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Lars Heslet Toronto February 07

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Lars Heslet Toronto February 07 Lars Heslet Toronto February 07 Presentation Transcript

  • Lars Heslet Professor ICU 4131 National University Hospital Rigshospitalet Copenhagen Denmark Best Practices in Pain Management in Critical Care
  • Introduction What is the problem?
  • Aim of sedation for Whom?
      • For the patient ?
      • For the Staff ?
    Shelly MP et al. Intensive Care Medicine 1999;25:137-9
  • Memory, delusions, and acute posttraumatic stress disorder C Jones et al. Memory, delusions, and the development of acute posttraumatic stress disorder-related symptoms after intensive care. CCM 2001; 29(3):573-580.
    • Patients with delusions, without memories of the ICU stay
    • Higher anxiety levels after ICU discharge,
    • More panic attacks after ICU discharge
    • More symptoms of posttraumatic stress disorder
    • after ICU discharge than patients with factual memories
    • and delusions or patients without delusion
    • Conclusion
    • Even unpleasant memories for real events during critical illness may protect from anxiety and development of PTSD-related symptoms when memories of delusions are prominent
    Do not sedate unless it is absolutely necessary
  • Effect of insufficient analgesia control
      • *DeKeyser F. Psychoneuroimmunology in critically ill patients.
      • AACN Clin Issues. 2003;14(1):25-32.
    Inadequate pain-treatment causes Organ involvement Autonomic reactions Tachycardia, Arterial hypertension Increased myocardial oxygen consumption Persistent catabolism Systemic effects Inadequate sleep,  exhaustion and disorientation Post traumatic stress disorder Continued stress response Agitation CNS Cytokine production* Immunosuppression* Neuroendocrine system dysfunction
  • To score or not to score that is the problem
  • The ”Sedation Scale” of the Staff Calm Comfortable
  • ” Patient´s scale”
    • Objective
    • Prospective controlled study of the effect of implementation of systematic evaluation of pain, agitation & sedation score in critically ill patients.
    • Interventions
    • Patients were scored twice daily.
    • The treating physician was alerted in case of increase pain and agitation score
    • Results
    • Incidence of pain and agitation decreased significantly in study group: Pain 63% vs. 42% (p=.002) and agitation 29% vs. 12% (p=.002)
    • Marked decrease in the duration of MV (17% vs. 8%, p<.05).
    • Conclusion
    • Systematic evaluation of pain and agitation, and analgesics and sedatives need was associated with a decrease in incidence of pain and agitation, duration of mechanical ventilation and nosocomial infections
    Impact of implementing numerical scoring rates (NSR) Chanques G, et al. Impact of systematic evaluation of pain and agitation in an intensive care unit. Crit Care Med. 2006 Jun;34(6):1691-9.
  • The most important treatment of anxiety is
    • Good human care – communication
    • Removal of pain, and unpleasant and unnecessary therapies
    • First thereafter might sedative drugs be considered
    • But do we need a ”speedometer” ?
  • Scoring systems Pain, Anxiety, Discomfort, Withdrawal Symptoms and Delirium VAS NRS PI SAS MAAS RAMSAY CAM- ICU RASS
  • Ramsay scale Ramsay MA, Savege TM, Simpson BR, Goodwin R: Controlled sedation with alphaxalone alphadolone. BMJ 1974, 2:656-659 The patient is Score Asleep no response to light glabellar tap or loud auditory stimulus 6 Asleep, sluggish reponse to light glabellar tap or loud auditory stimulus 5 Asleep brisk response to light glabellar tap or loud auditory stimulus 4 Responds to commands only 3 Cooperative, oriented & tranquil 2 Anxious & agitated/restless or both 1
  • The only way to be able to know whether the patient
    • is in pain
    • is anxious
    • is thirsty
    • is nauseated
    • is uncomfortable
    • due to e.g. the NG-tube
  • … is if the patient is awake !! (with the permission from the patient)
  • Effect on Morbidity of using Sedation and Analgesia Protocol
    • Objectives
    • To characterize the utilization of sedative, analgesic, and neuromuscular blocking agents,
    • The use of sedation scales, and daily sedative interruption in mechanically ventilated adults
    • - To define clinical factors that influence these practices - 60% of eligible physicians responded
    Protocols for sedation and analgesia A Canadia survey Mehta S et al. Canadian survey of the use of sedatives, analgesics, and neuromuscular blocking agents in critically ill patients Crit Care Med 2006; 34:374–380
  • Protocols for sedation and analgesia A Canadia survey
    • Use of sedation strategies that have been shown to improve outcome is not widespread, and tremendous variability exists in clinicians’ sedation practices throughout Canada.
