sedation in icu

Sedation in ICU Sedation in ICU

T Mphanza FRCA, FFICM

The correct management of sedation is one of the most

important aspects of Intensive Care management

AimsAimsComfortable and pain free

Minimise anxiety

Calm and co-operative

Ability to tolerate appropriate organ system support

Patients MUST NOT be paralysed and awake

Subjective Subjective ImpressionsImpressions

Bion JF. Sedation and analgesia in the intensive care unit. Hospital Update. 1988;

14:1271-1286.

ExperienceRecall of

Experience (%)Reported as

Unpleasant (%)

Anxiety 55 78

Pain 40 67

Thirst 67 60

ETT (N=50) 38 57

Face Mask 67 52

Physiotherapy 75 33

Urinary Catheter 75 17

Nausea 13 12

Paralysis 13 100

Critical Care 2007, 11:R124 doi:10.1186/cc6189

Changes in sedation management in German intensive care units between 2002

and 2006: a national follow up surveyJoerg Martin (Joerg.Martin@email.de) Martin Franck (mfranck@pipeline.com)

Stefan Sigel (Stefan.Sigel@kae.de) Manfred Weiss (manf

red.weiss.ulm@online.de) Claudia D Spies

(claudia.spies@charite.de)

82% response rate

67% changes in sedation managent

Critical Care 2007, 11:R124 doi:10.1186/cc6189

Critical Care 2007, 11:R124 doi:10.1186/cc6189

How often do we get it How often do we get it right?right?

Kaplan et al., Critical Care 2000; 4(1):s110

Olson D et al., NTI Proceedings 2003;CS 82:196

Does it matter?Does it matter?

Over - sedated

Increased drug costs

Delayed weaning

Increased ICU LOS

Increased testing

Does it matter?Does it matter?Under-sedated

Anxiety and agitation

Awareness and recall

PTSD

Increased adverse events

Increased use of NMR

AnalgesiaAnalgesiaWhy in pain:

Pre-existing conditions

Invasive procedures

Therapeutic devices

Catheters

Drains

NIV

ETT

AnalgesiaAnalgesiaUnrelieved pain

Stress response:

Tachycardia

Increased O2 consumption

Hypercoaguability

Immunosuppression

Persistent catabolism

AnalgesiaAnalgesiaPain assessment

Unidimensional

VAS

VRS

Multidimensional

McGill Pain Questionnaire

Wisconsin Brief Pain Questionnaire

AnalgesiaAnalgesiaPain Assessment

Behavioural-physiological scales

Behavioural

Facial expression

Posture

Movement

Physiological

RR

HR

BP

Analgesia TherapyAnalgesia TherapyNon-pharmacologic

Proper positioning

Stabilisation of fractures

Pharmacologic

Opioids

NSAIDs

Paracetamol

Analgesia TherapyAnalgesia TherapyDesirable attributes of opioids

Rapid onset

Ease of titration

Lack of accumulation

Low cost

Lack of adverse effects

Analgesia TherapyAnalgesia TherapyOpioid Administration Techniques

Route

IV

Intermittent

PCA

Infusion

Strategy

Daily awakening

SedationSedation

Indications

Anxiety

Agitation

Sleep deprivation

SedationSedation

Deleterious effects of anxiety

Ventilator dysynchrony

Increased oxygen consumption

Inadvertent removal of devices

SedationSedationBefore sedation ensure:

Correct physiological anomalies

Hypoxemia

Hypoglycaemia

Hypotension

Pain

Withdrawal from drugs

Sedation AssessmentSedation Assessment

SUBJECTIVE

Sedation AssessmentSedation Assessment

SUBJECTIVE

Sedation AssessmentSedation AssessmentObjective

Vital signs

Heart rate variability

Lower-oesophageal contractility

EEG

BIS

Sedation TherapySedation Therapy

Benzodiazepines

Anterograde amnesia

No analgesic property

Opioid-sparing

Sedation TherapySedation Therapy

Propofol

Central alpha agonists

Clonidine

Dexmedetomidine

Sedative SelectionSedative SelectionOutcome measures

Speed of onset

Ability to maintain target level of sedation

Adverse effects

Time to awakening

Ability to wean from ventilation

Sedative SelectionSedative SelectionDuration of Therapy

Short-term

Propofol V Midazolam

Intermediate

Propofol V Midazolam

Propofol V Midazolam V Lorazepam

Long-term

Propofol V Midazolam

Sedative and Analgesic Sedative and Analgesic WithdrawalWithdrawal

Beware of withdrawal symptoms after more than one week of medication. Doses should be tapered systematically.

Sedation in ICUSedation in ICU

An important component

Most common therapy

$ 1.2 billion per year

Treatment should have specific and individualised goals