Sedation in ICU • LITFL • CCC Ventilation

Sedation in ICU · Sedative medications should be titrated to maintain a light rather than a deep level of sedation in adult ICU patients, unless ... Skiptocontent OVERVIEW Sedationisthedepressionofapatient’sawarenesstotheenvironmentandreductionofhisorherresponsivenesstoexternalstimulationSedativeagentsalsohavevaryingdegreesofassociatedeffects,whichmaybedose-dependent,suchas:Anxiolysis–ReliefofapprehensionoragitationwithminimalalterationofsensoriumAmnesia– memorylossforaperiodoftimeAnalgesia–reliefofpainwithoutanalteredsensoriumAnaesthesia–lossofsensationSedationiscommonlyusedinICUandsedationprotocolsareinwidespreaduseandareconsideredbestpractice DEPTHOF SEDATION Depthofsedationisacontinuum,thatcanbesubjectivelyclassifiedas: Minimalsedation—anxiolysisonlyModeratesedation —responsivetoverbalortactilestimuli(verbalortactile);airwayreflexes,spontaneousventilation,andcardiovascularfunctionaremaintained.Deepsedation —responsivepurposefullytorepeatedorpainfulstimuli;airwayreflexesorspontaneousventilationmaynotbemaintained,butcardiovascularfunctionispreserved.Generalanesthesia —astateofunconsciousnessandprofoundunresponsivenesssuchthattheautonomicnervoussystemisunabletorespondtosurgicalorproceduralstimuli.Dissociation—adistincttypeofmoderatesedationcharacteristicofphencyclidinessuchasketaminethatcauseadisconnectionbetweenthethalamoneocorticalsystemandthelimbicsystems,preventinghighercentersfromreceivingsensorystimuli.Airwayreflexes,spontaneousventilation,andcardiovascularfunctionareallmaintained. Monitoringofdepthofsedationcanbeachievedbyclinicalassessmentorphysiologicalmonitoring(Seebelow). USES allowspatientstotoleratepainful/distressingprocedures(e.g.endotrachealintubation,invasivelines)optimisemechanicalventilation(e.g.toleratepermissivehypercapnea)usedtodecreaseO2consumption(e.g.sepsis)decreaseICPinneurosurgicalpatientsfacilitatecooling(e.g.therapeutichypothermia)controlagitation IDEALSEDATIONAGENT Theidealsedationagentdoesnotexist.Featuresofthehypotheticalidealsedationagentare: PharmaceuticsEaseofadministrationDoesnotpromotegrowthofpathogensEasilypreparedandlongshelflifePharmacodynamicsPredictabledose-dependenteffectswithminimalindividualvariationProvidesappropriatesedation,anxiolysis,amnesiaandanalgesiaNotoleranceandwithdrawalsymptomsProvidesfacilitationofventilatorsynchronyandtheperformanceofvariousproceduresandnursinginterventionsPharmacokineticsRapidonsetofactionEasilytitratablelevelofadequatesedationShort-acting,allowingpatientassessment,rapidrecoveryfollowingdiscontinuation,easyweaningfrommechanicalventilation,andearlyextubationMinimalmetabolism;notdependentonnormalhepatic,renal,orpulmonaryfunctionNoactiveortoxicmetabolitesSafeforallageswithnoage-relatedchangesinpharmacokineticsLackofaccumulationwithprolongedadministrationInteractionsNoorminimalinteractionswithother drugsNoorfewadverseeffectsNoanaphylaxisorallergicreactionNonausea,vomiting,orphlebitisMinimalrespiratorydepressionMinimaleffectoncardiovascularfunctionNopainoninjectionNosuppressionofcortisolproductionbytheadrenalcortex OtherCosteffectiveLackofabusepotentialWidelyavailable COMMONLYUSEDAGENTS