1. SEDATION IN THE ICU-SHIFTS & STRATEGIES
DR. RAKESH K. CHAWLA
MD,FCCP(USA)
SR. CONSULTANT RESPIRATORY MEDICINE, CRITICAL CARE AND SLEEP DISORDERS
JAIPUR GOLDEN HOSPITAL,SAROJ HOSPITAL & RAJIV GANDHI CANCER INSTITUTE
MOBILE

2. NISO FINANCIAL GRANT FOR THIS LECTURE.PURE ACADEMIC

3. Sedation in the ICU
The 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
Prevalence
50% incidence in those with length of stay > 24 hours
Primary causes: unrelieved pain, delirium, anxiety, sleep deprivation, etc.
Immediate sequelae:
Patient-ventilator dyssynchrony
Increased oxygen consumption
Self (and health care provider) injury
Family anxiety
Long-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 changes 11

12. Causes of Agitation Not to be Overlooked
Hypoxia
Hypercarbia
Hypoglycemia
Endotracheal tube malposition
Pneumothorax
Myocardial ischemia
Abdominal pain
Drug and alcohol withdrawal

13. Correctable Causes of Agitation
Full bladder
Uncomfortable bed position
Inadequate ventilator flow rates
Mental illness
Uremia
Drug side effects
Disorientation
Sleep deprivation
Noise
Inability to communicate

14. Medications Associated With Agitation in ICU Patients
Antibiotics
Acyclovir Amphotericin B
Cephalosporins Ciprofloxacin
Imipenem – cilastatin (Primaxin , Merck) Ketoconazole
Metronidazole Penicillin
Rifampin Trimethoprim – Sulfamethoxazole
Anticonvulsants
Phenobarbital Phenytoin
Cardiac Drugs
Captopril Clonidine
Digoxin Dopamine
Labetalol Lidocaine
Nifedipine Nitroprusside
Propranolol Quinidine Sulfate
Corticosteroids
Dexamethasone Methylprednisolone
Opiold Analgesics
Codeine Meperidine
Morphine Sulfate
Miscellaneous Drugs
Anticholinergics Benzodiazepines
Hydroxyzine Ketamine
Metoclopramide Nonsteroidal anti – inflammatory drugs
Theophylline

15. Recall in the ICU
Some 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 and
Control of pain
Anxiolysis and amnesia
Blunting adverse autonomic and hemodynamic responses
Facilitate nursing management
Facilitate mechanical ventilation
Avoid self-extubation
Reduce oxygen consumption
Treatment or Diagnostic procedures
The 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 depression
Analgesia, especially for surgical patients
Rapid onset, titratable, with a short elimination half-time
Sedation with ease of orientation and arousability
Anxiolytic
Hemodynamic stability
Speaker’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 sedation
Altered pharmacology
Tolerance
Delayed emergence
Withdrawal
Drug interaction

19. Sedation
Causes for Agitation
Sedatives

20. Incidence of Inadequate Sedation
Quantify
Kaplan L, et al. Crit Care 2000;4(suppl 1):S110. 20

21. Sedation: Background Significant issues with some current agents
Opiate/benzodiazepine – tolerance, efficacy
Chloral hydrate - predictability
Pentobarbital – agitation, duration
Propofol – limited access in some jurisdictions
Ketamine – emergence reactions, tolerance
2-adrenoreceptor agonists
Prototype agent is clonidine
Recent applications in clinical practice- Sedation, Behavior disorders , Drug withdrawal , Hypertension

22. Complications of Under/Over Sedation
Under sedation
Patient recall (PTSD)
Device removal
Ineffectual mechanical ventilation
Initiation of neuromuscular blocker therapy
Myocardial or cerebral ischemia
Decreased family satisfaction with care
Over sedation
Prolonged mechanical ventilation
Need for additional diagnostic testing
Increased length of ICU and hospital stay
Increased risk of complications
Ventilator-associated pneumonia
Thrombo-embolic events
Drug withdrawal
Increased catacholamine release, metabolic stress, cardiovascular stress, impaired wound healing and immune fxn 22

23. Undersedation Sedatives Causes for Agitation Agitation & anxiety
Pain and discomfort
Catheter displacement
Inadequate ventilation
Hypertension
Tachycardia
Arrhythmias
Myocardial ischemia
Wound disruption
Patient injury

24. AGITATED PATIENT

25. Oversedation Causes for Agitation Sedatives Prolonged sedation
Delayed emergence
Respiratory depression
Hypotension
Bradycardia
Increased protein breakdown
Muscle atrophy
Venous stasis
Pressure injury
Loss of patient-staff interaction
Increased cost

26. DEEPLY SEDATED

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 needs
50% reduction in tracheostomies
Three-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 another
Pain assessment tools - none validated in ICU (numeric rating scale [NRS], visual analogue scale [VAS], etc.)

