sedation and analgesia in the icu
DESCRIPTION
Sedation and analgesia in the ICU. Dr Jeju Nath Pokharel, MD Sr consultant anesthesiologist and Head Dept of Anesthesiology SGNHC, Bansbari, Kathmandu, Nepal. Some definitions. Pain – It is an unpleasant sensory and emotional experience associated with actual or potential tissue damage . - PowerPoint PPT PresentationTRANSCRIPT
Dr Jeju Nath Pokharel, MD
Sr consultant anesthesiologist andHead Dept of Anesthesiology
SGNHC, Bansbari, Kathmandu, Nepal
Sedation and analgesia in the ICU
Some definitionsPain – It is an unpleasant sensory and emotional
experience associated with actual or potential tissue damage.
Analgesia - is defined as the blunting or absence of sensation of pain or noxious stimuli. (ACCM 2002)
Anxiety - a sustained state of apprehension with accompanying autonomic arousal in response to a real or perceived threat.
Delirium – an acute, potentially reversible impairment of consciousness and cognitive function that fluctuates in severity.
Agitation – it is characterized by extreme arousal,irritability, excess motor activities driven by internal sense of discomfort such as disease, pain, anxiety and delirium.
BackgroundOne third of all patients in intensive care units
(ICUs)worldwide are mechanically ventilated. Common conditions in mechanically ventilated, critically
ill, trauma patients are acute pain, anxiety, and delirium.ICU patients frequently experience pain and physical
discomfort from obvious factors, such as pre-existing diseases, invasive procedures, or trauma. Pain and discomfort also can be caused by:
- monitoring and therapeutic devices such as catheters, drains, and endotracheal tubes
- performing routine nursing care (e.g., airway suctioning, physical therapy, dressing changes, patient mobilization)
-prolonged immobility.
Background unrelieved pain may contribute to inadequate
sleep and disorientation, and evoke a stress response, decreased cell repair cellular immunity.
Severely ill patients in a stressful environment for prolonged periods may also experience delirium.
Delirium itself is attributed to increased length of hospital stay, increased health care costs, and higher mortality.
Additionally, the ICU patient may experience heart, lung, liver, and kidney complications, Post Traumatic Stress Disorder (PTSD), and long-term cognitive decline.
Background Safe and effective management of an ICU
patient’s pain and anxiety demands a delicate balance of analgesia and sedation protocols while managing delirium.
Why sedation and analgesia is required ?To improve patient comfort.Reduce stress.Facilitate interventions.Allow effective ventilation/oxygenation.Encourage natural sleep.?? Prevent post-ICU psychosis.
Hypnosis
± MuscleRelaxation
Analgesia
• Sedation comes from the Latin word sedare.• Sedare = to calm or to allay fear
Balancing Pain and Anxiety Treatment
PROMOTE NATURAL SLEEP CYCLEAllow natural sleep at nightStick to the schedule for sleep.Avoid frequent waking tasks and prevent interruptions.Use back massage to relax the patient for sleep.Create a quiet, dark environment conducive to
sleep as much as possible, lessen outside lighting, turn off lights including flashing indicators, and reduce human and mechanical noise.
Use natural sleep cues ( lighting, noise, smells, room with windows which can mimic 24 hour day to regulate day light /darkness.
Use music therapy to encourage sleep.Facilitate patient’s familiarity with environment.
Employ comfort measures:• Provide complementary holistic therapies• Encourage family to stay at bedside• Remove unnecessary lines and tubes• Remove or minimize restraints• Encourage family to be at the bedside and
engage the patient in activities as well as sitting quietly with the patient to promote rest
PATIENT ASSESSMENT
PATIENT ASSESSMENT
Pain Pain is an unpleasant sensory or emotional
experience that is associated with tissue damage or described in terms of tissue damage. (International Association for the Study of Pain,www.iasp-pain.org).
All critically ill patients have the right to adequate analgesia and management of their pain.
A patient’s pain experience in the ICU need not be
memorable given effective attention and application of pain management and amnesic agents.
Self reporting pain assessment scale: Wong –Baker FACES Pain rating scale
Non – verbal reporting of pain:10 point non – verbal pain scale.
Non verbal reporting of pain:The Critical-Care Pain Observation Tool (CPOT)
Pain management algorithm
Some analgesics
SedationSedatives are drugs that calm a patient down, easing
agitation and permitting sleep.Sedatives generally work by modulating signals within
the central nervous system.The appropriate target level of sedation is a calm
patient that can be easily aroused with maintenance of the normal sleep-wake cycle (SCCM).