propofolbenzodiazepines,e.g.midazolamopioids,e.g.morphine,fentanylalpha2agonists,e.g.dexmedetomidine, clonidineketaminethiopentonetranquilisers,e.g.haloperidol SIDEEFFECTS hypotensionrespiratorydepressionarrhythmiasdrugspecificeffectssleepdisturbancewithdrawaldelirium MONITORING Subjectiveclinicalassessment RichmondAgitation-SedationScore(RASS)isthemost-validatedandmostwidely-usedtooltoassessdepthofsedation (theSedation-AgitationScale(SAS)isareasonablealternative)ViewssedationandagitationasacontinuumNotusefulinpatientsreceivingneuromuscularblockingagentsTitratealmostallpatientstoaRASSscoreof-2orhigher(nomorethanlightsedation);veryilloragitatedpatients(e.g.,severeARDS,raisedICP)may“rarely”requireRASS-3or-4 +4Combative+3Veryagitated+2Agitated+1Restless0Alertandcalm-1Drowsy-2Lightsedation-3Moderatesedation-4Deepsedation-5Unrousable ProcedureforRASSAssessment Observepatienta.Patientisalert,restless,agitatedorcombative(score0to+4)Ifnotalert,statepatient’snameandsaytoopeneyesandlookatspeakerb.Patientawakenswithsustainedeyeopeningandeyecontact(score–1)c.Patientawakenswitheyeopeningandeyecontact,butnotsustained(score–2)d.Patienthasanymovementinresponsetovoicebutnoeyecontact(score–3)Whennoresponsetoverbalstimulation,physicallystimulatepatientbyshakingshoulderand/orrubbingsternume.Patienthasanymovementtophysicalstimulation(score–4)f.Patienthasnoresponsetoanystimulation(score–5) Objectivephysiologicalassessment objectivemeasuresofbrainfunction(e.g.,AEPs,BIS,NI,PSI,orSE)arepoorsubstitutesforclinicalassessmentcanbeusedasan adjunctinICUpatientswhoarereceivingneuromuscularblockingagents,assubjectivesedationassessmentsmaybeunobtainableEEGmonitoringbeusedto:—monitornonconvulsiveseizureactivityinadultICUpatientswitheitherknownorsuspectedseizures—titrateelectrosuppressivemedicationtoachieveburstsuppressioninadultICUpatientswithelevatedICP ANAPPROACHTOSEDATIONINICU SedativemedicationsshouldbetitratedtomaintainalightratherthanadeeplevelofsedationinadultICUpatients,unlesscontraindicatedkeeppatientscomfortableandsafeusingtheminimumpossibleamountofsedationuseprotocolisedcarewithsedationscoremonitoringpropofoliswidelyusedasitusuallyallowsrapid,predictabledesedationdailysedationinterruptionsmaynotbenecessaryinICUswithprotocolisedsedationreviewinfusionratesatleastdaily,andafteranyprocedurestreatpainwithbolusesofanalgesics(e.g.IVmorphineorfentanyl),onlymakeminorincreasesinbasalinfusionratesavoidprolongeddeepcomawheneverpossibleusecautioninrenalandliverfailureusespontaneousbreathing,unlesscontra-indicateddexmedetomidineisincreasinglypreferedindeliriouspatientsrequiringongoingsedation EVIDENCE SummarisedfromJacobietal(2002)clinicalpracticeguidelines: MaintaininglightlevelsofsedationinadultICUpatientsisassociatedwithimprovedclinicaloutcomes—shorterdurationofmechanicalventilation—shorterICUlengthofstayMaintaininglightlevelsofsedationincreasesthephysiologicstressresponse,butisnotassociatedwithanincreasedincidenceofmyocardialischemiaTheassociationbetweendepthofsedationandpsychologicalstressinlightlysedatedpatientsisunclearTheRichmondAgitation-SedationScale(RASS)andSedation-AgitationScale(SAS)arethemostvalidandreliablesedationassessmenttoolsformeasuringqualityanddepthofsedationinadultICUpatientsnonbenzodiazepinesedatives(eitherpropofolordexmedetomidine)maybepreferredoversedationwithbenzodiazepines(eithermidazolamorlorazepam)toimproveclinicaloutcomesinmechanicallyventilatedadultICUpatients