29. Strategies for Patient Comfort
Set treatment goal
Quantitate sedation and pain
Choose the right medication
Use combined infusion
Reevaluate need
Treat withdrawal

30. How do we assess sedation?30

31. Sedation Scales : Very useful , very underused.

32. What Sedation Scales Do
Provide a semiquantitative “score”
Standardize treatment endpoints
Allow review of efficacy of sedation
Facilitate sedation studies
Help to avoid oversedation

33. What Sedation Scales Don’t Do
Assess anxiety
Assess pain
Assess sedation in paralyzed patients
Predict outcome
Agree with each other

34. Sedation Scoring Scales
Ramsay Sedation Scale (RSS)
Sedation-agitation Scale (SAS)
Observers Assessment of Alertness/Sedation Scale (OAASS)
Motor Activity Assessment Scale (MAAS)
BMJ 1974;2:
Crit Care Med 1999;27:
J Clin Psychopharmacol 1990;10:
Crit Care Med 1999;27:
Sedation Scoring Scales

35. Sedation should be targeted to a Ramsay score of 2 to 3.

36. Many levels of sedation and no levels of agitation36

38. 38

39. The Riker Sedation-Agitation Scale
Score
Description
Definition 7
Dangerous agitation
Pulling at endotracheal tube, trying to strike at staff, thrashing side to side 6
Very agitated
Does not calm despite frequent verbal commands, biting ETT 5
Agitated
Anxious or mildly agitated, attempting to sit 4
Calm and cooperative
Calm, awakens easily, follows commands 3
Sedated
Difficult to arouse, awakens to verbal stimuli, follows simple commands 2
Very sedated
Arouse to physical stimuli, but does not communicate spontaneously 1
Unarousable
Minimal 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
Score
Description
Definition 6
Dangerous agitation
Pulling at endotracheal tube, trying to strike at staff, thrashing side to side 5
Agitated
Does not calm despite frequent verbal commands, biting ETT 4
Restless and cooperative
Anxious or mildly agitated, attempting to sit 3
Calm and cooperative
Calm, awakens easily, follows commands 2
Responsive to touch or name
Opens eyes or raises eyebrows or turns head when touched or name is loudly spoken 1
Responsive only to noxious stimuli
Opens eyes or raises eyebrows or turns head with noxious stimuli
Unresponsive
Does 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. Level
Behaviors 7
Dangerous agitation pulls at endotracheal tube, tries to remove catheter climbs over bed rail , strikes at staff, thrashes side - to – side. 6
Very agitated . Does not calm , despite frequent verbal reminders; requires verbal reminding of limits, physical restraints; bites endotracheal tube. 5
Agitated , Anxious or mildly agitated , attempts to sit up, calms down to verbal instructions. 4
Calm and cooperative. Calm , awakens easily, follow commands 3
Sedated. Difficult to arouse, awakens to verbal stimuli or gentle shaking but drifts off again, follows simple commands 2
Very sedated. Arouses to physical stimuli but does not communicate or follow commands, may move spontaneously 1
Unarousable. Minimal or no response to noxious stimuli, does not communicate or follow commands.

