Lars Heslet Toronto February 07

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Lars Heslet Toronto February 07

  1. 1. Lars Heslet Toronto February 07 Lars Heslet Professor ICU 4131 National University Hospital Rigshospitalet Copenhagen Denmark Best Practices in Pain Management in Critical Care
  2. 2. Lars Heslet Toronto February 07 Introduction What is the problem?
  3. 3. Lars Heslet Toronto February 07 Aim of sedation for Whom? – For the patient ? – For the Staff ? Shelly MP et al. Intensive Care Medicine 1999;25:137-9
  4. 4. Lars Heslet Toronto February 07 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 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
  5. 5. Lars Heslet Toronto February 07 Effect of insufficient analgesia control *DeKeyser F. Psychoneuroimmunology in critically ill patients. AACN Clin Issues. 2003;14(1):25-32. Organ involvement Inadequate pain-treatment causes CNS Inadequate sleep, → exhaustion and disorientation Post traumatic stress disorder Continued stress response Agitation Systemic effects Autonomic reactions Tachycardia, Arterial hypertension Increased myocardial oxygen consumption Persistent catabolism Neuroendocrine system dysfunction Cytokine production* Immunosuppression*
  6. 6. Lars Heslet Toronto February 07 To score or not to score that is the problem
  7. 7. Lars Heslet Toronto February 07 The ”Sedation Scale” of the Staff CalmCalm ComfortableComfortable
  8. 8. Lars Heslet Toronto February 07 ”Patient´s scale”
  9. 9. Lars Heslet Toronto February 07 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 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. Impact of implementing numerical scoring rates (NSR)
  10. 10. Lars Heslet Toronto February 07 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” ?
  11. 11. Lars Heslet Toronto February 07 Scoring systems Pain, Anxiety, Discomfort, Withdrawal Symptoms and Delirium VAS NRS PI SAS MAAS RAMSAY CAM- ICU RASS
  12. 12. Lars Heslet Toronto February 07 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
  13. 13. Lars Heslet Toronto February 07 …is if the patient is awake !! (with the permission from the patient)
  14. 14. Lars Heslet Toronto February 07 Effect on Morbidity of using Sedation and Analgesia Protocol
  15. 15. Lars Heslet Toronto February 07 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 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
  16. 16. Lars Heslet Toronto February 07 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
  17. 17. Lars Heslet Toronto February 07 * 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 Variable Use of protocol Result P value Result P value Daily interuption* Nurse protocol** Time on ventilator days Yes 4.9 days 0.004 55.9 hrs 0.003 No 7.3 days 117 hrs LOS in ICU Yes 6.4 days 0.02 5.7 days 0.001 No 9.9 days 7.5 days Tracheostomy Rate Yes - - 6.2 % 0.038 No 13.2 %
  18. 18. Lars Heslet Toronto February 07 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).
  19. 19. Lars Heslet Toronto February 07 Total midazolam dose (mg)Median time to offset of effect (hrs) Analgesia based sedation a randomised during mechanical ventilation - Safety and Efficacy (II) 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.
  20. 20. Lars Heslet Toronto February 07 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.
  21. 21. Lars Heslet Toronto February 07 ► 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) 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.
  22. 22. Lars Heslet Toronto February 07 What are the therapeutic options? What is the price?
  23. 23. Lars Heslet Toronto February 07 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. Variable Remifentanil/ ± propofol Fentanyl/ ± Midazolam p-value Time to extubation (Hrs) 20 24 0.05 ICU LOS (Hrs) 46 62 0.05 Costs in € Drugs 353/343 42/46 0.05 Total 1,712/1,558 1,729/1,604 N.S. Conclusion Remifentanil based analgesia and sedation supplemented with propofol compared with Fentanyl/midazolam significantly i. Reduces time on mechanical ventilation ii. Earlier discharge from the ICU, at ”equal” overall costs.
  24. 24. Lars Heslet Toronto February 07 Comparison of opioids for ICU analgesia Opioid Fentanyl / Morphine Remifentanil Potency +++ +++ Onset of action and metabolism Short to medium Very short ~ 1 min Prolonged time to steady state Achieves steady state quickly. Metabolism depending on hepatic CYP activity Metabolised rapidly (non-specific esterases) ►Inactive metabolite. Elimination Prolonged if infusion duration > days. Redistribution. Active metabolites important in renal dysfunction Elimination half-life < 10 min, independent of infusion duration and organ function Accumulation +++ - Time to emergence Hours to days Depends on length of infusion Minutes. Independent on length of infusion Price + ++++ Remarks - Synergism with sedatives ► sedative- sparing effect
  25. 25. Lars Heslet Toronto February 07 How do we do it? The end
  26. 26. Lars Heslet Toronto February 07 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
  27. 27. Lars Heslet Toronto February 07 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. • 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.
  28. 28. Lars Heslet Toronto February 07 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 • 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
  29. 29. Lars Heslet Toronto February 07
  30. 30. Lars Heslet Toronto February 07
  31. 31. Lars Heslet Toronto February 07 A Danish survey on sedation and analgesia 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 82,9% of all hospitals answers, Response rate 57,7%
  32. 32. Lars Heslet Toronto February 07 Are the available scoringsystems used? 22,4% 58,2% 19,4% 0,0% 10,0% 20,0% 30,0% 40,0% 50,0% 60,0% 70,0% Allways Often Seldom A danish survey on sedation and analgesia
  33. 33. Lars Heslet Toronto February 07 Profession “Wakeup call test” Yes No All 43 (40%) 65 (60%) Nurses 27(63%) 31 (47%) Doctors 16 (37%) 34 (53%) A danish survey on sedation and analgesia
  34. 34. Lars Heslet Toronto February 07 Definition of an awake patient when using WCT 28% 51% 2% 0% 12% 7% 0% 10% 20% 30% 40% 50% 60% Opens eyes on speech Follow demands No contact, open eyes Moves Communicates Other A danish survey on sedation and analgesia
  35. 35. Lars Heslet Toronto February 07 A danish survey on sedation and analgesia
  36. 36. Lars Heslet Toronto February 07 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
  37. 37. Lars Heslet Toronto February 07 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 Reinforcement Before (166 ICU days) After (170 days) Incidence of Daily sedation interruption 73 % 78 % Sedation score daytime (Ramsay 2) 4 (3-5) 4 (3-5) Sedation score nighttime (Ramsay 4) 5 (4-5) 5 (4-5)
  38. 38. Lars Heslet Toronto February 07 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.
  39. 39. Lars Heslet Toronto February 07 • 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.
  40. 40. Lars Heslet Toronto February 07 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

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