Sedation in the ICU

Sedation in the ICUDoctor ChadPulmCrit.com+CaseA 60 year old woman with a past medical history of IVDU and poorly controlled COPD on home oxygen presents to the ED after being found down by her husband. He reported she had 2 days of increasing cough and on arrival, she was noted to have fevers to 103.4, was increasingly somnolent and hypotensive. In the emergency room, she received several liters of normal saline and was placed on a ventimask. Because of her increasing oxygen requirement, she was transferred to the ICU.

In the intensive care unit, she became combative and an initial ABG revealed hypercapnia with a pH of 7.25, pCO2 48, PaO2 of 69. She was tried on a BiPAP mask which she did not tolerate, her hypercapnia worsened, and therefore she was intubated.+PET 103.4, HR 132, RR 34, BP 85/56 oxygen saturation 100% on the ventilator with a tidal volume of 400, respiratory rate 20, FiO2 100% and a PEEP of 5. Gen: White obese female on the ventilator, intubated and sedated.HEENT: Pupils are equal, round, and reactive to light. Conjunctivae pale. ET tube in place. Right IJ triple lumen site clean.CHEST: Very coarse breath sounds anterior and posterior bilateral with occasional wheeze.ABDOMEN: Obese, positive bowel sounds, soft, non-tender.EXTREMITIES: Trace edema bilaterally and they are cool to the touch.NEUROLOGIC: Intubated, sedated and does not open eyes to voice. The patient does move her upper extremities and lower extremities.

+What are the goals of sedation in this patient?+Goals of SedationImproving patient comfortBlunting adverse autonomic and hemodynamic responsesControl of painAnxiolytics and amnesiaFacilitate nursing managementFacilitate mechanical ventilationAvoid self-extubation and removal of invasive lines and monitoring devices.Reduce oxygen consumption

+To use just enough of an optimally chosen sedative or analgesic for the shortest possible time [1]. By doing so we avoid deleterious cardiopulmonary effects and help reduce the risk of the late cognitive deficits and neuromuscular adverse effects of sedative medications.

5Case contdShe occasionally appears to be grimacing; she remains tachycardia and her eyes are tearing.

What are some methods of evaluating pain in the non-communicative adult patient?+Methods for assessing painTwo of the most popular methods with well established validity and reliability are the BPS and CPOT

The Behavior Pain Scale (BPS) is a scale based on a sum score of three items:

facial expressionmovements of upper limbscompliance with mechanical ventilation

Higher scores signify more pain. Each pain indicator is scored from 1 (no response) to 4 (full response), with a maximum score of 12.+CPOTCritical Care Pain Observational Tool is a similar tool that scores on facial expression, body movement, muscle tension, compliance with the ventilator OR vocalizations in extubated patients. Each of these behaviors is assigned a rating of 0 to 2. Higher scores imply pain is under-treated.+What are some choices for analgesic agents in this patient?

+OpiatesOpiates are the analgesics of choice in the ICU.

Morphine, Fentanyl and Dilaudid are the mainstays of this class.

Morphine is the recommended analgesic in critically ill patients owing to its low cost, potency, euphoric effects and analgesic efficacy. SE: morphine is metabolized to active metabolites, including morphine-6-glucuronide that accumulates in renal failure potentially resulting in prolonged sedation and respiratory depression

+Opiates contdFentanyl is the preferred analgesic for critically ill patients with hemodynamic instability, for patients with symptoms of histamine release with morphine (e.g. hypotension, pruritus) or morphine allergy. IV Fentanyl has a relatively short half-life (30 to 60 mins) Due to its high lipophilicity, ongoing use leads to accumulation in peripheral compartments increase in half-life to 9 to 16 hrs.+Opiates contdHydromorphone (Dilaudid) can serve as an acceptable alternative to morphine - more potent with less euphoria.

All opioids produce a dose-dependent respiratory depression; other common side effects include muscle rigidity, hypotension, delayed GI transit, nausea, pruritus, and urinary retention.

+methylnaltrexane12Analgesics to avoid in the ICUDemerol and NSAIDS are not recommended in the critically ill.Demerol has an active metabolite, normeperidine accumulates and produce central nervous system excitation leading to seizures. NSAIDs - potential risks of gastrointestinal bleeding, renal insufficiency.

+Case contdAn hour after intubation, she opens her eyes and begins to buck and fight against the ventilator. She unable to follow commands, lashes out trying to hit her nurse and appears to be trying to self extubate.+What are some methods you could use to assess her level of sedation and agitation?+Assessing agitationThere are several scales developed to assess the level of sedation of the critically ill adult. These include the:

Richmond Agitation-Sedation Scale (RASS)Ramsay Sedation Scale (RSS)Sedation Agitation Scale (SAS)Motor Activity Assessment Scale Vancouver Interactive and Calmness Scale (VICS)Adaptation to Intensive Care Environment (ATICE) instrument Minnesota Sedation Assessment Tool (MSAT)

+Ramsay Sedation Scale

Ramsay sedation scaleScoreResponse1Anxious or restless or both2Cooperative, orientated and tranquil3Responding to commands4Brisk response to stimulus5Sluggish response to stimulus6No response to stimulus

+Richmond Agitation Sedation Scale (RASS) *

Score Term Description +4 Combative Overtly combative, violent, immediate danger to staff +3 Very agitated Pulls or removes tube(s) or catheter(s); aggressive +2 Agitated Frequent non-purposeful movement, fights ventilator +1 Restless Anxious but movements not aggressive vigorous 0 Alert and calm -1 Drowsy Not fully alert, but has sustained awakening(eye-opening/eye contact) to voice (>10 seconds)-2 Light sedation Briefly awakens with eye contact to voice (