LOGO

Sedation in the ICU

Prof. Bahaa EweesAin Shams University

Contents

Definition of Sedation1

Importance of Sedation in the ICU2

Monitoring of Sedation3

Mode of Sedation4

Examples of Sedation Protocol5

Delivery of Sedation5

Sedation: depression of awareness and reduction of the response to external stimuli

Definition of Sedation1

Plays a vital role in the care of critically-ill patients and encompasses wide spectrum of symptom management.

Heavy sedation is used to facilitate ETT insertion and M.V. (replacing NMBA)

Importance of Sedation2

Monitoring of Sedation3

Done HourlyTo avoid:

Under-Sedation

Heavy Sedation

↑ catecholamines Coagulopathy and Immune Suppression

* ↑ duration of ICU stay and M.V.* Side Effects of sedationdrug

Monitoring of Sedation3

1. Scoring Systems

2. Instrumental

BIS

EEG

Mode of Sedation4

Non Pharmacological

Pharmacological

Mode of Sedation4

Non Pharmacological

1. Continuous communication with the patient

2. Good Hydration

3. Good Nutritional Support

4. Physiotherapy Ve………..ry Important

Mode of Sedation4

Pharmacological

A. Drugs used for Induction of Anaesthesia

B. Benzodiazepines

C. Neuroleptic Agents

D. Opioids

E. Clonidine and Dexmedetomedine

Pharmacological

A. Drugs used for Induction of AnaesthesiaA. Propofol

Widely used due to high clearance and metabolism. Dose: 0.5 – 4 mg/kg/h. Problems

↓ HR ↓ BP Propofol Infusion Syndrome

Pharmacological

Propofol Infusion Syndrome Rare Manifestations

↓ pH Arrhythmias Cardiovacular collapse Acute renal Failure Hyperkalaemia

Risk factors Sepsis Severe Cerebrovascular Stroke High propofol doses (> 5 mg/kg/h.)

Pharmacological

Propofol Infusion Syndrome (cont.) Recommendations

Once suspected, stop infusion Dose should be < 4mg/kg/h. Duration should be less than 24 h. Daily monitoring of triglyceride levels and renal

function.

Pharmacological

A. Drugs used for Induction of AnaesthesiaB. Thiopental used by infusion (for status epilepticus to

control convulsions) Problems:

Low clearance Metabolized by redistribution Myocardial depression Accumulation

Pharmacological

A. Drugs used for Induction of AnaesthesiaC. Etomidate Infusion Only BUT, ↓↓↓↓ adrenocortical

function

Pharmacological

A. Drugs used for Induction of AnaesthesiaD. Ketamine Can be used for intubation in the ICU Sedation especially in asthmatic patient

BUT, ↑↑ CMRO2, Delirium, and hallucination

Pharmacological

B. Benzodiazepines Acting on GABA receptors (the main inhibitory

neurotransmitter in CNS)

1. Midazolam Metabolized in liver to active metabolite Highest clearance among BZs Suitable for infusion (0.04 – 0.2 mg/kg/h.)

2. Diazepam Metabolized to active metabolite by liver Lowest clearance among BZs Suitable for oral use or bolus injection (2- 10 mg)

Pharmacological

C. Neuroleptic Agents Haloperidol or Chloropromazine Used for delirium and psychosis in the ICU Can cause:

Respiratory depression Prolonged QT interval Arrhythmias

Pharmacological

D. Opioids Provide analgesia and anxiolysis Better used by infusion Remifentanil (ultrashort acting opioid)

0.1 – 0.15 ug/kg/min.

Pharmacological

E. Clonidine and Dexmedetomedine Alpha 2 Agonists

Can be used for sedation in both spontaneous and mechanically ventilated patients.

Dexmedetomedine is more potent than clonidine Shorter elimination t1/2

So, it is widely used nowadays for sedation

Delivery of Sedation5

Intermittent Injection

Bolus Injection

Infusion

ConstantLevel ofsedation

1

Less chanceOf

Intermittentagitation

2

Delivery of Sedation5

Sedation Holiday

Stopping the sedation infusion and allowing the patient to awake.

Restarted once: Patient fully awake and obeying commands, or Patient becoming agitated or uncomfortable

Should be done on a daily basis!This strategy ↓ duration of MV and Length of

stay in ICU.

Example of Sedation Protocols6

Short term therapy< 72 h.

Hemodynamically stable?

YES

* Propofol infusion

* Opioid

- Remifentanil

- Fentanil

NO

* Alfentanil infusion

If necessary consider propofol infusion.

Example of Sedation Protocols6

Long-term therapy> 72 h.

CONSIDER

1. Opioid

- morphine infusion

- Alfentanil infsion (if Renal failure)

2. Benzodiazepine

LOGO