2. Copyrights apply
• 39 yr old Male Presented to ED via EMS with PMH of polysubstance abuse, depression with
chief complaints of Altered Mental Status. Pt was found on floor covered with Urine and
Vomitus, surrounded by 10-12 bags presumably used for drugs. Pt is alert and awake speaks
only short sentences upon presentation. Denies other complaints
• PMH- Substance abuse/withdrawal admitted in EMC 7/21.
• No significant PSHx, Family history
• Allergies: Guaifenesin
• ED Course
• Vitals: Temp: 98.4, HR: 112, RR: 30 BP: 110/78 mm Hg, Sat: 93% on RA
• Labs: chloride 93, bicarbonate 40,creatinine 1.3. WBC24.2, CK 2,283
Salicylate: <0.2 , Acetaminophen Level: 5.3 Tricyclic antidepressant: negative, Ethanol level: <
3
• UDS positive for Benzodiazepine and cannabinoid
• EKG : prolonged QT interval 549
• CXR : shows no active disease
• CT head: No acute intracranial abnormality
• Intervention: Given 1mg of ativan, 3.1 L NS bolus and aztreonam by the ED
• Pt acutely desaturated to 75% on RA and improved to 87% when placed on NRB.
• ABG : Ph: 7.587, PCo2: 35.4, HCo3: 31.5, sO2 88.2, lactate 2.7.
3. Copyrights apply
• Physical Exam
• General: Tachypneic, moderately distressed
• Head: Atraumatic
• HEENT: PERRL. No Icterus and pallor.
• Neck: Supple to palpation. Full range of Motion
• Cardiac: Regular rate and rhythm. S1S2 heard. No murmurs
• Respiratory: Clear to auscultation
• Abd: Soft, non tender, non distended. Normal bowel sounds. No organomegaly
• Neuro: Motor function grossly intact
• GU: Foley in place
• Skin: No petechiae or rashes
• Extremities: No cyanosis or edema
Pt was intubated to protect his airway and for acute hypoxic resp failure. Post intubation X ray
chest shows LLL consolidation likely Aspiration Pneumonia
Patient admitted with diagnosis of acute toxic encephalopathy, acute hypoxic resp
failure, Aspiration Pneumonia, AKI and Rhabdomyolysis
Post Intubation: Pt was difficult to sedate despite being given multiple pushes of Propofol(
125mcg), Fentanyl(100 mcg), versed (8mg total) drip. Phenobarbital 40 mg q8h was added as
patient was still awake on max dosage of propofol and versed
6. Copyrights apply
Day 2
• On ceftriaxone for aspiration pneumonia.
• SBT and liberation from Vent
• Post extubation pt was requiring only minimal oxygen 2L NC and tolerated diet .
Day 3-pt was downgraded to Telemetry.
Towards evening pt had increasing oxygen requirement, tacypneic, appeared increasingly lethargic. Had large
vomitus. Remained hypoxic and tachypniec despite trial of venturi and HFNC.
ABG- 7.54/26/56/22 With SO2 92%.
Reintubated and sedated.
7.
8.
9.
10. Why sedation and analgesia in
ICU?
• anxiety and fear
• Pain
• Acute confusional states
• Mechanical ventilation
• Treatment or diagnostic procedures
• Stress response to pain- Tachycardia,increased myocardial oxygen
demand,hypercoagulability, immunosuppression,persistant catabolism
11. Assessment of pain
• The two most widely studied pain assessment tools for use in patients in
the ICU who are unable to report pain are the Behavioral Pain Scale
(BPS) and the Critical Care Pain Observation Tool (CPOT).
• Both the BPS and CPOT utilize nonverbal cues and patient behaviors
commonly indicative of the presence of pain; these include facial
expressions, body movements, and compliance with mechanical
ventilation to establish the presence of pain
14. Fentanyl
• synthetic derivative of morphine, devoid of histamine-releasing
properties. Thus, it is preferred in patients with hemodynamic
instability or bronchospasm.
