Sedation practices in ICU
- 1. Dr. Abhijit S. Nair Consultant Anesthesiologist CITIZENS HOSPITALS Hyderabad
- 2. Sedation scores Problems of sedation To evolve a sedation protocol Emphasize on documentation
- 3. Pharmacology of drugs Dosing Preparation/ storage etc
- 5. Tube tolerance Ventilator synchronization Reduce agitation ( withdrawal etc) Pain relief Facilitate interventions
- 6. Sleep deprivation Increased stress Increased inflammatory mediators
- 8. Prolongs ICU stay Prolongs weaning Risk factor for delirium ( BZDs ) ?CIPN Hemodynamic disturbances
- 9. 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
- 10. Counselling ( family, primary, nursing staff ) Psychologist Psychiatrist Music Feeding Adequate hydration NOT FOR VENTILATED PATIENTS
- 11. 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
- 12. Narcotics Benzodiazepines Miscellaneous
- 17. Propofol Hypertriglyceridemia CVS depression Hypotension 2-agonists Hypotension Bradycardia Benzodiazepines Hypotension Respiratory depression Agitation/Confusion Ketamine Hypertension Secretions Dysphoria General Over sedation Delayed awakening/extubation
- 18. “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”
- 20. Suctioning Positioning/ bed making Procedures ( including removals )
- 23. Ramsay sedation score Bloomsbury sedation score RASS Sedation Agitation Scale
- 28. RAAS & SAS >>> Most valid and reliable sedation assessment tool in adult ICU
- 29. Auditory evoked potential BIS Narcotrend Index Patient State index State Entropy Scoring scales Not recommended by SCCM
- 31. 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
- 32. 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
- 34. Prolonged ICU stay Prolonged sedation Benzodiazepines Alcoholics, Chronic smokers Elderly Organ dysfunction
- 35. Acutely fluctuating mental status Inattention Disorganized thinking Altered mentation With/ without agitation
- 40. 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
- 43. Propofol / Dexmedetomidine : Short duration sedation( 24-48 hours ) Fentanyl ( long duration, > 48 hours ) Avoid BZD infusion SEDATION HOLIDAY
- 44. 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
- 45. > 48 hours ? High dose metabolic acidosis, rhabdomyolysis Arrhythmias myocardial & renal failure hepatomegaly Death
- 46. 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
- 48. Protocol for addressing Pain, Agitation, Delirium in ICU Monitor Pain, Agitation & Delirium ( Scoring systems ) Document SCORES
- 49. Use non-benzodiazepine sedative Light level of sedation is associated with improved clinical outcomes Adequate analgesia for procedures Review medications daily
- 50. Sedation Holiday Early mobilization Brain function monitoring recommended if NDMR used Brain function monitoring not recommended in non-comatose patients CONDUCIVE ENVIRONMENT IN ICU