SEDATION PRACTICES IN ICU

Dr. Abhijit S. NairConsultant Anesthesiologist

CITIZENS HOSPITALSHyderabad

Scope of the class:

Sedation scores Problems of sedation To evolve a sedation protocol Emphasize on documentation

What I won’t discuss?

Pharmacology of drugs Dosing Preparation/ storage etc

Why sedate?

Why sedate?

Tube tolerance Ventilator synchronization Reduce agitation ( withdrawal etc) Pain relief Facilitate interventions

Problems of inadequate sedation

Sleep deprivation Increased stress Increased inflammatory mediators

Over-sedation

Vs Under-sedation

Oversedation

Prolongs ICU stay Prolongs weaning Risk factor for delirium ( BZDs ) ?CIPN Hemodynamic disturbances

Undersedation:

hyper-catabolism immunosuppression Hyper-coagulability increased sympathetic activity Accidental extubation Hyperglycemia PTSD

Consales G, Chelazzi C, Rinaldi S, De Gaudio A R. Bispectral index compared to Ramsay score for sedation monitoring in intensive care units. Minerva Anestesiol 2006; 72: 329–36

Non-pharmacological sedation

Counselling ( family, primary, nursing staff )

Psychologist Psychiatrist Music Feeding Adequate hydration

NOT FOR VENTILATED PATIENTS

Ideal sedative: Short acting ( plasma t 1/2 & context

sensitivity ) Amnesia Analgesia Less accumulation in peripheral tissues Hemodynamically stable No withdrawal effects No respiratory depression Bronchodilator CHEAP

SEDATIVES

Narcotics Benzodiazepines Miscellaneous

Unwanted side-effects of opioids

Respiratorydepression

ConfusionVasodilation

Gut motilitydepression

Opioids

Unwanted side-effects of sedative agents

PropofolHypertriglyceridemia

CVS depressionHypotension

2-agonists

Hypotension

Bradycardia

BenzodiazepinesHypotension

Respiratory depressionAgitation/Confusion

KetamineHypertension

Secretions

Dysphoria

GeneralOver sedation

Delayed awakening/extubation

“the inability to communicate verbally does not negate the possibility that an individual is experiencing pain and is in need of appropriate pain-relieving treatment”

Painful situations:

Suctioning Positioning/ bed making Procedures ( including removals )

Critical care pain observation tool

Sedation scores

Ramsay sedation score Bloomsbury sedation score RASS Sedation Agitation Scale

Which scoring system to use?

RAAS & SAS >>> Most valid and reliable sedation assessment tool in adult ICU

Monitoring of brain function( Non-comatose patients )

Auditory evoked potential BIS Narcotrend Index Patient State index State Entropy Scoring scales

Not recommended by SCCM

BIS: No evidence or rationale at present

Brain function monitoring not recommended for non- comatose, non-paralysed patients

Brain function monitoring recommended along with sedation scores in patients who are paralysed in ICU

EEG monitoring recommended in patients with non-convulsive seizure activity, suspected seizure activity

ICU delirium

Syndrome characterized by the acute onset of cerebral dysfunction with a change or fluctuation in baseline mental status, inattention, and either disorganized thinking or an altered level of consciousness

Up to 80 % adults on ventilator experience delirium

Costly affair

Gupta N, de Jonghe J, Schieveld J, et al: Delirium phenomenology: What can we learn from the symptoms of delirium? J Psychosom Res 2008; 65:215–222

Delirium

Prolonged ICU stay Prolonged sedation Benzodiazepines Alcoholics, Chronic smokers Elderly Organ dysfunction

Delirium ct.

Acutely fluctuating mental status Inattention Disorganized thinking Altered mentation With/ without agitation

DELIRIUM Hyperactive

Hypoactive

Delirium monitoring tools

Management

Neuroleptic agents ( No evidence ) α 2 agonists ( limited evidence ) Treat the cause SCCM doesn’t support or recommend

use of prophylactic methods to prevent ICU delirium ( No evidence )

Early mobilization is the only proven way to prevent ICU delirium

What to use? Propofol / Dexmedetomidine : Short duration

sedation( 24-48 hours ) Fentanyl ( long duration, > 48 hours ) Avoid BZD infusion SEDATION HOLIDAY

Sedation holiday

Interruption of sedation ( preferably daily )

Assess neurological status Restart after assessment or if

agitation increased Shown to reduce duration of

ventilation & ICU stay

Kress JP, Pohlman AS, O’Conner MF, et al. Daily interruption of sedation infusions in critically ill patients undergoing mechanical ventilation. N Engl J Med 2000; 342: 1471–7

PIS

> 48 hours ? High dose metabolic acidosis, rhabdomyolysis Arrhythmias myocardial & renal failure hepatomegaly Death

What usually happens?

Pain/ sedation assessment infrequently done

Implementation of recommendations not possible ( although discussed )

No documentation of scores Scores not addressed?? Sedation Holiday is practiced most of

the times

Take home message

Protocol for addressing Pain, Agitation, Delirium in ICU

Monitor Pain, Agitation & Delirium ( Scoring systems )

Document SCORES

Ct.

Use non-benzodiazepine sedative Light level of sedation is associated with

improved clinical outcomes Adequate analgesia for procedures Review medications daily

Ct.

Sedation Holiday Early mobilization Brain function monitoring recommended

if NDMR used Brain function monitoring not

recommended in non-comatose patients CONDUCIVE ENVIRONMENT IN ICU