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  • CONSCIOUS SEDATION (Ability to make cognitive evaluation) A sedation goal or endpoint should be established and regularly redefined for each patient. Regular assessment and response to therapy should be systematically documented. Give examples of Insulin, Pressors and how we titrate to endpoint Grade of recommendation = C The use of a validated sedation assessment scale is recommended. Grade of recommendation = B A sedation goal or endpoint should be established and regularly redefined for each patient. Regular assessment and response to therapy should be systematically documented. Grade of recommendation = C
  • An acute brain dysfunction
  • Delirium is a syndrome of acute organ dysfunction. While “respiratory failure” is the most common reason for ICU admission, delirium (i.e., brain “failure”) is the number one organ dysfunction Three take home messages with this slide: 1. The DSM IV-TR14 and the CAM-ICU define delirium as noted in Figure 1 ,15 which distinguishes delirium from coma 2.Criteria for delirium diagnosis, highlights the cardinal symptoms of delirium 3. A dashed line encircles optional symptoms of delirium (i.e. those sometimes present but not mandatory for a diagnosis of delirium). Hallucinations equal not normal Missing a lot if we wait to see hallucinations
  • Up to 75% of delirium missed if a tool is not used…Most delirium is invisible unless you look for it
  • Not a lot of great data to describe which are highly associated with delirium Benzos are a strong association
  • Investigator initiated- D-RCT, with the investigators holding the FDA IND
  • Sedation with dexmedetomidine in SEDCOM was safe (for up to 28 days, which is different than the currently approved 24-hour period) Max Dose: 1.4mcgs/kg/hr
  • There was no difference between dexmedetomidine and midazolam in time at targeted sedation level in mechanically ventilated ICU patients. At comparable sedation levels, dexmedetomidine-treated patients spent less time on the ventilator, experienced less delirium, and developed less tachycardia and hypertension.
  • Under-sedated in florid ARDS, increase drug delivery (gtt likely best approach), mobilize
  • Over-sedated and delirious, stop sedation, daily wake-up, mobilize, cognitive stimulation, sleep preservation, sensory stimulation, tight titration Reorientation and cognitive stimulation Talk about family, friends, current events Convey day, date, place Reason for hospitalization Hearing aids and/or eye glasses Pain management Sleep preservation Maintain sleep hygiene Minimize interruptions Maintain vent synchrony Promote comfort and relaxation
  • Need to think about cause of delirium, consider antipsychotics, mobilize, Reorientation and cognitive stimulation Talk about family, friends, current events Convey day, date, place Reason for hospitalization Hearing aids and/or eye glasses Pain management Sleep preservation: Maintain sleep hygiene, Minimize interruptions, Maintain vent synchrony, Promote comfort and relaxation THINK T oxic Situations CHF, shock, dehydration Deliriogenic meds (Tight Titration) New organ failure, e.g, liver, kidney H ypoxemia; also, consider giving H aloperidol or other antipsychotics I nfection/sepsis (nosocomial), I mmobilization N onpharmacological interventions Hearing aids, glasses, reorient, sleep protocols, music, noise control, ambulation K + or Electrolyte problems

Transcript

  • 1. Sedation in the ICU: Liberation strategies for improved outcomes Leanne Boehm, MSN, RN, ACNS-BC Delirium and Cognitive Impairment Study Group Vanderbilt University Medical Center Nashville, TN USA
  • 2. Disclosures
    • Hospira
  • 3. Need for Sedation & Analgesia
    • Prevention of pain and anxiety
    • Decrease oxygen consumption
    • Decrease the stress response
    • Patient-ventilator synchrony
    • Avoid adverse neurocognitive sequelae
      • Depression, PTSD
    Rotondi AJ, et al. Crit Care Med . 2002;30:746-52A . Weinert C, et al. Curr Opin in Crit Care . 2005;11(4):376-380. Kress JP, et al. J Respir Crit Care Med . 1996;153:1012-1018.
  • 4. Pitfalls of sedatives and analgesics
    • Oversedation:
      • Failure to initiate spontaneous breathing trials (SBT) leads to increased duration of mechanical ventilation
      • Longer duration of ICU stay
    • Impede assessment of neurologic function
    • Increase risk for delirium
    • Numerous agent-specific adverse events
    Kollef M, et al. Chest . 1998;114:541-548. Pandharipande, et al. Anesthesiology . 2006;124:21-26.
