New Insights in ICU Sedation

2,583 views

Published on

Dr. Jean Mantz presentation at Cairo, Egypt

Published in: Health & Medicine
0 Comments
8 Likes
Statistics
Notes
  • Be the first to comment

No Downloads
Views
Total views
2,583
On SlideShare
0
From Embeds
0
Number of Embeds
208
Actions
Shares
0
Downloads
0
Comments
0
Likes
8
Embeds 0
No embeds

No notes for slide
  • Role of the severity of illness
  • Role of the patients’ status and comorbidities with aprtciular atention to elderly persons (frequently admitted into ICU)
  • Role of the environment (noise, light, emergency situaions)
  • Role of pain and pain treatment in sleep disturbances
  • Speaker’s Notes: Alpha 2 -adrenoceptor agonists are not a new class of drug. But a highly selective alpha 2 agonist like dexmedetomidine is an entirely different mechanism for providing sedation (and many other clinical effects). Because the alpha 2 adrenoceptors are located primarily in the CNS, dexmedetomidine delivers its clinical effects in a more targeted manner throughout the body.
  • New Insights in ICU Sedation

    1. 1. New insights in ICU sedation Jean Mantz, MD, PhD Professor and Chair, Department of Anesthesia and Critical Care F- Paris Val de Seine University Hospitals Univ Paris Diderot, Paris Sorbonne Cité INSERM U 676, Pharmacological Neuroprotection
    2. 2. Disclosures• Invited speaker by Hospira and Orionpharma.
    3. 3. Goals of the lecture To review the recent changes in goals and practices of ICU sedation. To focus on the detrimental role of the ICU environment(including sedation) on brain function (delirium, sleep disorders, cognitive impairment) To discuss the role of dexmedetomidine in the modern era of sedation and analgesia
    4. 4. Goals of the lecture To review the recent changes in goals and practices of ICU sedation. To focus on the detrimental role of the ICU environment(including sedation) on brain function (delirium, sleep disorders, cognitive impairment) To discuss the role of dexmedetomidine in the modern era of sedation and analgesia
    5. 5. The moving landscape of ICU sedation 1980-2000: to provide sedation is beneficial to the ICU mechanically ventilated patient 2000: to alleviate sedation improves patient outcome (except specific situations) 2000-2010: to protocolize, monitor and titrate sedation by nurses-driven algorithms allows to improve pain control and avoid oversedation 2010-….: to develop cooperative sedation and physiotherapy still improves outcome, during and after the ICU stay.
    6. 6. Kress et al N Engl J Med 2000; 342: 1471-7
    7. 7. Principles of sedation in the non brain- injured ICU patient Prevention and treatment of pain Calm, cooperative state No anxiety
    8. 8. Target [RASS -2; +1] Calm, cooperative, No anxiety No ventilator asynchronyOVERSEDATION UNDERSEDATION
    9. 9. Delirium (DSM IV) 20% 4% 0.04
    10. 10. Pitfalls with sedatives and analgesics Sedatives and analgesics may contribute to increased duration of mechanical ventilation and length of stay (perhaps mortality ?) They may impede neurological examination and favor delirium. They may have detrimental consequences on cognitive function after ICU.
    11. 11. Goals of the lecture To review the recent changes in goals and practices of ICU sedation. To focus on the detrimental role of the ICU environment(including sedation) on brain function (delirium, sleep disorders, cognitive impairment) To discuss the role of dexmedetomidine in the moderns era of sedation and analgesia
    12. 12. Brain dysfunction in the critically illPatients’status Anesthesia ICUAddiction sedation Surgical traumaSleep disorders Postop care Pain InflammationMedications Delirium Recall Sleep disorders PTSD, Cognitive dysfunction Altered recovery and QOL
    13. 13. Ely EWCrit Care Med 2002
    14. 14. Recall and PTSD
    15. 15. Delirium
    16. 16. Issues with diagnosis of post-operative delirium in the elderly • Hypoactive vs hyperactive forms • Pre-existing delirium • Pre-existing cognitive function
    17. 17. Ely EW et al. JAMA 2001;286:2703-10 CAM-ICU1 + 2 + [3 or 4]1. Acute, fluctuating2. Inattention3. Disorganized ABRACADABRA thinking4. Altered consciousness
    18. 18. Sleep disorders
    19. 19. Hypnogram in a young and healthy subject Anaesthesia, 2004; 59: 374–84
    20. 20. Perspectives to attenuate brain dysfunction in ICU patients Alleviate sedation (benzodiazepines) Monitor delirium Develop rehabilitation programs Preserve sleep Target an organic cause of delirium ++++ Use restricted and reasonable pharmacologic therapy.
    21. 21. Goals of the lecture To review the recent changes in goals and practices of ICU sedation. To focus on the detrimental role of the ICU environment(including sedation) on brain function (delirium, sleep disorders, cognitive impairment) To discuss the role of dexmedetomidine in the modern era of sedation and analgesia
    22. 22. E001121H 45 Direct effect
    23. 23. Alpha2-adrenergic receptors1. Hayashi, Mase. Br J Anaesth.1993;71.
    24. 24. Properties of dexmedetomine Short acting sedative AND analgesic drug Maintains rousability Experimental neuroprotectant Preserves non-REM sleep No respiratory depression Decreases blood pressure and heart rate Miscellaneous (renal, anti-shivering…)
    25. 25. Primary judgementcriterion: Time spent ata target of RASS [0;-3] withoutpharmacologicintervention
    26. 26. Dexmedetomidine decreases length of stay incomparison with a benzodiazepine comparatorTrend toward more hypotension andbradycardia requiring interventions
    27. 27. Is there a role for dexmedetomidine in the ICU?• Primary agent for cooperative sedation and analgesia• Weaning from the ventilator• Sedation weaning syndromes
    28. 28. Conclusion The landscape of ICU sedation has moved from the concept of « comatose » to « cooperative » patient. Attenuation of brain dysfunction at the early stage of ICU stay may improve long term recovery, cognitive function and quality of life post ICU. Dexmedetomidine may play a major role in ensuring cooperative ICU sedation.
    29. 29. Thank you for your kind attention ! Thank you for your kind attention

    ×