jurding sedation and delirium in the intensive care unit

7/25/2019 JURDING Sedation and Delirium in the Intensive Care Unit

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SEDATION AND DELIRIUM

IN THE INTENSIVE CAREUNIT


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PENDAHULUAN

Patients in intensive care units (ICUs) are treated wit!an" interventi#ns (!#st n#ta$%" end#trac ea%intu$ati#n and invasive !ec anica% venti%ati#n) t at are#$served #r &erceived t# $e distressin' Pain is t e !#st

c#!!#n !e!#r" &atients ave # t eir ICU sta"A'itati#n can &reci&itate accidenta% re!#va% #end#trac ea% tu$es #r # intravascu%ar cat eters used

#r !#nit#rin' #r ad!inistrati#n # %i e*sustainin'!edicati#ns C#nse+uent%", sedatives and ana%'esics are

a!#n' t e !#st c#!!#n%" ad!inistered dru's in ICUs


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Ear%" intensive care &ractice ev#%ved r#!intra#&erative anest etic care at a ti!e w en!ec anica% venti%ati#n was de%ivered $" rudi!entar"!ac ines t att were n#t ca&a$%e # s"nc r#ni-in' wit&atients. res&irat#r" e #rts As a resu%t, dee& sedati#n

was c#!!#n%" used unti% a &atient was a$%e t# $reat ewit #ut assistance Deve%#&!ents #ver t e &ast /0 "ears,inc%udin' !icr#&r#cess#r*c#ntr#%%ed venti%at#rs t ats"nc r#ni-e wit &atients. #wn res&irat#r" e #rts andnew, s #rter*actin' sedative and ana%'esic !edicati#ns,

ave dra!atica%%" c an'ed t is a&&r#ac E+ua%%"i!rtant as $een t e rec#'niti#n t at &ain,#versedati#n, and de%iriu! are issues t at i undetectedand untreated are distressin' t# &atients and ass#ciatedwit increased !#r$idit" and !#rta%it"


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1ust as t e c#nce&t # t e 2triad # anest esia3undersc#res t e & ar!ac#d"na!ic interacti#ns a!#n'

"&n#tics, ana%'esics, and !usc%e re%a4ants and t erec#'niti#n t at t e si!u%tane#us ad!inistrati#n #a'ents # eac c%ass &er!its t e use # %#wer d#ses #

dru's # a%% c%asses, t e c#nce&t # t e 2ICU triad3rec#'ni-es t at &ain, a'itati#n, and de%iriu! 5 andt ere #re a&&r#ac es t# t eir !ana'e!ent 5 areine4trica$%" %in6ed Acc#rdin' t# t e &rinci&%e t at it is$etter t# treat disease t an t# !as6 it, sedatives s #u%d$e used #n%" w en &ain and de%iriu! ave $eenaddressed wit t e use # s&eci ic & ar!ac#%#'ic andn#n& ar!ac#%#'ic strate'ies


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PAIN, ANALGESIA, AND SEDATION IN THE ICU

The majority of patients who aretreated in ICUs have pain. Theshort-term consequences ofuntreated pain include higher

energy expenditure andimmunomodulation. Longer-termuntreated pain increases the ris!of post-traumatic stress disorder.


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"hysiological indicators such ashypertension and tachycardiacorrelate poorly with moreintuitively valid measures ofpain #ut pain scales such asthe $ehavioral "ain %cale andthe Critical Care "ain

servation Tool providestructured and repeata#leassessments and are

currently the #est availa#le


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' minority of ICU patients havean indication for continuousdeep sedation for reasonssuch as the treatment ofintracranial hypertensionsevere respiratory failurerefractory status epilepticus

and prevention of awarenessin patients treated withneuromuscular #loc!ing

agents


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This review will focus onthe remainingoverwhelming majority of

patients undergoingmechanical ventilation forwhom the use of sedatives

and analgesics should #eminimi(ed with the goalthat they #e calm lucid

pain-free interactive and


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)vidence from randomi(edcontrolled trials consistentlysupports the use of the minimumpossi#le level of sedation

"atients whose sedation wasroutinely interrupted received lesssedation overall and spent fewerdays undergoing mechanicalventilation and fewer days in theICU


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*aily interruption of sedation wasassociated with reducedadministration of a#en(odia(epine sedative reduced

duration of mechanicalventilation reduced length ofstay in the ICU and signi+cantlyincreased survival


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"atients undergoingmechanical ventilationreceived morphine for thetreatment of pain in an,analgesia +rst approachcompared a protocol of nosedation with the routine use

of sedation with dailyinterruption. "atients whowere assigned to the protocol

of no sedation had shorter


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CHOICE OF SEDATIVE AGENT

%edatives that are commonlyused in the ICU are the#en(odia(epines mida(olamand lora(epam and to alesser extent dia(epam/ theshort-acting intravenousanesthetic agent propofol

and dexmedetomidine.0emifentanil an opioid isalso used as a sole agent

#ecause of its sedative


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If minimi(ing the depth and durationof sedation is accepted as a desira#legoal then the use of a short-actingagent with an e1ect that can #erapidly adjusted such as propofol orremifentanil should o1er advantagesover longeracting agents or agentswith active meta#olites


