Sedation and Sedation and Analgesia in the Analgesia in the

ICUICU

34 year old man was admitted to the 34 year old man was admitted to the intensive are unit 3 days ago for intensive are unit 3 days ago for increasing respiratory failure from increasing respiratory failure from community acquired pneumonia.community acquired pneumonia.

He is intubated and ventilated in an He is intubated and ventilated in an ARDSNet lung protective strategy ARDSNet lung protective strategy and on 5 mcg/min of levophed.and on 5 mcg/min of levophed.

The bedside nurse calls you at 0342 The bedside nurse calls you at 0342 because the patient is distressed.because the patient is distressed.

When you examine the patient, his When you examine the patient, his eyes are open and he is pulling at the eyes are open and he is pulling at the restraints.restraints.

His blood pressure is 193/90, heart His blood pressure is 193/90, heart rate 120, respiratory rate 34, oxygen rate 120, respiratory rate 34, oxygen saturations 91%.saturations 91%.

Last ABG: pH 7.37, PCO2 43, PO2 84, Last ABG: pH 7.37, PCO2 43, PO2 84, BE-1.BE-1.

Physical exam is unchanged from your Physical exam is unchanged from your last examination in the morning.last examination in the morning.

What are some physiological reasons for What are some physiological reasons for the patient’s current condition?the patient’s current condition?

You rule out any obvious physical causes You rule out any obvious physical causes for this behavior. What are 5 possible for this behavior. What are 5 possible causes for patient distress?causes for patient distress? AnxietyAnxiety PainPain DeliriumDelirium DyspneaDyspnea Neuromuscular paralysis while awareNeuromuscular paralysis while aware

What is the definition of anxiety?What is the definition of anxiety? State of apprehension and autonomic State of apprehension and autonomic

arousal in response to real of perceived arousal in response to real of perceived threats.threats.

What is the definition of delirium?What is the definition of delirium? Acute, reversible, impairment of Acute, reversible, impairment of

consciousness and cognitive function consciousness and cognitive function that fluctuates in severity.that fluctuates in severity.

Can a patient with normal blood Can a patient with normal blood gases be dyspneic? Why?gases be dyspneic? Why?

The patient is obviously not paralyzed and The patient is obviously not paralyzed and the nurse really wants you to do something the nurse really wants you to do something as the patient is getting worse and as the patient is getting worse and becoming a danger to himself.becoming a danger to himself.

What non-pharmacological methods of What non-pharmacological methods of treating distress may help?treating distress may help? Fix reversible causes identifiedFix reversible causes identified Minimize irritating stimuli such as pulling on Minimize irritating stimuli such as pulling on

the ETTthe ETT ReassuranceReassurance Communication to and from the patientCommunication to and from the patient Family visitsFamily visits Sleep cycle hygieneSleep cycle hygiene

Your attempts at reassurance has Your attempts at reassurance has been met with marginal success.been met with marginal success.

What four drug types are used to What four drug types are used to treat patient distress?treat patient distress? BenzodiazepinesBenzodiazepines OpiodsOpiods NeurolepticsNeuroleptics Propofol Propofol

What is the mechanism of action of What is the mechanism of action of benzodiazepines?benzodiazepines?

Are they indicated for anxiety, pain, Are they indicated for anxiety, pain, delirium, dyspnea, or awake paralysis?delirium, dyspnea, or awake paralysis?

What benzodiazepines are usually What benzodiazepines are usually available in the ICU?available in the ICU?

How are they different from each How are they different from each other?other?

What are the doses for each of these?What are the doses for each of these?

What factors determine Ativan and Verseds’ What factors determine Ativan and Verseds’ differences between each other?differences between each other? Receptor binding affinityReceptor binding affinity

Ativan is higher and therefore is more potent.Ativan is higher and therefore is more potent. LipophilicityLipophilicity

Versed is more lipophilic and therefore crosses the Versed is more lipophilic and therefore crosses the blood-brain barrier faster giving it a more rapid onset. blood-brain barrier faster giving it a more rapid onset. Can store in adipose tissueCan store in adipose tissue

Elimination kineticsElimination kinetics Versed undergoes rapid hepatic oxidation.Versed undergoes rapid hepatic oxidation. Ativan has a low hepatic clearance and Vd and is Ativan has a low hepatic clearance and Vd and is

glucuronide conjugation and excreted in the kidneys glucuronide conjugation and excreted in the kidneys Why is Ativan not generally given by Why is Ativan not generally given by

continuous infusion?continuous infusion? What happens to the kinetics of Versed if What happens to the kinetics of Versed if

given continuously over several days? Why?given continuously over several days? Why?