45. AVRIPAS
This 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. Bloomsbury
Also 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 Drug
Sedation
Analgesia
Amnesia
Hypnosis
Anxiolysis
Propofol
Benzodiazepines
Opioids
Patient Comfort
-2 agonists

48. Sedation Options: Benzodiazepines (Midazolam and Lorazepam)
Pharmacokinetics/dynamics
Lorazepam: onset minutes, half-life 10 hours, glucuronidated
Midazolam: onset minutes, half-life 3 hours, metabolized by cytochrome P450, active metabolite (1-OH) accumulates in renal disease
Benefits
Anxiolytic
Amnestic
Sedating
Risks
Delirium
NO analgesia
Excessive sedation: especially after long-term sustained use
Propylene glycol toxicity (parenteral lorazepam): significance uncertain
- Evaluate when a patient has unexplained acidosis
- Particularly problematic in alcoholics (due to doses used) and renal failure
Respiratory failure (especially with concurrent opiate use)
Withdrawal

49. Benzodiazepines Onset Peaks Duration Diazepam 2-5 min 5-30 min
>20 hr
Midazolam
2-3 min
5-10 min
min
Lorazepam
5-20 min
30 min
10-20 hr

50. Sedation Options: Propofol
Pharmacology: GABA agonist
Pharmacokinetics/dynamics: onset minutes, terminal half-life 6 hours, duration 10 minutes, hepatic metabolism
Benefits
Rapid onset and offset and easily titrated
Hypnotic and antiemetic
Can be used for intractable seizures and elevated intracranial pressure
Risks
Not reliably amnestic, especially at low doses
NO analgesia!
Hypotension
Hypertriglyceridemia; lipid source (1.1 kcal/ml)
Respiratory depression
Propofol 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

51. Propofol
Onset
Peaks
Duration
Propofol
30-60 sec
2-5 min
short

52. Propofol Dosing 3-5 g/kg/min antiemetic 5-20 g/kg/min anxiolytic
20-50 g/kg/min sedative hypnotic
>100 g/kg/min anesthetic

53. Problems with Current Sedative Agents
Midazolam
Propofol
Opioids
Prolonged weaning X -
Respiratory depression
Severe hypotension
Tolerance
Hyperlipidemia
Increased infection
Constipation
Lack of orientation and cooperation

54. Opiate and Benzodiazepine Withdrawal
Frequency related to dose and duration
32% if receiving high doses for longer than a week
Onset depends on the half-lives of the parent drug and its active metabolites
Clinical signs and symptoms are common among agents
CNS activation: seizures, hallucinations,
GI disturbances: nausea, vomiting, diarrhea
Sympathetic hyperactivity: tachycardia, hypertension, tachypnea, sweating, fever
No 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 sedation
Return of underlying agitation
Hyperadrenergic syndrome
Hypertension, tachycardia,sweating
Opioid withdrawal
Salivation, yawning, diarrhea

56. Treat Withdrawal Acute management Prolonged management Resume sedation
Beta-blockade, dexmedetomidine
Prolonged management
Methadone 5-10 mg VT bid
Clonidine mg VT q8h
Lorazepam 1-2 mg IV q8h

57. Sedation Options: Dexmedetomidine
Alpha-2-adrenergic agonist like clonidine but with much less imidazole activity
Has been shown to decrease the need for other sedation in postoperative ICU patients
Potentially useful while decreasing other sedatives to prevent withdrawal
Benefits
Does not cause respiratory depression
Short-acting
Produces sympatholysis which may be advantageous in certain patients such as postop cardiac surgery
Risks
No amnesia
Small number of patients reported distress upon recollection of ICU period despite good sedation scores due to excessive awareness
Bradycardia 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%
Administration
Diluted 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 Sedation
Initiation- 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 Sedation
Clinically effective onset of sedation 10 to 15 minutes after start of infusion
Initiation- 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 suitable
Maintenance- Generally initiated at 0.6 mcg /kg/hr and titrated from 0.2 to 1 mcg/kg/hr
Following 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 Sedation
Sedation 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 effects
0.17% incidence on monogram
Most data suggests SaO2 and PaCO2 unaffected , Numerous reports during spont vent
NON-CNS EFFECTS
Hypertension: peripheral 1-agonism
Bradycardia/hypotension: Sympathetic inhibition - medullary VMC
 shivering, Diuresis:  renin, vasopressin;  ANP
PERIOPERATIVE OBSERVATIONS
 hypotension vs propofol
Blunted tachycardia during controlled hypotension
  PACU analgesia requirements
Blunted catecholamine response: Potential importance with vascular procedures

61. Clinical Uses of Dex . Sedation in CT and MRI imaging studies
Mason K, Ped Anesth 2008
Koroglu A, Anesth Analg 2006
Outpatient third molar surgery
Ustin Y, J Oral Maxilfac Surg 2006
Cheung C, Anaesthesia 2007
Cataract surgery
Alhashemi J, Br J Anaest 2006
Cardiac catheterization
Tosun Z, J Card Vasc Anesth 2006
Mester R, Am J Therap 2008
GI Procedures
Demiraran Y, Can J Gastroenter 2007
Dex may be a good alternative to midazolam for upper endoscopy 61