Advantage/disadvantageRobinson et al (2008) found continuous sedative
infusions for critically ill patients have been shown to increase the duration of mechanical ventilation and length of intensive care stay, despite perceived advantages.
coordinated daily interruption of sedative infusions with objective re-titration in critically ill patients has been shown to decrease the durations of mechanical ventilation and length of ICU stay.
Sedation assessment scalesRichmond Agitation Sedation Scale (RASS) RASS Target Sedation = 0 to -3 Riker Sedation-Agitation Scale (SAS) SAS Target Sedation = 3 to 4 Ramsay scale ( RS )VICS (Vancouver Interaction and Calmness Scale)MAAS (Motor Activity Assessment Scale)The AVRIPAS scaleThe BLOOMSBURY ScaleHS (Harris Scale)ATICE (Adaptation to the Intensive Care
Environment).
Sedation assessment scales
Sedation assessment scale
Sedation assessment scales- RS (Ramsay Scale):Level Response 1 Awake and anxious, agitated, or restless 2 Awake, cooperative, accepting ventilation,
oriented, tranquil 3 Awake; responds only to commands 4 Asleep; brisk response to light glabellar tap or
loud noise 5 Asleep; sluggish response to light glabellar tap
or loud noise stimulus but does not respond to painful stimulus
6 Asleep; no response to light glabellar tap or loud noise
Figure . The Ramsay Scale. Modified from Ramsay M, Savege T, Simpson BRJ, et al. Controlled sedation with alphaxalone/alphadolone. BMJ 1974;2:656–569.
Non pharmacological methods of sedationenvironment modification,relaxation, back massage, and music
therapy when appropriate.
Pharmacological method of sedation
Pharmacology of selected sedatives
Daily awakening trialA Daily Awakening Trial (or Sedation Vacation) is
titrating down continuous infusions of sedatives or holding sedation bolus until the patient is awake
Once the patient is awake and responsive, an accurate sedation, pain, and delirium assessment can be obtained
It is recommended to couple spontaneous breathing trial protocols with sedation protocols
combining a spontaneous breathing trial protocol with a daily wakening trial results in patients spending less time on mechanical ventilation, less time in coma, and less time in intensive care and the hospital.
Daily Awakening Trial and Spontaneous Breathing Trial
SEDATIVE AND ANALGESICWITHDRAWALBenzodiazepines dysphoria, tremor, headache, nausea, sweating, fatigue, anxiety, agitation, increased sensitivity to light and
sound, paresthesias, muscle cramps, myoclonus, sleep disturbances, delirium, and seizures.
Opioids dilation of the pupils sweating, lacrimation rhinorrhea, piloerection tachycardia, vomiting, diarrhea, hypertension, yawning, fever, tachypnea, restlessness, irritability, increased sensitivity to pain, cramps, muscle aches, anxiety.
DELIRIUM Delirium, characterized by fluctuations in
mental status such as inattention,disorganized thinking,hallucinations, disorientation, and an altered level of consciousness, is a frequent occurrence in the intensive care unit (ICU).
Occurs in up to 65 percent of hospitalized patients, and up to 87percent of patients admitted to the ICU.
Hyperactive delirium, Hypoactive delirium, Mixed delirium
Agitation & delirium: an aide memoire for routine useI WATCH DEATH InfectionWithdrawalAcute metabolic problemTrauma/ painCNS pathologyHypoxia/Hypoglycemia
Deficiencies (B1, B12)
EndocrinopathiesAcute vascularToxins/ drugsHeavy metals
DELIRIUMDrugsElectrolyte
abnormalitiesLack of drugs InfectionReduced sensory input Intracranial problem
Urinary retention & fecal impaction
Myocardial infarction
Drugs that can cause Delirium
Anti-arrhythmics Lidocaine Mexilitine QuinidineAntibiotics: PenicillinAnti-cholinergics: atropineAnti-histaminicsBeta-blockers: propranololNarcotics: meperidineMorphinePentazocine
Delirium Assessment (CAM-ICU) Algorithm
Intensive Care Delirium Screening Checklist (ICDSC)
Risk Factors for DeliriumDelirium in patients usually develops between 24
and 72 hours after admission to ICU.Risk factors before hospitalization: cognitive
impairment, chronic illness (including hypertension), advanced age (over 65 years), depression, smoking, alcoholism, and severity of illness.
Risk factors during hospitalization: Congestive heart failure, sepsis, prolonged restraint use and immobility, withdrawal, seizures, dehydration, hyperthermia, head trauma, intracranial space-occupying lesions, and the use of specific medications: LORazepam/ Midazolam, Morphine/fentanyl, and Propofol.
Delirium Management Algorithm
ConclusionICU sedated pt care map
Thank you for attention !