    • The results of this survey emphasize the need for further educational and research efforts in sedative/ analgesic use in the ICU .
    Mehta S et al. Canadian survey of the use of sedatives, analgesics, and neuromuscular blocking agents in critically ill patients Crit Care Med 2006; 34:374–380
  • * Kress JP et al .Daily interruption of sedative infusions in critically ill patients undergoing mechanical ventilation. N Engl J Med. 2000 May 18;342:1471-7. ** Brook AD et al. Effect of a nursing-implemented sedation protocol on the duration of mechanical ventilation. Crit Care Med. 1999;27(12):2609-15
    • Comparison of 2 randomized trials: Morbidity was reduced by
    • using a sedation protocol
    P value Result P value Result Use of protocol Variable 13.2 % No 0.038 6.2 % - - Yes Tracheostomy Rate 7.5 days 9.9 days No 0.001 5.7 days 0.02 6.4 days Yes LOS in ICU 117 hrs 7.3 days No 0.003 55.9 hrs 0.004 4.9 days Yes Time on ventilator days Nurse protocol** Daily interuption*
  • Breen D et al. Decreased duration of mechanical ventilation when comparing analgesia based sedation using remifentanil with standard hypnotic based sedation for up to 10 days in intensive care unit patients: a randomised trial. Critical Care 2005; 9:R200-R210.
    • Analgesia based sedation a randomised during
    • mechanical ventilation - Safety and Efficacy (I)
    • Remifentanil-based sedation regime titrated to response before addition of midazolam for further sedation ( n = 57), or
    • Midazolam-based sedation regime with fentanyl or morphine added for analgesia ( n = 48)
    • Results
    • Remifentanil-based regime reduced duration of mechanical ventilation by more than 54 hours (p = 0.03),
    • Reduced the time to extubation with 27 hours (p < 0.001).
  • Breen D et al. Decreased duration of mechanical ventilation when comparing analgesia based sedation using remifentanil with standard hypnotic based sedation for up to 10 days in intensive care unit patients: a randomised trial. Critical Care 2005; 9:R200-R210. Analgesia based sedation a randomised during mechanical ventilation - Safety and Efficacy (II) Total midazolam dose (mg) Median time to offset of effect (hrs)
  • Breen D et al. Decreased duration of mechanical ventilation when comparing analgesia based sedation using remifentanil with standard hypnotic based sedation for up to 10 days in intensive care unit patients: a randomised trial. Critical Care 2005; 9:R200-R210. Analgesia based sedation a randomised during mechanical ventilation - Safety and Efficacy (III)
  • Breen D et al. Decreased duration of mechanical ventilation when comparing analgesia based sedation using remifentanil with standard hypnotic based sedation for up to 10 days in intensive care unit patients: a randomised trial. Critical Care 2005; 9:R200-R210.
    • In patients receiving midazolam, the use of remifentanil considerably reduced the total dose of midazolam required.
    • Mean infusion rate of remifentanil remained constant with no evidence of accumulation or of a development of tolerance to remifentanil.
    • Remifentanil was well tolerated.
    • Conclusion
    • Analgesia-based sedation with remifentanil was well tolerated;
    • Duration of mechanical ventilation was reduced
    • Improves the weaning process compared with standard hypnotic-based sedation regimes in ICU patients requiring longterm ventilation for up to 10 days.
    Analgesia based sedation a randomised during mechanical ventilation - Safety and Efficacy (VI)
  • What are the therapeutic options? What is the price?
  • Muellejans B et al. Sedation in the intensive care unit with remifentanil/propofol vs midazolam/fentanyl: a randomised, open-label,pharmacoeconomic trial. Critical Care 2006, 10:R91 Open-label, randomised trial of 2 analgesia sedation regimes after cardiac surgery in the ICU.
    • Conclusion
    • Remifentanil based analgesia and sedation supplemented
    • with propofol compared with Fentanyl/midazolam significantly
    • Reduces time on mechanical ventilation
    • Earlier discharge from the ICU, at ”equal” overall costs.