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's compared with #en(odia(epinespropofol has not #een shown toreduce mortality #ut may result ina reduction in the length of stay in

the ICU*exmedetomidine may also have

advantages over #en(odia(epinessince it produces analgesiacauses less respiratorydepression and seeminglyprovides a qualitatively di1erenttype of sedation in which patientsare more interactive and so


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's compared with lora(epam andmida(olam dexmedetomidineresulted in less delirium and ashorter duration of mechanical

ventilation #ut not reduced staysin the ICU or hospital


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PREVENTION AND TREATMENT OF DELIRIUM

2our domains of delirium3distur#ance of consciousnesschange in cognition developmentover a short period and

4uctuation*elirium is a nonspeci+c #ut

generally reversi#le manifestationof acute illness that appears tohave many causes includingrecovery from a sedated oroversedated state


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The pathophysiology ofdelirium that is associatedwith critical illness remainslargely uncharacteri(ed andmay vary depending on thecause. The increased ris!associated with the use of

5'$'a agonists andanticholinergic drugs led tothe suggestion that the

5'$'ergic and cholinergic


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%tudies using magneticresonance imaging haveshown a positive association#etween the duration ofdelirium in the ICU and #othcere#ral atrophy and cere#ralwhite-matter disruption


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There are two distinct forms ofdelirium hypoactive and agitated

or hyperactive/The hypoactive form is

characteri(ed #y inattentiondisordered thin!ing and adecreased level of consciousnesswithout agitation


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"atients with hypoactivedelirium are the least li!ely tosurvive #ut those who dosurvive may have #etter long-term function than those withagitated or mixed delirium


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ASSESSMENT AND MONITORINGOF SEDATION AND DELIRIUM

Sedation scale

2or the majority of patients undergoing mechanicalventilation in an ICU an appropriate target is ascore of 6 to 7 on the 0i!er %edation8'gitation

%cale which ranges from 9 to : with scores of ;7indicating deeper sedation a score of 7 indicatingan appearance of calm and cooperativeness andscores of ? to @ on the 0ichmond 'gitation8

%edation %cale which ranges from >= to A7 withmore negative scores indicating deeper sedationand more positive scores indicating increasingagitation and with @ representing the appearanceof calm and normal alertness/


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IDENTIFYING DELIRIUM


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PREVENTION AND TREATMENTOF DELIRIUM

P e!ention

&utside the ICU repeatedreorientation noisereduction cognitivestimulation vision an hearingaids adequate hydration andearly mo#ili(ation can reducethe incidence of delirium inhospitali(ed patients


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low-dose haloperidol and low-dose risperidone #othreduced the incidence ofdelirium as did a single lowdose of !etamine during theinduction of anesthesia

These trials were conductedamong patients undergoingelective surgical proceduresand it is not clear whether

their results can #e


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Cholinesterase inhi#itorrivastigmine wasine1ective inpreventing delirium

%edation with dexmedetomidinerather than #en(odia(epinesappears to reduce theincidence of delirium in the ICU


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'dministration of dexmedetomidine ormida(olam resulted in similarproportions of time within the targetrange of >? to A9 on the 0ichmond'gitation8%edation %cale among

patients #ut those assigned to receivedexmedetomidine had a reduced ris!of delirium and spent less timeundergoing mechanical ventilation


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T eat"ent

In a study of 6B patients who wererandomly assigned to treatmentwith quetiapine or place#o

delirium resolved faster inpatients who received quetiapine.The use of quetiapine alsoincreased the num#er of patientswho were discharged to their ownhome or to reha#ilitation


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' study of 9@6 patients who wererandomly assigned to receiveregular haloperidol (iprasidoneor place#o showed no signi+cant

di1erences in the num#er of daysthat patients survived withoutdelirium or coma


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The single study comparinghaloperidol with an atypicalantipsychotic olan(apine/ showedequivalent e cacy

Comparing dexmedetomidine withhaloperidol in patients withhyperactive deliriumdexmedetomidine was associatedwith a shorter time to extu#ationand shorter length of stay in theICU


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CONCLUSIONS

Danagementof sedation anddelirium can have animportante1ect on the outcomes of patientswho are treated in ICUs


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The #est outcomes are achieved with the

use of a protocol in which the depth ofsedation and the presence of pain anddelirium are routinely monitored pain istreated promptly and e1ectively theadministration of sedatives is !ept to theminimum necessary for the comfort andsafety of the patient and earlymo#ili(ation is achieved wheneverpossi#le


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T)0ID'

E'%IF

jurding sedation and delirium in the intensive care unit

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