• Compared with morphine, it is approximately 100 times more
potent and has faster onset of action due to greater lipid
solubility and improved penetration of the blood–brain barrier,
• Fentanyl is highly lipophilic, with rapid distribution to highly
perfused tissues (eg, brain, heart, kidney, and GI tract) and a
slower redistribution to muscle and fat .
• Compared with morphine, fentanyl has a shorter half-life (two
to three hours). It is metabolized in the liver to norfentanyl, an
inactive metabolite that is then excreted in the urine.
• Renal insufficiency does not appear to affect its
pharmacokinetics.
15. Fentanyl
• Bolus/Load: 25–50 mcg.
• Initial Maintenance Drip Rate: 25–50 mcg/hr.
• Maintenance Drip Range: 25–300 mcg/hr
• Constipation, drowsiness,tolerance.Opioid withdrawal with prolonged
infusions . Skeletal muscle rigidity
• Fast onset, First line for pain and sedation in most intubated patients
.Fat soluble = prolonged duration even after gtt off
16. Morphine
• Morphine is the prototype opioid agent and remains
widely used in the critical care setting.
• Onset of analgesia is 5 to 10 minutes, with peak effect
occurring in one to two hours.
• Morphine has an elimination half-life of three to five
hours. After hepatic conjugation to glucuronide
metabolites, renal elimination usually occurs within 24
hours.
• Renal insufficiency permits accumulation of an active
metabolite (morphine-6-glucuronide), which also has
mu-receptor-stimulating properties .
• dose adjustment is necessary to avoid oversedation
and respiratory depression in patients with impaired
renal function (creatinine clearance less than 30
mL/minute)
• Bolus/Load: 2–4 mg. Initial Maintenance Drip Rate: 1–
4 mg/hr. Maintenance Drip Range: 1–15 mg/hr
17. Hydropmorphone
• Hydromorphone is semisynthetic morphine derivative. Compared with
morphine, hydromorphone is 5 to 10 times more potent and has a more rapid
onset of analgesia (within 30 minutes) and shorter half-life.
• Due to its availability in a highly concentrated preparation (10 mg/mL), this
agent may be beneficial in fluid-restricted patients with high opioid
requirements.
• Bolus/Load: 0.25–1 mg. Initial Maintenance Drip Rate: 0.5–2 mg/hr.
Maintenance Drip Range: 0.5–5 mg/hr
• Safer in organ dysfunction than morphine
18. Adverse Effects
• respiratory depression, which is centrally mediated and dose
dependent. Depression is mediated by the μ2 receptors in
the brainstem medulla; the typical pattern is one of reduced
respiratory rate but preserved tidal volume.
• The hemodynamic effects of opiates in euvolemic patients
are typically minimal. Hypovolemic patients with blood
pressure sustained by sympathetic hyperactivity may suffer
hypotension after the administration of opiates.
• Most opiates cause a decrease in heart rate because of
decreased sympathetic activity. Although morphine causes
histamine release, this does not usually cause hemodynamic
compromise.
19. • Nausea and vomiting may occur due to opioid-induced direct stimulation of
the chemoreceptor trigger zone
• Gastrointestinal (GI) transit may slow with prolonged opioid administration due
to binding to local opiate receptors in the gut, resulting in ileus and
constipation
• All opioids act directly on blood and tissue cells to release histamine, which
may produce flushing, tachycardia, hypotension, pruritus, and bronchospasm.
20. • Muscle rigidity occasionally occurs with synthetic opiates
such as fentanyl and remifentanil. It is usually seen when
high doses of these drugs are injected rapidly and may affect
chest wall muscles.
• The mechanism of opiate induced skeletal muscle rigidity,
although not fully understood, is thought to involve
supraspinal activity of the drugs in the striata and substantia
nigra.
• Neuromuscular blockade, typically with succinylcholine,
reverses this problem. Fortunately, this problem is extremely
rare with the doses of opiates used in the management of
ventilated patients in the ICU.
21. Withdrawal
symptoms
• signs and symptoms seen in
withdrawal syndromes are
mostly nonspecific and include
pupillary dilation, sweating,
lacrimation, rhinorrhea,
piloerection, tachycardia,
vomiting, diarrhea,
hypertension, yawning, fever,
tachypnea, restlessness,
irritability, increased sensitivity
to pain, nausea, cramps,
muscle aches, dysphoria,
insomnia, symptoms of opioid
craving, and anxiety.