  • 5. Identifying and Treating Pain
  • 6. Behavioral Pain Scale (BPS) 3-12 Payen JF, et al. Crit Care Med. 2001;29(12):2258-2263. Item Description Score Facial expression Relaxed 1 Partially tightened (eg, brow lowering) 2 Fully tightened (eg, eyelid closing) 3 Grimacing 4 Upper limbs No movement 1 Partially bent 2 Fully bent with finger flexion 3 Permanently retracted 4 Compliance with ventilation Tolerating movement 1 Coughing but tolerating ventilation for most of the time 2 Fighting ventilator 3 Unable to control ventilation 4
  • 7. A note on pain control
    • Pain can cause agitation and lead to excessive use of sedatives
    • Adequate pain management often reduces the need for sedation 1
    • Reports suggest narcotic-based sedation may result in improved patient outcomes 2-3
    1 Kress JP et al, AJRCCM 2002; 168(8): 1024-8 2 Breen D et al, Crit Car 2005; 9(3): R200-10 3 Pandharipande P & Ely EW, Crit Car 2005; 9(3): 247-8
  • 8. Analgosedation
    • “ Analgesia-first sedation” & sedative if needed
    • Increasingly used in many countries
    • Acknowledges discomfort as a cause of agitation
    • Usually continuous infusion
    • 30-74% required benzodiazepine/propofol rescue
    • Study of remifentanil vs midazolam sedation
      • Reduction in vent time (2 d) and ICU LOS (1d)
    • Not appropriate for drug or alcohol withdrawal
    Dahaba AA, et al. Anesthesiology. 2004;101:640-646. Park G, et al. Br J Anaesth. 2007;98:76-82. Rozendall FW, et al. Intensive Care Med. 2009;35:291-298. Strøm T, et al. Lancet . 2010;375(9713):475-480
  • 9. Sedation assessment and maintaining a sedation goal
  • 10. Sedation Scales Pun & Dunn, AJN 2007; 107(7):40-48
  • 11. Richmond Agitation Sedation Scale (RASS) Ely EW, et al. JAMA . 2003;289(22):2983-2991. Sessler CN, et al. Am J Respir Crit Care Med. 2002;166(10):1338-1344. Verbal Stimulus Physical Stimulus
  • 12. ICU Sedation: The Balancing Act Patient Comfort and Ventilatory Optimization G O A L
    • Patient recall
    • Device removal
    • Ineffectual mechanical ventilation
    • Initiation of neuromuscular blockade
    • Myocardial or cerebral ischemia
    • Decreased family satisfaction w/ care
    • Severe discomfort
    • Hypertension
    • Tachycardia
    • Increased ICP
    • Increase metabolic demand
    • Delirium
    • Prolonged mechanical ventilation
    • Increase length of stay
    • Increased risk of complications (I.e. VAP)
    • Increased diagnostic testing
    • Inability to evaluate for delirium
    • Cardio/respiratory depression
    • Decreased GI motility
    • Immunosuppression
    • Delirium
    Jacobi J, et al. CCM. 2002;30:119-141 Carrasco G. Crit Care. 2000;4:217-225 McGaffigan PA. CCN. 2002 ; Fe b(suppl): 29-36 Blanchard AR. Postgrad Med . 2002;111:59-74 ASHP Therapeutic Guidelines. Best Practices for Health-System Pharmacy. 2003-2004;486-512 Oversedation Undersedation
  • 13. Setting Targets
    • Aim for Cooperative:
    • Calm & Easily Arousable State while minimizing pain, anxiety, or agitation unless contraindicated
    • Easy transition from sleep to wakefulness 1
    • Can participate in weaning and physical therapy 1
    • Perform therapeutic maneuvers
    • Able to perform a cognitive evaluation
    • Adjust depending on patient need
    • Over the course of Illness/Treatment
    • Initial Intubation vs Stabilization
    • Weaning Phase
    1 Bekker AY, et al. Neurosurgery 2005;57(1 Suppl 1):1-10
  • 14. The importance of preventing and identifying delirium
  • 15. What is delirium?
