Jean Mantz, MD, PhD discussed new insights in ICU sedation. The goals of ICU sedation have changed from providing deep sedation to alleviating sedation to improve outcomes. Overly deep sedation can contribute to increased ventilation time and length of stay, and impair neurological examination and cognition. The ICU environment, including sedation, can negatively impact brain function by causing delirium, sleep disorders, and long-term cognitive impairment. Dexmedetomidine is a short-acting sedative and analgesic that maintains arousability while reducing the detrimental effects of other sedatives. It may play a major role in ensuring cooperative sedation in the ICU.

1. New insights in ICU sedation
Jean Mantz, MD, PhD
Professor and Chair, Department of
Anesthesia and Critical Care
F- Paris Val de Seine University Hospitals
Univ Paris Diderot, Paris Sorbonne Cité
INSERM U 676, Pharmacological
Neuroprotection

2. Disclosures
• Invited speaker by Hospira and Orionpharma.

3. Goals of the lecture
 To review the recent changes in goals and
practices of ICU sedation.
 To focus on the detrimental role of the ICU
environment(including sedation) on brain function
(delirium, sleep disorders, cognitive impairment)
 To discuss the role of dexmedetomidine in the
modern era of sedation and analgesia

4. Goals of the lecture
 To review the recent changes in goals and
practices of ICU sedation.
 To focus on the detrimental role of the ICU
environment(including sedation) on brain function
(delirium, sleep disorders, cognitive impairment)
 To discuss the role of dexmedetomidine in the
modern era of sedation and analgesia

5. The moving landscape of ICU sedation
 1980-2000: to provide sedation is beneficial to
the ICU mechanically ventilated patient
 2000: to alleviate sedation improves patient
outcome (except specific situations)
 2000-2010: to protocolize, monitor and titrate
sedation by nurses-driven algorithms allows to
improve pain control and avoid oversedation
 2010-….: to develop cooperative sedation and
physiotherapy still improves outcome, during and
after the ICU stay.

7. Kress et al N Engl J Med 2000; 342: 1471-7

9. Principles of sedation in the non brain-
injured ICU patient
 Prevention and treatment of pain
 Calm, cooperative state
 No anxiety

10. Target
[RASS -2; +1]
Calm, cooperative,
No anxiety
No ventilator
asynchrony
OVERSEDATION UNDERSEDATION

14. Delirium (DSM IV) 20% 4% 0.04

16. Pitfalls with sedatives and analgesics
 Sedatives and analgesics may contribute to
increased duration of mechanical ventilation and
length of stay (perhaps mortality ?)
 They may impede neurological examination and
favor delirium.
 They may have detrimental consequences on
cognitive function after ICU.

17. Goals of the lecture
 To review the recent changes in goals and
practices of ICU sedation.
 To focus on the detrimental role of the ICU
environment(including sedation) on brain function
(delirium, sleep disorders, cognitive impairment)
 To discuss the role of dexmedetomidine in the
moderns era of sedation and analgesia

18. Brain dysfunction in the critically ill
Patients’status Anesthesia ICU
Addiction sedation
Surgical trauma
Sleep disorders Postop care
Pain Inflammation
Medications
Delirium
Recall
Sleep disorders
PTSD, Cognitive dysfunction
Altered recovery and QOL

19. Ely EW
Crit Care Med 2002

23. Recall and PTSD

27. Delirium

28. Issues with diagnosis of post-operative delirium
in the elderly
• Hypoactive vs hyperactive forms
• Pre-existing delirium
• Pre-existing cognitive function

29. Ely EW et al. JAMA 2001;286:2703-10
CAM-ICU
1 + 2 + [3 or 4]
1. Acute, fluctuating
2. Inattention
3. Disorganized
ABRACADABRA
thinking
4. Altered
consciousness

36. Sleep disorders

37. Hypnogram in a young and healthy subject
Anaesthesia, 2004; 59: 374–84

43. Perspectives to attenuate brain dysfunction in
ICU patients
 Alleviate sedation (benzodiazepines)
 Monitor delirium
 Develop rehabilitation programs
 Preserve sleep
 Target an organic cause of delirium ++++
 Use restricted and reasonable pharmacologic
therapy.

44. Goals of the lecture
 To review the recent changes in goals and
practices of ICU sedation.
 To focus on the detrimental role of the ICU
environment(including sedation) on brain function
(delirium, sleep disorders, cognitive impairment)
 To discuss the role of dexmedetomidine in the
modern era of sedation and analgesia

45. E001121H 45
Direct effect

46. Alpha2-adrenergic receptors
1. Hayashi, Mase. Br J Anaesth.1993;71.

47. Properties of dexmedetomine
 Short acting sedative AND analgesic drug
 Maintains rousability
 Experimental neuroprotectant
 Preserves non-REM sleep
 No respiratory depression
 Decreases blood pressure and heart rate
 Miscellaneous (renal, anti-shivering…)

51. Primary judgement
criterion: Time spent at
a target of RASS [0;
-3] without
pharmacologic
intervention

52. Dexmedetomidine decreases length of stay in
comparison with a benzodiazepine comparator
Trend toward more hypotension and
bradycardia requiring interventions

53. Is there a role for dexmedetomidine in the
ICU?
• Primary agent for cooperative sedation and
analgesia
• Weaning from the ventilator
• Sedation weaning syndromes

54. Conclusion
 The landscape of ICU sedation has moved from
the concept of « comatose » to « cooperative »
patient.
 Attenuation of brain dysfunction at the early
stage of ICU stay may improve long term
recovery, cognitive function and quality of life
post ICU.
 Dexmedetomidine may play a major role in
ensuring cooperative ICU sedation.

55. Thank you for your kind attention !
Thank you
for your kind
attention