This document summarizes strategies for improving outcomes in ICU patients receiving sedation, including:
1) Using analgesia-first sedation and targeting light sedation to minimize risks of oversedation like longer duration of mechanical ventilation.
2) Regularly assessing sedation levels and pain to guide treatment. Non-benzodiazepine sedatives like dexmedetomidine may reduce risks of delirium.
3) Daily sedation interruption or awakening trials combined with early mobility can decrease duration of mechanical ventilation and length of stay.
Watch the webinar recording: http://bit.ly/1hnf3Os
Objectives:
1.Understanding when delirium can and cannot be assessed, and how sedatives make an accurate assessment more complicated
2.Understanding why different genetics, administering more than one drug or duration of sedative drug administration can change therapeutic effect and why it matters in the critically ill
"If you don't take a temperature, you can't find a fever...(The House of God)" James Sartain cleverly uses case studies to highlight attitudes, issues and management of acute pain in ICUs. He'll make you think as he uncovers the discrepancies between guidelines and clinical practice. This podcast was recorded at BCC4.
Watch the webinar recording: http://bit.ly/1hnf3Os
Objectives:
1.Understanding when delirium can and cannot be assessed, and how sedatives make an accurate assessment more complicated
2.Understanding why different genetics, administering more than one drug or duration of sedative drug administration can change therapeutic effect and why it matters in the critically ill
"If you don't take a temperature, you can't find a fever...(The House of God)" James Sartain cleverly uses case studies to highlight attitudes, issues and management of acute pain in ICUs. He'll make you think as he uncovers the discrepancies between guidelines and clinical practice. This podcast was recorded at BCC4.
This presentation by Gavin Giovannoni looks at the new treatment paradigm for MS. It includes: arguments for early treatment in multiple sclerosis, the effect of MS on quality of life and whether highly-effective treatments stabilise MS.
It was presented at the MS Trust Annual Conference in November 2013.
Peripheral neuropathy is a common condition, encountered by physicians as well as neurologists. However, a large number of challenges remain. These include difficulty in diagnosing, delay in diagnosis, investigations and lack of effective treatments. This presentation discusses these unmet needs and provides suggestions to overcome them.
Post-discharge issues beyond pain in out-patient surgeryscanFOAM
A presentation by Johan Ræder at the 2017 meeting of the Scandinavian Society of Anaestesiology and Intensive Care Medicine.
All available content from SSAI2017: https://scanfoam.org/ssai2017/
Delivered in collaboration between scanFOAM, SSAI & SFAI.
A diagnostic schema is a cognitive tool that allows clinicians to systematically approach a clinical problem by providing an organizing scaffold. A commonly used schema for acute kidney injury (AKI) separates this problem into pre-renal, intrinsic, and post-renal causes. By approaching AKI using these categories, clinicians can systematically access and explore individual illness scripts as potential diagnoses.
This presentation by Gavin Giovannoni looks at the new treatment paradigm for MS. It includes: arguments for early treatment in multiple sclerosis, the effect of MS on quality of life and whether highly-effective treatments stabilise MS.
It was presented at the MS Trust Annual Conference in November 2013.
Peripheral neuropathy is a common condition, encountered by physicians as well as neurologists. However, a large number of challenges remain. These include difficulty in diagnosing, delay in diagnosis, investigations and lack of effective treatments. This presentation discusses these unmet needs and provides suggestions to overcome them.
Post-discharge issues beyond pain in out-patient surgeryscanFOAM
A presentation by Johan Ræder at the 2017 meeting of the Scandinavian Society of Anaestesiology and Intensive Care Medicine.
All available content from SSAI2017: https://scanfoam.org/ssai2017/
Delivered in collaboration between scanFOAM, SSAI & SFAI.
A diagnostic schema is a cognitive tool that allows clinicians to systematically approach a clinical problem by providing an organizing scaffold. A commonly used schema for acute kidney injury (AKI) separates this problem into pre-renal, intrinsic, and post-renal causes. By approaching AKI using these categories, clinicians can systematically access and explore individual illness scripts as potential diagnoses.
The evaluation of back pain can be a pain in the neck or a back-breaking exercise, so to speak. However, the diagnosis hinges always on a focused History and Physical Exam and not really on labs or imaging. Knowing what to ask and where to look can make the evaluation of this all-too-common condition manageable for the internist.
This lecture focuses on the evaluation of low back pain and will guide the reader on the key points in the Hx and PE and prevent unnecessary testing/imaging. It also presents 3 "unusual" cases of low back pain which may be disabling if not recognized immediately.