    • Common clinical syndrome that is characterized by:
      • Inattention
      • Acute cognitive dysfunction
    • Thought to be due to disruption of neurotransmission related to:
      • Drug toxicity
      • Inflammation
      • Acute stress responses
  • 16. Delirium Morandi, A et al., ICM 2009;34:1907-15
  • 17. Prevalence of Delirium in the ICU
    • 60–80% MICU/SICU/TICU ventilated patients develop delirium
    • 20–50% of lower severity ICU patients develop delirium
    • Majority goes undiagnosed if routine monitoring is not implemented
    • Hypoactive or mixed forms most common
    Ouimet S, et al. Intensive Care Med . 2007;33:66-73 Ely EW, et al. JAMA . 2001;286,2703-2710 Pandharipande PP, et al. J Trauma . 2008;65:34-41 Ely EW, et al. Intensive Care Med . 2001;27:1892-1900. Dubois MJ, et al. Intensive Care Med 2001;27:1297-1304
  • 18. Patient Factors Increased age Alcohol use Male gender Living alone Smoking Renal disease Depression Vision/Hearing impaired Environment Admission via ED or through transfer Isolation No clock No daylight No visitors Noise Use of physical restraints Sleep deprivation Predisposing Disease Cardiac disease Cognitive impairment (eg, dementia) Pulmonary disease HIV
    • Acute Illness
    • Length of stay
    • Fever
    • Medicine service
    • Lack of nutrition
    • Hypotension
    • Sepsis
    • Metabolic disorders
    • Tubes/catheters
    • Medications:
    • Anticholinergics
    • Corticosteroids
    • - Benzodiazepines
    Less Modifiable More Modifiable DELIRIUM Inouye SK, et al. JAMA .1996;275:852. Van Rompaey B, et al. Crit Care 2009;13:R77. Skrobik Y. Crit Care Clin . 2009;25(3):585-591. Devlin J, et al. ICM , 2007; 33:929-940.
  • 19. Sequelae of Delirium After Hospital Discharge During the ICU/Hospital Stay - Increased mortality - 3x greater re-intubation rate - Average 10 additional days in hospital - Higher costs of care - Increased mortality - Long-term cognitive impairment - D/c requirement for chronic care facility - Decreased functional status at 6 months Milbrandt EB, et al. Crit Care Med. 2004;32:955-962. Nelson JE, et al. Arch Intern Med. 2006;166:1993-1999. Ely EW, et al. JAMA. 2004;291:1753-1762. Jackson JC, et al. Neuropsychol Rev. 2004;14(2):87-98.
  • 20. Intensive Care Delirium Screening Checklist
    • 1. Altered level of consciousness
    • 2. Inattention
    • 3. Disorientation
    • 4. Hallucinations
    • 5. Psychomotor agitation or retardation
    • 6. Inappropriate speech
    • 7. Sleep/wake cycle disturbances
    • 8. Symptom fluctuation
    Bergeron N, et al. Intensive Care Med . 2001;27:859-864. Ouimet S, et al. Intensive Care Med. 2007;33:1007-1013.
    • Score 1 point for each component present during shift
      • Score of 1-3 = Subsyndromal Delirium
      • Score of ≥ 4 = Delirium
  • 21. Confusion Assessment Method (CAM-ICU) or 3. Altered level of consciousness 4. Disorganized thinking = Delirium Ely EW, et al. Crit Care Med . 2001;29:1370-1379. Ely EW, et al. JAMA . 2001;286:2703-2710. 1. Acute onset of mental status changes or a fluctuating course 2. Inattention and and
  • 22. Feature 1: Alteration/Fluctuation in Mental Status
    • Is the pt different than his/her baseline mental status?
    • OR
    • Has the patient had any fluctuation in mental status in the past 24 hours (eg fluctuating RASS, GCS, previous delirium assessments, etc)?
    • Positive/Present: If either question is YES.
  • 23. Feature 2: Inattention
    • Attention Screening Exam
    • Auditory : Letter “A”
      • Say 10 letters & tell patient to squeeze on “A”
      • Letters: S A V E A H A A R T
      • Scoring : Count error if patient fails to squeeze on “A” and when they squeeze on any letter other than “A”
    • Visual: Pictures
      • Similar to letters but with pictures
    • Positive/Present : If score is <8
  • 24. Feature 4: Alt Level of Consciousness
    • Any LOC other than Alert.
    • Positive/Present: If the Actual RASS score is anything other than “0”
  • 25. Feature 3: Disorganized Thinking
    • A: Yes/No Questions
    • 1. Will a stone float on water?
    • 2. Are there fish in the sea?
    • 3. Does one pound weigh more than two pounds?
    • 4. Can you use a hammer to pound a nail?
    • B: Command
    • Say to patient: “Hold up this many fingers” (Examiner holds two fingers in front of patient) “Now do the same thing with the other hand” (Not repeating the number of fingers).
    • Positive/Present: If combined score (questions + command) is less than 4
  • 26. If sedation is required, what is the optimal sedative choice?