    N.S. 1,729/1,604 1,712/1,558 Total 0.05 42/46 353/343 Drugs Costs in € 0.05 62 46 ICU LOS (Hrs) 0.05 24 20 Time to extubation (Hrs) p-value Fentanyl/  Midazolam Remifentanil/  propofol Variable
  • Comparison of opioids for ICU analgesia Synergism with sedatives ► sedative-sparing effect - Remarks ++++ + Price Minutes. Independent on length of infusion Hours to days Depends on length of infusion Time to emergence - +++ Accumulation Elimination half-life < 10 min, independent of infusion duration and organ function Prolonged if infusion duration > days. Redistribution. Active metabolites important in renal dysfunction Elimination Metabolised rapidly (non-specific esterases) ►Inactive metabolite. Metabolism depending on hepatic CYP activity Achieves steady state quickly. Prolonged time to steady state Very short ~ 1 min Short to medium Onset of action and metabolism +++ +++ Potency Remifentanil Fentanyl / Morphine Opioid
  • Comparison of sedatives in the ICU Preferred for long sedation Anxiolytic effect Preferred for 2-3 days sedation Vasodilatation ► Pulmonary shunt/ & NA inf. Remarks + +++ Price Days Unpredictable depending on length of infusion Hours Predictable independent on length of infusion Time  emergence +++ (+) Accumulation Prolonged if infusion duration > days. Accumulation important in renal dysfunction Elimination half-life < 10 min, independent of infusion duration and organ function Elimination Prolonged time to steady state Achieves steady state quickly Long Short Onset of action and metabolism +++ +++ Potency Midazolam Propofol Sedatives
  • How do we do it? The end
  • How we do it - A 3 step model Propofol (Short) Midazolam (Long) Fentanyl (Bolus) Remifentanil infusion Haloperidol Light/Dark, Tube placement II. Treat Need for frequent Bolus administration Consider ! Opioid infusion - Fentanyl/remifentanil Sedative infusion - Propofol/midazolam Re-evaluation - Every 3rd hr - Diurnal variation? -Daily wakeup call III. Re-evaluate Set a goal Score Day/Night VAS & Ramsay General factors 3. Delirium ? Confusion ? 2. Agitated ? Anxiety ? 1. Pain? I. Observe
  • Conclusion I
    • Daily wake-up call important, avoid long acting drugs
    • - (Morphine & Midazolam)
    • Optimal: shift to Remifentanil
    • Analgesics/Sedatives induce increased morbidity: LOS in ICU/prolonged MV difficult weaning/complications tracheostomy and VAP
    • Reduce use of sedative. Ensure analgesia before sedation
    • Measure and use score systems to define objective goals VAS/ sedation scores with predefined score values.
  • Conclusion II
    • Daily wake up calls i.e. use short acting analgesics with wakeup time independent on state of metabolism (renal and/or hepatic dysfunction)
    • The optimal analgesics and sedatives are the most expensive  shift to Remifentanil 2-3 days before expected extubation
    • Abstinence regimes
    • Use protocols and NRS evaluation for sedation & analgesia reduces i.e. on Morbidity: LOS, MV, VAP-incidence
    • Pain and sedation must be current standard for assess-ment using numerical Rating Scales (NRS) (Grade B)
    • Use dose titration to defined endpoint with systematic tapering of the dose or daily interruption to minimize prolonged effects. (Grade A)
    • Use pain & sedation guidelines (Grade B)
    • Doses of opioids and sedatives tapered to prevent withdrawal symptoms until 7 days after continuous therapy (Grade B)
    Clinical practice guidelines for use of sedatives & analgesics in the critically ill Jacobi J et al. Clinical practice guidelines for the sustained use of sedatives and analgesics in the critically ill adult. Crit Care Med. 2002 Jan;30(1):119-41
    • Is it beneficial for the patient to have
      • Amnesia ?
      • Inability to indicate pain?
      • Inability to communicate?
      • Inadequate sleep?
      • Immobility?
      • Cardiovascular depression?
      • Immunodepression & lipid overload?
      • Withdrawal symptoms & delirium?
      • Prolonged ventilator treatment/ ICU -days?
      • Post-traumatic disstress syndrome?
    BJA 1997;79:276-9, ICM 2003; 29:1417-25, CCM1999;27:196-9, AJRCCM 2003;168:1457-61, BMJ 2002;324:1386-9, NEJM 2000;342:1471-7 Is sedation of the patient for the patient -or…? There is a price for everything But who is paying?