22. Sedation Goal
Pt comfort and control of pain
Anxiolysis and amnesia
Blunting adverse hemodynamic and
autonomic responses
Facilitate nursing managemnet
Facilitate mechanical ventilation
Avoid self extubation
26. Propofol
• Propofol is an intravenous anesthetic that is
commonly used for sedation of the agitated adult
intensive care unit (ICU) patient. It is particularly
useful when rapid sedation and rapid awakening is
desirable
• CNS receptors to block neural transmission, including
gammaaminobutyric acid (GABA).
• Propofol has amnesic, anxiolytic, anticonvulsant, and muscle relaxant
(including bronchodilation) effects. It has no direct analgesic effects.
27. • Maintenance dose- 5 to 50 mcg/kg/minute
• Titrate every 5 to 10 minutes in increments of 5 to
10 mcg/kg/minute
• Some patients require up to 70 mcg/kg/minute,
which can increase risk of propofol infusion
syndrome
28. • Propofol - continuous infusion in the ICU and not
by intermittent infusion because it is associated
with dose- and rate-dependent hypotension.
• an observational study of 25,981 patients
receiving propofol anesthesia, 4079 patients (15.7
percent) developed hypotension. Among those
who became hypotensive, 77 percent of the
hypotensive episodes occurred within 10 minutes
of induction via a bolus infusion.
29. • Hypotension is a common consequence of propofol infusion, occur in
approximately 25 percent of ICU patients who receive propofol for
sedation.
• uncommon include bradycardia, arrhythmias, neuroexcitatory effects
(seizure-like activity, myoclonus, choreoathetoid movements,
meningismus),
• Unusual and potentially serious complications are associated with
continuous infusion of propofol for longer than 24 to 48 hours.
• progressive hypertriglyceridemia, pancreatitis, increased carbon dioxide
production, and an excessive caloric load . Despite these complications,
continuous infusion of propofol for greater than 24 hours does not appear
to increase overall mortality, according to a meta-analysis of 14 randomized
trials (1184 patients)
30. Propofol-related infusion
syndrome
• PRIS is a rare complication of propofol infusion. It is
generally associated with high doses (>4 mg/kg per hour or
>67 mcg/kg per minute) and prolonged use (>48 hours)
• risk factors include a young age, critical illness, high fat
and low carbohydrate intake, inborn errors of
mitochondrial fatty acid oxidation, and concomitant
catecholamine infusion or steroid therapy .
• Characteristics of PRIS include acute refractory
bradycardia, severe metabolic acidosis, cardiovascular
collapse, rhabdomyolysis, hyperlipidemia, renal failure, and
hepatomegaly .
• The incidence of PRIS is unknown, but it is probably less
than 1 percent . Mortality is variable but high (33 to 66
percent) Treatment involves discontinuation of
the propofol infusion and supportive care
31. Dexmedetomidine/Percedex
• highly selective, centrally acting alpha-2-agonist with anxiolytic, sedative, and
some analgesic effects.
• dexmedetomidine is indicated for initial sedation of mechanically ventilated
patients for up to 24 hours. The rationale for the 24 hour limit is that longer
use may increase the risk of withdrawal effects (eg, hypertension),
• Dexmedetomidine may reduce the duration of mechanical ventilation and
intensive care unit (ICU) stay
32. • A meta-analysis of seven studies totaling 1624 patients
reported a mean reduction in duration of mechanical
ventilation by 22 percent and length of stay by 14
percent .
• the quality of evidence - low to very low, limiting
interpretation of the analysis. The seven studies
included medical and surgical patients and patients
with low to moderate risk of mortality.
• When compared with midazolam, two studies suggest
that dexmedetomidine decreased the duration of
mechanical ventilation (SEDCOM: 3.7 versus 5.6 days;
MIDEX: 5.1 versus 6.8 days, respectively), but had no
effect of length of ICU stay
33. • small observational studies have shown
mixed effects of dexmedetomidine in duration
of mechanical ventilation.
