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Sedation practices in ICU

An overview of sedation practices in medical ICU

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Sedation practices in ICU

  1. 1. Dr. Abhijit S. Nair Consultant Anesthesiologist CITIZENS HOSPITALS Hyderabad
  2. 2.  Sedation scores  Problems of sedation  To evolve a sedation protocol  Emphasize on documentation
  3. 3.  Pharmacology of drugs  Dosing  Preparation/ storage etc
  4. 4.  Tube tolerance  Ventilator synchronization  Reduce agitation ( withdrawal etc)  Pain relief  Facilitate interventions
  5. 5.  Sleep deprivation  Increased stress  Increased inflammatory mediators
  6. 6. Over-sedation Vs Under-sedation
  7. 7.  Prolongs ICU stay  Prolongs weaning  Risk factor for delirium ( BZDs )  ?CIPN  Hemodynamic disturbances
  8. 8. 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
  9. 9.  Counselling ( family, primary, nursing staff )  Psychologist  Psychiatrist  Music  Feeding  Adequate hydration NOT FOR VENTILATED PATIENTS
  10. 10.  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
  11. 11.  Narcotics  Benzodiazepines  Miscellaneous
  12. 12. Respiratory depression ConfusionVasodilation Gut motility depression Opioids
  13. 13. 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
  14. 14. “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”
  15. 15.  Suctioning  Positioning/ bed making  Procedures ( including removals )
  16. 16.  Ramsay sedation score  Bloomsbury sedation score  RASS  Sedation Agitation Scale
  17. 17.  RAAS & SAS >>> Most valid and reliable sedation assessment tool in adult ICU
  18. 18.  Auditory evoked potential  BIS  Narcotrend Index  Patient State index  State Entropy  Scoring scales Not recommended by SCCM
  19. 19.  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
  20. 20.  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
  21. 21.  Prolonged ICU stay  Prolonged sedation  Benzodiazepines  Alcoholics, Chronic smokers  Elderly  Organ dysfunction
  22. 22.  Acutely fluctuating mental status  Inattention  Disorganized thinking  Altered mentation  With/ without agitation
  23. 23. DELIRIUM Hyperactive Hypoactive
  24. 24.  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
  25. 25.  Propofol / Dexmedetomidine : Short duration sedation( 24-48 hours )  Fentanyl ( long duration, > 48 hours )  Avoid BZD infusion  SEDATION HOLIDAY
  26. 26.  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
  27. 27.  > 48 hours  ? High dose  metabolic acidosis, rhabdomyolysis  Arrhythmias  myocardial & renal failure  hepatomegaly  Death
  28. 28.  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
  29. 29.  Protocol for addressing Pain, Agitation, Delirium in ICU  Monitor Pain, Agitation & Delirium ( Scoring systems )  Document SCORES
  30. 30.  Use non-benzodiazepine sedative  Light level of sedation is associated with improved clinical outcomes  Adequate analgesia for procedures  Review medications daily
  31. 31.  Sedation Holiday  Early mobilization  Brain function monitoring recommended if NDMR used  Brain function monitoring not recommended in non-comatose patients  CONDUCIVE ENVIRONMENT IN ICU

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