  • The patient´s scale Kvale R, Ulvik A, Flaatten H. Follow-up after intensive care: a single center study. Intensive Care Med. 2003;29(12):2149-56. 136 patients followed up 6 months > discharge from the ICU
  •  
  •  
  • A Danish survey on sedation and analgesia 82,9% of all hospitals answers, Response rate 57,7% Do you have a Protocol for sedation / analgesia? N = 108 26% 37% 14% 74% 63% 86% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% All Physicians Nurses Yes No
  • A danish survey on sedation and analgesia
  • A danish survey on sedation and analgesia 34 (53%) 16 (37%) Doctors 31 (47%) 27(63%) Nurses 65 (60%) 43 (40%) All No Yes “ Wakeup call test” Profession
  • A danish survey on sedation and analgesia
  • A danish survey on sedation and analgesia
  • Journal of Clinical Nursing 2002; 11: 831–840 Nurses view of sedation
    • inconsistency of sedation practices
    • need of clarification of sedation practices and
    • terminology
    • experienced nurses provide a better quality of
    • sedation than less experienced nurses
    • inappropriate sedation because of lack of problem
    • identification
  • How to improve sedation practice in daily care ? Effects of reinforcement of an existing sedation protocol M. Tallgren et al. Acta Anaesthesiol Scand 2006; 50: 942–946 5 (4-5) 5 (4-5) Sedation score nighttime (Ramsay 4) 4 (3-5) 4 (3-5) Sedation score daytime (Ramsay 2) 78 % 73 % Incidence of Daily sedation interruption After (170 days) Before (166 ICU days) Reinforcement
    • Control group (100 pt´s) scored with Behavioral Pain Scale,
    • Numeric Rating Scale and Richmonds Agitation Sedation
    • Scale twice daily in 21 weeks by interdependent observers
    • 4 weeks of training and education
    • Intervention group (130 pt´s) scored by nurses in 29
    • weeks.
    • The treating physician was alerted in case of pain
    • or NRS >3 or in case of agitation
    Impact of systematic evaluation of pain and agitation in an ICU Chanques et al. Impact of systematic evaluation of pain and agitation in an intensive care unit. Crit Care Med. 2006;34:1691-9.
    • Decreased incidence of pain and agitation in the interventionGroup
    • 63% vs. 42% ( p .002) and 29% vs. 12% ( p .002), respectively.
    • Decreased rate of severe pain and agitation events defined by NRS >6 and RASS >2.
    • Significantly more therapeutic changes in the intervention group in the way of an escalation but also in the way of a de-escalation for analgesic and psychoactive drugs.
    • A marked decrease in the duration of mechanical ventilation120 (8–312) vs. 65 (24 –192) hrs, (p = 0 .01)
    • A marked decrease in nosocomial infections rate 17% vs. 8%, ( p < =.05)
    • There was no significant difference in median length of stay and mortality in ICU
    Impact of systematic evaluation of pain and agitation in an ICU Chanques et al. Impact of systematic evaluation of pain and agitation in an intensive care unit. Crit Care Med. 2006;34:1691-9.
  • Conclusions
    • There are many aspects of sedation
    • Pain management has the primary priority
    • A awake painfree patient has the opportunity to
    • communicate discomfort
    • Treatment of discomfort has to be targeted and
    • individualized
    • Sedation must be a last option
    • Every unit must have a sedation strategy policy
    • & guideline, which is implemented to all
    • personnel in the unit
    • Daily wake-up test
  • Protocols for sedation and analgesia A Canadia survey - Effect of training Mehta S et al. Canadian survey of the use of sedatives, analgesics, and neuromuscular blocking agents in critically ill patients Crit Care Med 2006; 34:374–380 67% use the Ramsay scale
  • Protocols for sedation and analgesia A Canadia survey – effect of N o beds Mehta S et al. Canadian survey of the use of sedatives, analgesics, and neuromuscular blocking agents in critically ill patients Crit Care Med 2006; 34:374–380
  • Protocols for sedation and analgesia A Canadia survey – Which drugs? Mehta S et al. Canadian survey of the use of sedatives, analgesics, and neuromuscular blocking agents in critically ill patients Crit Care Med 2006; 34:374–380 Frequency of use of sedatives, analgesics,