Sedation in icu

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Sedation in icu

  1. 1. Sedation in ICUSedation in ICUT Mphanza FRCA, FFICM
  2. 2. The correct management ofsedation is one of the mostimportant aspects of IntensiveCare management
  3. 3. AimsAimsComfortable and pain freeMinimise anxietyCalm and co-operativeAbility to tolerate appropriate organ system supportPatients MUST NOT be paralysed and awake
  4. 4. Subjective ImpressionsSubjective ImpressionsBion JF. Sedation and analgesia in the intensivecare unit. Hospital Update. 1988; 14:1271-1286.
  5. 5. ExperienceRecall ofExperience (%)Reported asUnpleasant (%)Anxiety 55 78Pain 40 67Thirst 67 60ETT (N=50) 38 57Face Mask 67 52Physiotherapy 75 33Urinary Catheter 75 17Nausea 13 12Paralysis 13 100
  6. 6. Critical Care 2007, 11:R124doi:10.1186/cc6189Changes in sedation management in German intensive care units between2002and 2006: a national follow up surveyJoerg Martin (Joerg.Martin@email.de)Martin Franck (mfranck@pipeline.com)Stefan Sigel (Stefan.Sigel@kae.de)Manfred Weiss (manfred.weiss.ulm@online.de)Claudia D Spies (claudia.spies@charite.de)
  7. 7. 82% response rate67% changes in sedation managentCritical Care 2007, 11:R124doi:10.1186/cc6189
  8. 8. Critical Care 2007, 11:R124doi:10.1186/cc6189
  9. 9. How often do we get it right?How often do we get it right?Kaplan et al., Critical Care 2000; 4(1):s110Olson D et al., NTI Proceedings 2003;CS 82:196
  10. 10. Does it matter?Does it matter?Over - sedatedIncreased drug costsDelayed weaningIncreased ICU LOSIncreased testing
  11. 11. Does it matter?Does it matter?Under-sedatedAnxiety and agitationAwareness and recallPTSDIncreased adverse eventsIncreased use of NMR
  12. 12. AnalgesiaAnalgesiaWhy in pain:Pre-existing conditionsInvasive proceduresTherapeutic devicesCathetersDrainsNIVETT
  13. 13. AnalgesiaAnalgesiaUnrelieved painStress response:TachycardiaIncreased O2 consumptionHypercoaguabilityImmunosuppressionPersistent catabolism
  14. 14. AnalgesiaAnalgesiaPain assessmentUnidimensionalVASVRSMultidimensionalMcGill Pain QuestionnaireWisconsin Brief Pain Questionnaire
  15. 15. AnalgesiaAnalgesiaPain AssessmentBehavioural-physiological scalesBehaviouralFacial expressionPostureMovementPhysiologicalRRHRBP
  16. 16. Analgesia TherapyAnalgesia TherapyNon-pharmacologicProper positioningStabilisation of fracturesPharmacologicOpioidsNSAIDsParacetamol
  17. 17. Analgesia TherapyAnalgesia TherapyDesirable attributes of opioidsRapid onsetEase of titrationLack of accumulationLow costLack of adverse effects
  18. 18. Analgesia TherapyAnalgesia TherapyOpioid Administration TechniquesRouteIVIntermittentPCAInfusionStrategyDaily awakening
  19. 19. SedationSedationIndicationsAnxietyAgitationSleep deprivation
  20. 20. SedationSedationDeleterious effects of anxietyVentilator dysynchronyIncreased oxygen consumptionInadvertent removal of devices
  21. 21. SedationSedationBefore sedation ensure:Correct physiological anomaliesHypoxemiaHypoglycaemiaHypotensionPainWithdrawal from drugs
  22. 22. Sedation AssessmentSedation AssessmentSUBJECTIVE
  23. 23. Sedation AssessmentSedation AssessmentSUBJECTIVE
  24. 24. Sedation AssessmentSedation AssessmentObjectiveVital signsHeart rate variabilityLower-oesophageal contractilityEEGBIS
  25. 25. Sedation TherapySedation TherapyBenzodiazepinesAnterograde amnesiaNo analgesic propertyOpioid-sparing
  26. 26. Sedation TherapySedation TherapyPropofolCentral alpha agonistsClonidineDexmedetomidine
  27. 27. Sedative SelectionSedative SelectionOutcome measuresSpeed of onsetAbility to maintain target level of sedationAdverse effectsTime to awakeningAbility to wean from ventilation
  28. 28. Sedative SelectionSedative SelectionDuration of TherapyShort-termPropofol V MidazolamIntermediatePropofol V MidazolamPropofol V Midazolam V LorazepamLong-termPropofol V Midazolam
  29. 29. Sedative and AnalgesicSedative and AnalgesicWithdrawalWithdrawalBeware of withdrawal symptoms after more than one week ofmedication. Doses should be tapered systematically.
  30. 30. Sedation in ICUSedation in ICUAn important componentMost common therapy$ 1.2 billion per yearTreatment should have specific and individualised goals

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