Deciding When Hospice Care is Needed | VITAS HealthcareVITAS Healthcare
The goal of this webinar is to help healthcare professionals address the specific challenges of end-of-life care when determining a terminal prognosis, so they can provide the optimum care for the patient and family during the final stages of life.
I performed a presentation to the board of directors in Labib Medical Center on the Early Warning Score with a view to introducing this tool which has been standardised across centers in the UK. The evidence states that this tool reduces mortality and morbidity rates and also reduces admissions into Intensive Care Unit.
Death by Neurological Criteria and Organ Donation: Bill KnightSMACC Conference
Bill Knight explains the concept of death by neurological criteria and the complexities surrounding organ donation in such situations.
Bill discusses the process of dying, the definition of death, how to approach the neurologically dead patient and how to consider organ donation.
Death is a complex topic.
Due to advancements in medical technology and processes, the definition of death is a challenging one.
Bill talks at length about the definition of death by the neurological criteria. Dying is an active process, whereas death is an event.
The acceptance of death by the neurological criteria is often challenging as Bill will highlight. Bill talks about the care of the dying or dead patient.
There is a point at which care will transition from supporting the patient to supporting the organs. This is still good care.
There is an alignment of parallel intentions – first and foremost resuscitation of patients and then failing that, proceeding to considering and actioning organ donation. This is important due to the shortage of viable donor organ worldwide.
The donation process itself is complex. Bill provides his thoughts. He insists that an intensivist be involved as this has been shown to increase the number of viable and healthy organs made available.
The timing is also important. Available evidence does not support the need for immediate procurement after brain death. Taking time to optimise perfusion and allow recovery and cardiac function is appropriate and should be done.
Bill also discusses other treatment options at the time of death such as optimising endocrine function.
Finally, Bill will provide some practical considerations when communicating with the dead patient’s family. This involves being clear on your messaging. You are supporting organs, not life.
To reinforce this point, Bill suggests not examining or talking to the patient. He also recommends using all of the available hospital support services.
Similarly, it is best to not introduce the topic of organ donation to the family yourself as the treating clinician. Utilise the Organ Procurement Organisations (or similar services) and get them involved early to speak with the family.
Join Bill Knight in his talk on the North American perspective on Organ Donation, brain death and management of the brain dead donor prior to organ donation.
For more like this, head to our podcast page. #CodaPodcast
1. Sedation in the ICU: Liberation strategies for improved outcomes Leanne Boehm, MSN, RN, ACNS-BC Delirium and Cognitive Impairment Study Group Vanderbilt University Medical Center Nashville, TN USA
6. Behavioral Pain Scale (BPS) 3-12 Payen JF, et al. Crit Care Med. 2001;29(12):2258-2263. Item Description Score Facial expression Relaxed 1 Partially tightened (eg, brow lowering) 2 Fully tightened (eg, eyelid closing) 3 Grimacing 4 Upper limbs No movement 1 Partially bent 2 Fully bent with finger flexion 3 Permanently retracted 4 Compliance with ventilation Tolerating movement 1 Coughing but tolerating ventilation for most of the time 2 Fighting ventilator 3 Unable to control ventilation 4
19. Sequelae of Delirium After Hospital Discharge During the ICU/Hospital Stay - Increased mortality - 3x greater re-intubation rate - Average 10 additional days in hospital - Higher costs of care - Increased mortality - Long-term cognitive impairment - D/c requirement for chronic care facility - Decreased functional status at 6 months Milbrandt EB, et al. Crit Care Med. 2004;32:955-962. Nelson JE, et al. Arch Intern Med. 2006;166:1993-1999. Ely EW, et al. JAMA. 2004;291:1753-1762. Jackson JC, et al. Neuropsychol Rev. 2004;14(2):87-98.
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21. Confusion Assessment Method (CAM-ICU) or 3. Altered level of consciousness 4. Disorganized thinking = Delirium Ely EW, et al. Crit Care Med . 2001;29:1370-1379. Ely EW, et al. JAMA . 2001;286:2703-2710. 1. Acute onset of mental status changes or a fluctuating course 2. Inattention and and
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26. If sedation is required, what is the optimal sedative choice?
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30. Risk of delirium with benzodiazepines Pandharipande P, et al. J Trauma. 2008; 65:34-41. Pandharipande P, et al. Anesthesiol. 2006:104:21-26.
