cars, only me, floating or seeming to float, on something…
-SB
Travis Smith via Flickr

38. Sarah Beth tells her story

39. Confusion Assessment Method for the ICU (CAM-ICU)
Feature 1: Acute change or fluctuating course of mental status
And
Feature 2: Inattention
And
Feature 3: Altered level of consciousness
Feature 4: Disorganized thinking Or
Inouye, et. al. Ann Intern Med 1990; 113:
Ely, et. al. CCM 2001; 29:
Ely, et. al. JAMA 2001; 286:

40. Step 1: Sedation Assessment (RASS)
Sessler CN, AJRCCM 2002;166:
Ely EW, AJRCCM 2001;163:A954

41. Step 2: Content Assessment
Assess For Delirium With the
CAM-ICU

43. Feature 1: Alteration/Fluctuation in Mental Status
Is the pt different than his/her baseline mental status? or
Has the patient had any fluctuation in mental status in the past 24 hours (e.g. fluctuating RASS, GCS, previous delirium assessments, etc)
The Feature is Present if either question is YES.

44. Screening for Attention– two options
Feature 2: Inattention
Screening for Attention– two options
Inattention Present: If >2 errors
Letter “A” test
Letters: S A V E A H A A R T
Say 10 letters and instruct the patient to squeeze on the letter “A”
Pictures
Similar test with pictures
(instructions are in picture packets)

45. Feature 3: Altered Level of Consciousness
You already did this assessment when you did the RASS. It was the first thing you did when you walked in the room!
If the Actual RASS score is anything other than “0” (zero) and alert, then altered LOC is Present

46. Teaching Point
It is only necessary to proceed to Disorganized Thinking when a patient is Feature 2 positive (Inattentive) and Awake and Alert (RASS 0) at the time of CAM-ICU evaluation.

47. Feature 4: Disorganized Thinking
Yes/No Questions (Use either Set A or Set B) :
Set A Set B
1. Will a stone float on water? Will a leaf float on water?
2. Are there fish in the sea? Are there elephants in the sea?
3. Does one pound weigh more than Does two pounds weigh
two pounds? more than one pound?
4. Can you use a hammer to pound a nail? Can you use a hammer to cut wood?
Note: Use whatever form of communication that works (nodding, hand squeezing, blinking, etc).

48. Feature 4: Disorganized Thinking
Command
Say to patient: “Hold up this many fingers” (Examiner holds two fingers in front of patient) “Now do the same thing with the other hand” (Not repeating the number of fingers).
Patient gets credit only if able to successfully complete the entire command.

49. CAM-ICU FAQs Patient with severe depression: Patient with dementia:
May result in a false positive—consult psych
Patient with dementia:
CAM-ICU reliable in both groups of patients
Patients can have both
Assessment is more difficult, must know the baseline

50. CAM-ICU FAQs Neuro patients e.g. stroke, TBI, disease, SDH, SAH
This may represent the patient’s new baseline
Look for fluctuation
Are there structural neurologic changes?
Are there reversible causes of delirium?
Use last know baseline and adjust as more info is obtained
Alterations and fluctuations include those caused by us from sedatives etc.

51. CAM-ICU FAQs ETOH withdrawal Tetraplegia or Blind Can be CAM-ICU ⊕
Also do CIWA-Ar
Tetraplegia or Blind
Score Feature 4 on just the questions
Cannot make more than 1 error

52. Delirium Management

53. SCCM recommended approach to management of delirium
Identify etiology
Identify risk factors
Consider pharmacologic treatment
So: STOP & THINK before you medicate
Jacobi J, et al. Crit Care Med 2002;30:

54. Risk Factors for Developing Delirium
Age
Sensory impairment
History of dementia, ETOH, smoking, depression
Malnutrition
Disease processes
Polypharmacy and psychotropic meds
Renal/liver impairment
Dehydration
Sleep deprivation
Restraints/lines/tubes
Excessive noise
Day/night disorientation
Constipation
Any patient with these problems should be flagged as high risk for delirium

55. Ambien
Consult pharmacy for patients with these drugs who are at high risk for delirium or patients who have delirium.