• one large randomized study of a mixed
population of critically-ill patients showed no
effect of dexmedetomidine (PRODEX) on the
duration of mechanical ventilation when
compared with propofol
• multicenter, double-blind trial of adults with
sepsis (MENDS 2) also reported no difference
in the number of ventilator-free days at 28
days in patients who received
dexmedetomidine compared with propofol
when a target goal of light sedation was set
34. bENZODIAZEPINES
• Midazolam and lorazepam are the benzodiazepines that are best suited for
sedation in the intensive care unit (ICU) because they can be administered by
either intermittent or continuous infusion and have a relatively short duration
of effect.
• Intravenous diazepam is used less often to sedate patients in the ICU. It can be
administered by intermittent infusion, but not continuous infusion.
• Mechanism — Benzodiazepines bind to specific receptors in the gamma
aminobutyric acid (GABA) receptor complex, which enhances the binding of
this inhibitory neurotransmitter
• Anxiolysis is achieved at low doses. Higher doses are associated with sedation,
muscle relaxation, anterograde amnesia, anticonvulsant effects, and both
respiratory and cardiovascular depression. Coadministration with an opioid
analgesic may potentiate respiratory and cardiovascular depression.
35. Midazolam/versed
• Midazolam has a short duration of effect (2 to 4 hours) when it is given short-
term (<48 hours) by intermittent infusion to a patient with intact hepatic
function because it has rapid hepatic clearance and there is rapid
redistribution to peripheral tissue sites.
• Midazolam may cause prolonged sedation if it is administered over a longer
duration because it has a large volume of distribution, binds to peripheral
tissues, and has an active metabolite (alpha-hydroxymidazolam).
• The active metabolite is most likely to accumulate in patients who have poor
hepatic or renal function or who are receiving medications that inhibit CYP3A4
metabolism (eg, fluconazole, macrolide
antibiotics, amiodarone, metronidazole).
36. Propylene glycol toxicity
• Propylene glycol is the carrier (solvent) that is used to administer
intravenous lorazepam or diazepam.
• Propylene glycol toxicity is characterized by hyperosmolarity and an
anion gap metabolic acidosis, which is often accompanied by acute
kidney injury and can progress to multisystem organ failure, if severe
• . It can occur with normal doses and renal function, but it is usually
associated with dosages above the recommended range of 0.1
mg/kg/hour and/or renal impairment .
• An osmolar gap >10 mmoles/L suggests that the serum propylene
glycol concentration is high enough to cause toxicity . Treatment
consists of discontinuing the offending agent and, if severe, dialysis .
• Propylene glycol is not the solvent for intravenous midazolam.
Therefore, patients who receive intravenous midazolam are not at risk
for propylene glycol toxicity.
37.
38. Practice
• depth of sedation should be routinely monitored and quantified using a
validated assessment tool
• titrating medications to keep patients continuously lightly sedated unless
a contraindication exists (severe ARDS, refractory intracranial
hypertension, status asthmaticus, or epilepticus) appears noninferior to
standard therapy with DSIs
• titration of sedation and SBTs should be closely coordinated in a
multidisciplinary team that involves respiratory therapists, nurses, and
the medical team.
39. To remember
Light sedation and daily awakening of
intubated patients is an evidencebased
practice and part of routine ICU care.
Daily awakening protocols reduce ICU
length of stay and decrease tracheostomy
procedures, diagnostic studies ordered, and
the amount of sedating drugs required.
Daily awakening may also reduce the
incidence of PTSD. Light sedation and daily
awakening should not be employed in
patients requiring neuromuscular blockade.
To determine the RASS, proceed as follows:
Step 1 Observation: Observe the patient without interaction. If patient is alert, assign the appropriate score (0 to +4). If patient is not alert, go to Step 2. Step 2 Verbal Stimulation: Address patient by name in a loud voice and ask the patient to look at you. Can repeat once if necessary. If patient responds to voice, assign the appropriate score (-1 to -3). If there is no response, go to Step 3. Step 3 Physical Stimulation: Shake the patient's shoulder. If there is no response, rub the sternum vigorously. Assign the appropriate score (-4 to -5).