62. Dex: Use in Sleep Apnea, Gastric Bypass
Sleep Apnea Patients
Anesthesia considerations
Morbid obesity, at risk for aspiration
Difficult IV access
Systemic + pulm HTN, cor pulmonale
Postop airway obstruction + ventilatory arrest with anesthetic drugs
Dex: Anesthetic adjunct to minimize opioid + sedative use
Ogan OU, Plevak DJ: Mayo Clinic;
Gastric Bypass Surgery Patients
Morbidly obese patients, Prone to hypoxemia
Sleep apnea is common, Respiratory depression w opioids
Dexmedetomidine, 0.1 to 0.7 ug/kg/hr, prospectively studied in 32 pts
 opioid use in dex group, pts more normotensive
Craig 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 magnitude
Cytochrome P-450- No evidence of cytochrome P450 mediated drug interactions
Vagal effects- can be counteracted by atropine / glyco
Contraindications
Patients who are hypersensitive to drug or to any ingredient
Caution 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 hypertension
Most common treatment-emergent adverse reactions, occurring in greater than 2% of patients include hypotension, bradycardia and dry mouth.
Clinical Trial Adverse Drug Reactions
Intensive 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 , Thirst
Conscious Sedation: Hypotension , Hypertension , Respiratory depression, Hypoxia, Bradypnea, Bradycardia , Tachycardia , Nausea , Dry mouth
Post-Market Adverse Drug Reactions
Hypotension 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 measures
Minimize:
Blood draws, X-rays
Blood pressure measurements, Blood glucose measurements
Dimming lights at night (sleep-wake cycle)
Massage, therapeutic touch and music therapy
Selection of Sedatives
Benzodiazepines- Diazepam, Lorazepam, Midazolam
Propofol
Dexmedetomidine
Haloperidol, other neuroleptics

66. Patient Focused Sedation: Key Points
Choose medications best suited to the patient’s characteristics
Organ function and Drug metabolism
Risk of side effects
Sedation needs differ among patients and vary over time
Tips to minimize sedation
Use a sedation protocol
Incorporate Daily Interruption of Sedation (DIS)
Provide Analgesia Management First
Use Newer Medications With Different Properties
Use Other Non pharmacologic Interventions

67. Overview of SCCM Algorithm1 2 3 4
Jacobi J, Fraser GL, Coursin D, et al. Crit Care Med. 2002;30:

69. Acute onset of mental status changes or a fluctuating course
Delirium
Acute onset of mental status changes or a fluctuating course
&
2. Inattention
3. Disorganized
Thinking or
4. Altered level of
consciousness
Courtesy of W Ely, MD

70. Risk Factors for Delirium
Primary CNS Dx
Infection
Metabolic derangement
Pain
Sleep deprivation
Age
Substances including tobacco (withdrawal as well as direct effect)

71. Significance of ICU Delirium
Seen in > 50% of ICU patients
Three times higher risk of death by six months
Five fewer ventilator free days (days alive and off vent.), adjusted P = 0.03
Four times greater frequency of medical device removal
Nine times higher incidence of cognitive impairment at hospital discharge

72. Treatment of Delirium
Correct inciting factor, but as for pain…relief need not be delayed while identifying causative factor
Control symptoms?
No evidence that treatment reduces duration and severity of symptoms
Typical and atypical antipsychotic agents
Sedatives?
Particularly in combination with antipsychotic and for drug/alcohol withdrawal delirium
No treatment FDA approved

73. Case Scenario #1
22-year-old male with isolated closed head injury who was intubated for GCS of 7
He 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 exam
Can treat seizures and elevated ICP which may be present in a head trauma with GCS of eight or less
Minimizing dose and duration will avoid side effects.

75. Case Scenario #2
54-year-old alcoholic who has been admitted for Staph sepsis
Intubated in the ICU for seven days and is currently on midazolam at 10 mg/hour
His 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 #3
62-year-old, 65-kg woman with ARDS from aspiration pneumonia
Her 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.

78. THANK YOU