56. Consider antipsychotics after evaluating etiology & risk factors
Stop and THINK
Do any meds need to be stopped or lowered?
Especially consider sedatives
Is patient on minimal amount necessary?
Daily sedation cessation
Targeted sedation plan
Assess target daily
Do sedatives need to be changed?
Remember to assess for pain!
Toxic Situations
CHF, shock, dehydration
New organ failure (liver/kidney)
Hypoxemia
Infection/sepsis (nosocomial), Immobilization
Nonpharmacologic interventions
Hearing aids, glasses, reorient, sleep protocols, music, noise control, ambulation
K+ or electrolyte problems
Consider antipsychotics after evaluating etiology & risk factors

57. Standardized Intervention
Elder Life Program
Targeted Risk Factor
Standardized Intervention
Cognitive impairment
Orientation & therapeutic activity protocol
(discuss current events, word games, reorient, etc)
Sleep deprivation
Sleep enhancement & nonpharm sleep protocol
(noise reduction, back massages, schedule adjustment)
Immobility
Early mobilization protocol
(active ROM, reduce restraint use, ambulation, remove catheters)
Visual impairment
Vision protocol
(glasses, adaptive equipment, reinforce use)
Hearing impairment
Hearing protocol
(amplification devices, hearing aids, earwax disimpaction)
Dehydration
Dehydration protocol
(early recognition of dehydration & volume repletion)
Inouye, et al. NEJM. 1999;340:

58. Nonpharmacologic interventions
Early Mobility*—the only nonpharmacologic intervention shown to reduce ICU delirium
Other Interventions:
Environmental changes (e.g., noise reduction)
Sensory aids (e.g., glasses)
Reorientation and cognitive stimulation
Sleep preservation and enhancement
*Schweickert WD, et al. Lancet. 2009;373:

59. Nonpharmacologic interventions
Pain:
Monitor and manage pain using an objective scale (e.g., FACES, BPS, VAS, CPOT, etc.)
Orientation:
Convey the day, date, place, and reason for hospitalization
Update the whiteboards with caregiver names
Request placement of a clock and calendar in room
Discuss current events

60. Nonpharmacologic interventions
Sensory:
Determine need for hearing aids and/or eye glasses
If needed, request surrogate provide these for patient when appropriate
Sleep:
Noise reduction strategies (e.g. minimize noise outside the room, offer white noise or earplugs)
Normal day-night variation in illumination
Use “time out” strategy to minimize interruptions in sleep
Maintain ventilator synchrony
Promote comfort and relaxation (e.g., back care, oral care, washing face/hands, daytime bath, and massage)

64. Documentation Issues
In many cases, the nurse had documented on both CAM and CAM-ICU. This is problematic for several studies that depend on data collection through chart review. It is also unnecessary documentation.
In the majority of cases, the CAM-ICU was incorrect because the RASS or Ramsay was in the correct range, but the nurse documented CAM-ICU not indicated.
In many cases, the CAM-ICU was considered incorrect because at some point during the shift the patient progressed to a RASS or Ramsay in the correct range, but the nurse never attempted a CAM-ICU during these times.

65. Improvement Strategies
People/Process
Super trainers demo correct use of the CAM-ICU
Provide scenarios
Allow nurses to demo to each other and rate each others performance
Competency tool for all staff
Pizza party!
Technology
Demonstrate correct documentation

67. Early Mobility

68. “Look at the patient lying long in bed.
What a pathetic picture he makes.
The blood clotting in his veins,
The lime draining from his bones,
The scybala stacking up in his colon,
The flesh rotting from his seat,
The urine leaking from his distended bladder,
And the spirit evaporating from his soul.”
Dr. Richard Asher, British Medical Journal, 1947

69. "Teach us to live that we may dread Unnecessary time in bed.
Get people up and we may save
Our patients from an early grave”
Dr. Richard Asher, British Medical Journal, 1947

70.
Gary’s story

71. Mobility safety screen first
Responds to verbal stimuli
RASS> (-4) or Ramsay <5
FiO2 <0.6
PEEP <7.5 cmH2O
No increased dose of vasopressor
No evidence of AMI in past 24 hours
No arrhythmia requiring new anti-arrhythmic in past 24 hours

72. Mobility safety screen
Pass
Fail
Exercise/Mobility Therapy
Too Ill for Exercise/Mobility
Active ROM
Dangle
Chair
Ambulate
Passive ROM
Nursing: Consult PT to evaluate and treat if patient unable to perform any of the above activities. Consult OT if patient is unable to perform ADLs once able to dangle safely.

78. Improvement Strategies
People
Who gets patients up?
Do your nurses know how to do this? Do they want to do this?
What are your MDs ordering?
Processes
When does PT get involved?
What about other therapies?
Technology
Do you have gait belts? Chairs? Lift equipment?
Is this being documented?