  • 27. Characteristics of an Ideal Sedative
    • Rapid onset of action allows rapid recovery after d/c 1
    • Effective at providing adequate sedation with predictable dose response 1,2
    • Easy to administer 1,3
    • Lack of drug accumulation 1
    • Few adverse effects 1-3
    • Minimal adverse interactions with other drugs 1-3
    • Cost-effective 3
    • Promotes natural sleep 4
    1. Ostermann ME, et al. JAMA. 2000;283:1451-1459. 2. Jacobi J, et al. Crit Care Med . 2002;30(1):119-141. 3. Dasta JF, et al. Pharmacother. 2006;26:798-805. 4. Nelson LE, et al. Anesthesiol . 2003;98:428-436.
  • 28. Choice of Sedatives
    • Benzodiazepines
      • GABA A receptor modulation in CNS
        • Facilitates binding of GABA
      • Hyperpolarize cells, making them more resistant to excitation
    • Propofol
      • Not well understood
      • GABA receptor modulation is likely
    • Dexmedetomidine
      • α 2 -adrenergic agonist (inhibits NE release in CNS & PNS)
        • CNS : sedation/hypnosis, anxiolysis, and analgesia
        • PNS : decreases BP and HR; activates endogenous sleep-promoting pathway
      • No respiratory suppression
      • Enables cognitive evaluation & patient communication
  • 29. Consider Comorbidities When Choosing a Sedation Regimen
    • Chronic pain
    • Organ dysfunction
    • CV instability
    • Substance withdrawal
    • Respiratory insufficiency
    • Obesity
    • Obstructive sleep apnea
  • 30. Risk of delirium with benzodiazepines Pandharipande P, et al. J Trauma. 2008; 65:34-41. Pandharipande P, et al. Anesthesiol. 2006:104:21-26.
  • 31. Propofol vs benzodiazepines Outcomes improved by propofol : sedation quality, ventilator synchrony, time to awakening, variability of awakening, time to extubation from discontinuation of sedation, overall time to extubation, ventilator days, ICU LOS among survivors, costs of sedation
  • 32. MENDS MICU/SICU Patients Ventilated & Sedated N=103 Control Lorazepam (GABA) ± Fentanyl Intervention Dexmedetomidine ( α 2) ± Fentanyl Pandharipande PP, et al. JAMA 2007;298:2644-53
    • Double-blind RCT of dexmedetomidine vs lorazepam infusion
    • Intervention:
      • Dexmedetomidine 0.15–1.5 mcg/kg/hr
      • Lorazepam infusion 1–10mg/hr
    • No daily interruption, patient targeted sedation
  • 33. MENDS: dexmedetomidine vs lorazepam Pandharipande P et al – JAMA, 2007; 298:2644-2653
    • Dexmedetomidine resulted in :
      • More days alive without delirium or coma (p=.01)
      • Lower prevalence of coma (p=.001)
      • More time spent within sedation goals (p=.04)
    • Differences in 28-day mortality and delirium-free
    • days were not significant
  • 34. SEDCOM MICU Patients Ventilated & Sedated n=366 Control Midazolam (GABA) ± Fentanyl Intervention Dexmedetomidine ( α 2) ± Fentanyl Riker, R., et al. JAMA 2009; 301(5): 489-499
    • Double-blind, RCT comparing long-term dexmedetomidine vs midazolam
    • Sedatives (dex 0.2-1.4 μ g/kg/hr or midaz 0.02-0.1 mg/kg/hr) titrated for light sedation, administered up to 30 days
    • Daily arousal assessments and drug titration Q4h
  • 35. SEDCOM: dexmedetomidine vs midazolam
    • Dexmedetomidine resulted in :
      • less time on the ventilator (p=.01)
      • less delirium (p<.001)
      • less tachycardia (p<.001)
      • less hypertension (p=.02)
    • Most notable adverse effect of dexmedetomidine was bradycardia (p<.001)
  • 36. Strategies to Reduce the Duration of Mechanical Ventilation in Patients Receiving Continuous Sedation
  • 37. Daily sedation interruption decreases days of MV
    • Hold infusion until patient awake, then restart at 50% of prior dose
    • “ Awake” defined as 3 of the following 4:
      • Open eyes in response to voice
      • Use eyes to follow investigator on request
      • Squeeze hand on request
      • Stick out tongue on request
    Kress JP, et al. N Engl J Med. 2000;342:1471-1477.
    • Fewer diagnostic tests to assess changes in mental status
    • No increase in rate of agitated-related complications or episodes
    • of patient-initiated device removal
    • No increase in PTSD or cardiac ischemia
  • 38. The ABC Trial (both groups get patient targeted sedation) Control Intervention Girard TD, et al. Lancet. 2008;371:126-134.