ReferencesandLinks LITFL CCC— DailyInterruptionsofSedationinMechanicallyVentilatedPatientsCCC— DeliriuminICU Journalarticles:Trials AugustesR,HoKM.Meta-analysisofrandomisedcontrolledtrialsondailysedationinterruptionforcriticallyilladultpatients.AnaesthIntensiveCare.2011May;39(3):401-9.PubMedPMID:21675059.GirardTD,etal.Efficacyandsafetyofapairedsedationandventilatorweaningprotocolformechanicallyventilatedpatientsinintensivecare(AwakeningandBreathingControlledtrial):arandomisedcontrolledtrial.Lancet.2008Jan12;371(9607):126-34.PMID:18191684.JacobiJ,etal.Clinicalpracticeguidelinesforthesustaineduseofsedativesandanalgesicsinthecriticallyilladult.CritCareMed.2002Jan;30(1):119-41.Erratumin:CritCareMed2002Mar;30(3):726.PMID:11902253.KressJP,PohlmanAS,O’ConnorMF,HallJB.Dailyinterruptionofsedativeinfusionsincriticallyillpatientsundergoingmechanicalventilation.NEnglJMed.2000May18;342(20):1471-7.PMID:10816184.MehtaS,etal;SLEAPInvestigators;CanadianCriticalCareTrialsGroup.Dailysedationinterruptioninmechanicallyventilatedcriticallyillpatientscaredforwithasedationprotocol:arandomizedcontrolledtrial.JAMA.2012Nov21;308(19):1985-92.Erratumin:JAMA.2013Jan16;309(3):237.PMID:23180503.StrømT,MartinussenT,ToftP.Aprotocolofnosedationforcriticallyillpatientsreceivingmechanicalventilation:arandomisedtrial.Lancet.2010Feb6;375(9713):475-80.PMID:20116842. Journalarticles:Reviews HughesCG,McGraneS,PandharipandePP.Sedationintheintensivecaresetting.ClinPharmacol.2012;4:53-63.PMC3508653.WeinhouseGL,WatsonPL.SedationandsleepdisturbancesintheICU.AnesthesiolClin.2011Dec;29(4):675-85.PMID:22078916. FOAMandwebresources EMCritPodcast21–ABadSedationPackageLeavesyourPatientTrappedinaNightmare (2011)EMCrit–Podcast115–ANewParadigmforPost-IntubationPain,Agitation,andDelirium(2013)PulmCCM.org—Sedationvacationsdon’timproveoutcomesinlargetrial(RCT,JAMA)PulmCCM.org—Paincontrolandsedationinmechanicallyventilatedpatients(Review,AJRCCM)ScanCrit—SedatedinsomniaintheICUScanCrit—GastheICU CriticalCareCompendium…moreCCC ChrisNickson ChrisisanIntensivistandECMOspecialistatthe AlfredICUinMelbourne.HeisalsotheInnovationLeadfortheAustralianCentreforHealthInnovationatAlfredHealthandClinicalAdjunctAssociateProfessoratMonashUniversity. Heisaco-founderofthe AustraliaandNewZealandClinicianEducatorNetwork (ANZCEN)andistheLeadforthe ANZCENClinicianEducatorIncubator programme.HeisontheBoardofDirectorsforthe IntensiveCareFoundation andisaFirstPartExaminerforthe CollegeofIntensiveCareMedicine.HeisaninternationallyrecognisedClinicianEducatorwithapassionforhelpingclinicianslearnandforimprovingtheclinicalperformanceofindividualsandcollectives. AfterfinishinghismedicaldegreeattheUniversityofAuckland,hecontinuedpost-graduatetraininginNewZealandaswellasAustralia’sNorthernTerritory,PerthandMelbourne.Hehascompletedfellowshiptraininginbothintensivecaremedicineandemergencymedicine,aswellaspost-graduatetraininginbiochemistry,clinicaltoxicology,clinicalepidemiology,andhealthprofessionaleducation. HeisactivelyinvolvedininusingtranslationalsimulationtoimprovepatientcareandthedesignofprocessesandsystemsatAlfredHealth.HecoordinatestheAlfredICU’seducationandsimulationprogrammesandrunstheunit’seducation