31. Propofol vs benzodiazepines Outcomes improved by propofol : sedation quality, ventilator synchrony, time to awakening, variability of awakening, time to extubation from discontinuation of sedation, overall time to extubation, ventilator days, ICU LOS among survivors, costs of sedation
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36. Strategies to Reduce the Duration of Mechanical Ventilation in Patients Receiving Continuous Sedation
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38. The ABC Trial (both groups get patient targeted sedation) Control Intervention Girard TD, et al. Lancet. 2008;371:126-134.
47. Clinical case Male patient, age 74 Hx : Dementia, coronary artery disease, diabetes, hypertension CC : altered mental status, shortness of breath Currently hypoxic and required MV Dx : Septic shock, ARDS, acute renal failure
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49. Clinical case Current vent settings : A/C 16, TV 400, PEEP 5, FiO2 40% Current infusions : propofol 40 mcg/kg/hr, norepinephrine 4 mcg/min, vasopressin 0.4 units/min, insulin gtt, IVF Intermittent fentanyl for analgesia Assessment : Target RASS -1, actual RASS -3, CAM-ICU positive, not breathing over vent set rate, bilat rhonchi, pulses present, moving extremities spontaneously Nursing interventions : for sedation? for delirium? (pharm/nonpharm)
50. Clinical case Current vent settings : PS 5, PEEP 5, FiO2 40%, RR 22 Current infusions : Norepinephrine/vasopressin off, insulin gtt, IVF, propofol off Septic shock resolved, passed SAT/SBT Assessment : Target RASS 0, actual RASS 0, CAM-ICU positive, lungs clear, moves all extremities Nursing interventions : for sedation? for delirium? (pharm/nonpharm)
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Editor's Notes
CONSCIOUS SEDATION (Ability to make cognitive evaluation) A sedation goal or endpoint should be established and regularly redefined for each patient. Regular assessment and response to therapy should be systematically documented. Give examples of Insulin, Pressors and how we titrate to endpoint Grade of recommendation = C The use of a validated sedation assessment scale is recommended. Grade of recommendation = B A sedation goal or endpoint should be established and regularly redefined for each patient. Regular assessment and response to therapy should be systematically documented. Grade of recommendation = C
An acute brain dysfunction
Delirium is a syndrome of acute organ dysfunction. While “respiratory failure” is the most common reason for ICU admission, delirium (i.e., brain “failure”) is the number one organ dysfunction Three take home messages with this slide: 1. The DSM IV-TR14 and the CAM-ICU define delirium as noted in Figure 1 ,15 which distinguishes delirium from coma 2.Criteria for delirium diagnosis, highlights the cardinal symptoms of delirium 3. A dashed line encircles optional symptoms of delirium (i.e. those sometimes present but not mandatory for a diagnosis of delirium). Hallucinations equal not normal Missing a lot if we wait to see hallucinations
Up to 75% of delirium missed if a tool is not used…Most delirium is invisible unless you look for it
Not a lot of great data to describe which are highly associated with delirium Benzos are a strong association
Investigator initiated- D-RCT, with the investigators holding the FDA IND
Sedation with dexmedetomidine in SEDCOM was safe (for up to 28 days, which is different than the currently approved 24-hour period) Max Dose: 1.4mcgs/kg/hr
There was no difference between dexmedetomidine and midazolam in time at targeted sedation level in mechanically ventilated ICU patients. At comparable sedation levels, dexmedetomidine-treated patients spent less time on the ventilator, experienced less delirium, and developed less tachycardia and hypertension.
Under-sedated in florid ARDS, increase drug delivery (gtt likely best approach), mobilize
Over-sedated and delirious, stop sedation, daily wake-up, mobilize, cognitive stimulation, sleep preservation, sensory stimulation, tight titration Reorientation and cognitive stimulation Talk about family, friends, current events Convey day, date, place Reason for hospitalization Hearing aids and/or eye glasses Pain management Sleep preservation Maintain sleep hygiene Minimize interruptions Maintain vent synchrony Promote comfort and relaxation
Need to think about cause of delirium, consider antipsychotics, mobilize, Reorientation and cognitive stimulation Talk about family, friends, current events Convey day, date, place Reason for hospitalization Hearing aids and/or eye glasses Pain management Sleep preservation: Maintain sleep hygiene, Minimize interruptions, Maintain vent synchrony, Promote comfort and relaxation THINK T oxic Situations CHF, shock, dehydration Deliriogenic meds (Tight Titration) New organ failure, e.g, liver, kidney H ypoxemia; also, consider giving H aloperidol or other antipsychotics I nfection/sepsis (nosocomial), I mmobilization N onpharmacological interventions Hearing aids, glasses, reorient, sleep protocols, music, noise control, ambulation K + or Electrolyte problems