While you are up, another nurse While you are up, another nurse approaches you about his patient.approaches you about his patient.

He is taking care of a 56 year old woman He is taking care of a 56 year old woman who is one day post op for a bowel who is one day post op for a bowel resection due to ischemic colitis.resection due to ischemic colitis.

The patient has awoken and complaints of The patient has awoken and complaints of diffuse abdominal pain particularly around diffuse abdominal pain particularly around the wound.the wound.

She is hemodynamically stable and physical She is hemodynamically stable and physical exam finds diffuse tenderness but no exam finds diffuse tenderness but no rebound or guarding.rebound or guarding.

WBC is going down and her creatinine and WBC is going down and her creatinine and ABG are normal.ABG are normal.

What are some causes for this pain?What are some causes for this pain? How do opiods work?How do opiods work? What types of opiods are commonly used in the What types of opiods are commonly used in the

ICU?ICU? What is the usual dose range for bolus and What is the usual dose range for bolus and

infusion of morphine, fentanyl, and infusion of morphine, fentanyl, and hydromorphone?hydromorphone?

What is the time to peak effect and elimination What is the time to peak effect and elimination of each of these drugs?of each of these drugs?

Why is transdermal fentanyl usually not used in Why is transdermal fentanyl usually not used in the ICU?the ICU?

The nurse for the first patient comes over The nurse for the first patient comes over to get you. Her patient is now much to get you. Her patient is now much more combative and confused after being more combative and confused after being given 2 mg of ativan twice in the last given 2 mg of ativan twice in the last hour.hour.

Why is this patient more agitated?Why is this patient more agitated? What alternative treatment can be used What alternative treatment can be used

in this case?in this case? What is the mechanism of action of What is the mechanism of action of

haloperidol? haloperidol?

What is the usual dosage range for What is the usual dosage range for haloperidol?haloperidol?

What is the half-life and elimination What is the half-life and elimination for haloperidol?for haloperidol?

What are the two most important What are the two most important side effects of haloperidol?side effects of haloperidol? Prolonged QT and Torsade de pointesProlonged QT and Torsade de pointes Extrapyramidal effectsExtrapyramidal effects

As you are wandering back to bed, As you are wandering back to bed, you check in on a patient who was you check in on a patient who was admitted two days ago with epiglottis.admitted two days ago with epiglottis.

She is sedated on a propofol infusion.She is sedated on a propofol infusion. What is the mechanism of action of What is the mechanism of action of

propofol?propofol? What are the indications for propofol What are the indications for propofol

use in the ICU?use in the ICU?

What is the usual dose range for propofol?What is the usual dose range for propofol? What are the contraindications for What are the contraindications for

propofol?propofol? What are three of the most important side What are three of the most important side

effects of propofol?effects of propofol? HypotensionHypotension HypertriglyceridemiaHypertriglyceridemia Lactic acidosis and rhabdomyolysisLactic acidosis and rhabdomyolysis

Why is the patient’s urine bag green?Why is the patient’s urine bag green? How many calories/mL are in propofol?How many calories/mL are in propofol?

In the morning, you come back to In the morning, you come back to see and examine your patient with see and examine your patient with agitation and pneumonia. He is now agitation and pneumonia. He is now completely unresponsive to voice or completely unresponsive to voice or pain.pain.

Overnight he has received 15 mg of Overnight he has received 15 mg of ativan and 25 mg of haloperidol.ativan and 25 mg of haloperidol.

His nurse now states that the patient His nurse now states that the patient is comfortable and wants to continue is comfortable and wants to continue the current plan.the current plan.

What methods or tools can we use to What methods or tools can we use to measure depth of sedation?measure depth of sedation? ConsiderConsider

SASSAS RASSRASS MSATMSAT MAASMAAS

How is the sedation tools at this site How is the sedation tools at this site performed?performed?

What is a BIS monitor?What is a BIS monitor? What role do they have in the ICU?What role do they have in the ICU?

What are the consequences to oversedation What are the consequences to oversedation in critically ill patients?in critically ill patients?

What are some methods to avoid What are some methods to avoid oversedation?oversedation? ConsiderConsider

Intermittent bolus dosing, no continuous infusionsIntermittent bolus dosing, no continuous infusions Daily interruption of sedationDaily interruption of sedation

What are the long term psychological What are the long term psychological consequences of ICU?consequences of ICU? PTSDPTSD Cognitive dysfunctionCognitive dysfunction DementiaDementia

Questions??Questions??