website, INTENSIVE. Hecreatedthe‘CriticallyIllAirway’courseandteachesonnumerouscoursesaroundtheworld.Heisoneofthefoundersofthe FOAM movement(FreeOpen-AccessMedicaleducation)andisco-creatorof litfl.com, the RAGEpodcast,the Resuscitology course,andthe SMACC conference. Hisonegreatachievementisbeingthefatheroftwoamazingchildren. On Twitter,heis @precordialthump. |INTENSIVE|RAGE|Resuscitology|SMACC Related LeaveaReplyCancelreply ThissiteusesAkismettoreducespam.Learnhowyourcommentdataisprocessed. SubscribetoLITFLviaEmail Blog ECGlibrary CCC Eponyms PartONE Top100 Podcasts FullMenu Weusecookiesonourwebsitetogiveyouthemostrelevantexperiencebyrememberingyourpreferencesandrepeatvisits.Byclicking“Accept”,youconsenttotheuseofALLthecookies.Incaseofsaleofyourpersonalinformation,youmayoptoutbyusingthelinkDonotsellmypersonalinformation.CookiesettingsACCEPTCookiesPolicy Close PrivacyOverview Thiswebsiteusescookiestoimproveyourexperiencewhileyounavigatethroughthewebsite.Outofthesecookies,thecookiesthatarecategorizedasnecessaryarestoredonyourbrowserastheyareessentialfortheworkingofbasicfunctionalitiesofthewebsite.Wealsousethird-partycookiesthathelpusanalyzeandunderstandhowyouusethiswebsite.Thesecookieswillbestoredinyourbrowseronlywithyourconsent.Youalsohavetheoptiontoopt-outofthesecookies.Butoptingoutofsomeofthesecookiesmayhaveaneffectonyourbrowsingexperience. Necessary Necessary AlwaysEnabled Necessarycookiesareabsolutelyessentialforthewebsitetofunctionproperly.Thiscategoryonlyincludescookiesthatensuresbasicfunctionalitiesandsecurityfeaturesofthewebsite.Thesecookiesdonotstoreanypersonalinformation. NonNecessary non-necessary Anycookiesthatmaynotbeparticularlynecessaryforthewebsitetofunctionandisusedspecificallytocollectuserpersonaldataviaanalytics,ads,otherembeddedcontentsaretermedasnon-necessarycookies.Itismandatorytoprocureuserconsentpriortorunningthesecookiesonyourwebsite. Uncategorized uncategorized Undefinedcookiesarethosethatarebeinganalyzedandhavenotbeenclassifiedintoacategoryasyet. Analytics analytics Analyticalcookiesareusedtounderstandhowvisitorsinteractwiththewebsite.Thesecookieshelpprovideinformationonmetricsthenumberofvisitors,bouncerate,trafficsource,etc. Advertisement advertisement Advertisementcookiesareusedtoprovidevisitorswithrelevantadsandmarketingcampaigns.Thesecookiestrackvisitorsacrosswebsitesandcollectinformationtoprovidecustomizedads. Performance performance Performancecookiesareusedtounderstandandanalyzethekeyperformanceindexesofthewebsitewhichhelpsindeliveringabetteruserexperienceforthevisitors. Preferences preferences Preferencecookiesareusedtostoreuserpreferencestoprovidecontentthatiscustomizedandconvenientfortheusers,likethelanguageofthewebsiteorthelocationofthevisitor. Functional functional Functionalcookieshelptoperformcertainfunctionalitieslikesharingthecontentofthewebsiteonsocialmediaplatforms,collectfeedbacks,andotherthird-partyfeatures. Save&Accept