  • 39. The ABC Trial SBT+usual care vs SAT+SBT
    • Patients in the intervention group:
      • Less time in coma (p=.002)
      • 2 days less on the ventilator (p=.02)
      • 4 days less in the ICU (p=.02)
      • 4 days less in the hospital (p=.04)
      • Less exposure to benzodiazepines
      • Were more likely to be alive in 1 year (p=.01)
      • More self extubations, but not more reintubations
    Girard TD, et al. Lancet. 2008;371:126-134.
  • 40. Early Mobilization Schweickert et al, Lancet 2009;373:1874-82
  • 41. Mobility
    • A fundamental nursing activity
    • Enhances gas exchange
    • Reduces VAP rates
    • Shortened duration of MV
    • Enhances long-term functional ability
  • 42. Schweickert WD, et al. Lancet. 2009;373:1874-1882.
      • 24% improvement (1.7-fold better) return to independent functional status at discharge (NNT=4)
  • 43. Daily Wake-Up + Early Mobility Schweickert WD, et al. Lancet . 2009;373:1874-1882. Outcome Intervention (n=49) Control (n=50) P Functionally independent at discharge 29 (59%) 19 (35%) .02 ICU delirium (days) 2.0 (0.0-6.0) 4.0 (2.0-7.0) .03 Time in ICU with delirium (%) 33% (0-58) 57% (33-69) .02 Hospital delirium (days) 2.0 (0.0-6.0) 4.0 (2.0-8.0) .02 Hospital days with delirium (%) 28% (26) 41% (27) .01 Barthel Index score at discharge 75 (7.5-95) 55 (0-85) .05 ICU-acquired paresis at discharge 15 (31%) 27 (49%) .09 Ventilator-free days 23.5 (7.4-25.6) 21.1 (0.0-23.8) .05 Length of stay in ICU (days) 5.9 (4.5-13.2) 7.9 (6.1-12.9) .08 Length of stay in hospital (days) 13.5 (8.0-23.1) 12.9 (8.9-19.8) .93 Hospital mortality 9 (18%) 14 (25%) .53
  • 44. Implementation challenges
    • Many issues to address
    • Multiple disciplines are involved
      • RN, RT, MD, PT/OT, pharmacist
    • Timing
    • Coordination, collaboration, & teamwork
    • Protocol development
    • Change in culture of workplace
    • Costs
    • Resistance to change
  • 45. Putting it all together
  • 46.  
  • 47. Clinical case Male patient, age 74 Hx : Dementia, coronary artery disease, diabetes, hypertension CC : altered mental status, shortness of breath Currently hypoxic and required MV Dx : Septic shock, ARDS, acute renal failure
  • 48. Clinical case
    • Current vent settings : A/C 16, TV 400, PEEP 14, FiO2 80%
    • Current infusions : norepinephrine 10 mcg/min, vasopressin 0.4 units/min, insulin gtt, IVF
    • Assessment : Target RASS -4, actual RASS +1 to -1, displaying vent asynchrony, CAM-ICU positive, bilat rhonchi, pulses present
    • Receiving intermittent boluses of fentanyl and lorazepam
    • Nursing interventions?
  • 49. Clinical case Current vent settings : A/C 16, TV 400, PEEP 5, FiO2 40% Current infusions : propofol 40 mcg/kg/hr, norepinephrine 4 mcg/min, vasopressin 0.4 units/min, insulin gtt, IVF Intermittent fentanyl for analgesia Assessment : Target RASS -1, actual RASS -3, CAM-ICU positive, not breathing over vent set rate, bilat rhonchi, pulses present, moving extremities spontaneously Nursing interventions : for sedation? for delirium? (pharm/nonpharm)
  • 50. Clinical case Current vent settings : PS 5, PEEP 5, FiO2 40%, RR 22 Current infusions : Norepinephrine/vasopressin off, insulin gtt, IVF, propofol off Septic shock resolved, passed SAT/SBT Assessment : Target RASS 0, actual RASS 0, CAM-ICU positive, lungs clear, moves all extremities Nursing interventions : for sedation? for delirium? (pharm/nonpharm)
  • 51. Clinical Case
    • What if the patient had not passed the SBT and was beginning to become agitated?
    • Would you consider pharmacologic treatment for delirium at this point?
    • What if we extubated this patient and he later became agitated?
  • 52. Summary
    • Goals for sedation: Are we on the same page?
    • Daily Sedation Cessation : Did you wake up your patient today?
    • Sedative Choice: What is the best option for my patient right now?
    • Roadmap: How do we put it all together at the bedside?
  • 53. Educational Delirium Website
    • www.ICUdelirium.org
    • [email_address]
    • [email_address]