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Sedation , analgesia & paralysis

The document discusses guidelines for sedation, analgesia, and paralysis in the ICU. It notes that 50% of ICU patients experience agitation due to pain, delirium, anxiety, or sleep deprivation. Up to 70% of ICU patients have some recall of their time in the ICU, which can cause anxiety, fear, or PTSD. The optimal level of sedation allows for patient comfort while allowing interaction. Protocols for daily awakening and sedation titration can reduce length of stay, need for tracheostomies, and diagnostic evaluations. Validated scales like the Ramsay Sedation Scale and Sedation-Agitation Scale can help assess sedation levels, while the Numeric Rating Scale and Visual Analog Scale assess pain.

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Sedation , Analgesia & Paralysis in ICU Dr.Venugopalan.P.P DA,DNB,MNAMS Chief, Emergency Medicine –MIMS Site Director ,Masters program in EM Executive director ,Angels international foundation
Objectives Guidelines for sedation, analgesia, and chemical paralysis Benefits of daily awakening/lightening and sedation titration programs Rational pharmacologic strategy based on treatment goals and co morbidities
What We Know About ICU Agitation/Discomfort? Prevalence • 50% incidence in those with length of stay > 24 hours Primary causes • Unrelieved pain • Delirium • Anxiety • Sleep deprivation.
ICU Agitation/Discomfort sequelae
Recall in the ICU Some degree of recall occurs in up to 70% of ICU patients. • Anxiety, fear, pain, panic, agony, or nightmares reported in 90% of those who did have recall. Potentially cruel: • Up to 36% recalled some aspect of paralysis. Associated with PTSD in ARDS? • 41% risk of recall of two or more traumatic experiences. Associated with PTSD in cardiac surgery
Appropriate Recall May be Important Factual memories help to put ICU experience into perspective Delusional memories cause panic attacks and PTSD The optimal level of sedation for most patients - Offers comfort while allowing for interaction with the environment.
Why sedation in ICU? • Anxiety • Pain • Acute confusional status • Mechanical ventilation • Treatment or diagnostic procedures • Psychological response to stress
Sedation Goal • Patient comfort • Control of pain • Anxiolysis and amnesia • Blunting adverse autonomic and hemodynamic responses • Facilitate nursing management • Facilitate mechanical ventilation • Avoid self-extubation • Reduce oxygen consumption
Ideal sedation agents • No respiratory depression • Analgesia • Rapid onset, titratable, with a short elimination half-time • Sedation with ease of orientation and arousability • Anxiolytic • Hemodynamic stability
The Challenges • Assessment of sedation • Altered pharmacology • Tolerance • Delayed emergence • Withdrawal • Drug interaction
Sedation Causes for Agitation Sedatives
Undersedation Sedatives Causes for Agitation Agitation & anxiety Pain and discomfort Catheter displacement Inadequate ventilation Hypertension Tachycardia Arrhythmias Myocardial ischemia Wound disruption Patient injury
Oversedation Sedatives Causes for Agitation Prolonged sedation Delayed emergence Respiratory depression Hypotension Bradycardia Increased protein breakdown Muscle atrophy Venous stasis Pressure injury Loss of patient-staff interaction Increased cost
Reversible Causes of Agitation • Full bladder • Uncomfortable bed position • Inadequate ventilator flow rates • Mental illness • Uremia • Drug side effects • Disorientation • Sleep deprivation • Noise • Inability to communicate
Life threatening Causes • Hypoxia • Hypercarbia • Hypoglycemia • Endotracheal tube malposition • Pneumothorax • Myocardial ischemia • Abdominal pain • Drug and alcohol withdrawal
Daily Goal is Arousable, Comfortable Sedation Effect of this strategy on outcomes: • One- to seven-day reduction in length of sedation and mechanical ventilation needs • 50% reduction in tracheostomies • Three-fold reduction in the need for diagnostic evaluation of CNS Sedation needs to be protocolized and titrated to goal: •Lighten sedation to appropriate wakefulness daily.
Protocols and Assessment Tools Sedation o Validated sedation assessment tools (Ramsay Sedation Scale [RSS], o Sedation-Agitation Scale [SAS] o Richmond Sedation-agitation Scale [RSAS] No evidence that one is preferred over another Pain o Numeric rating scale [NRS] o Visual analogue scale [VAS] Pain assessment tools - none validated in ICU
Sedation/Analgesia ICU Rule out reversible causes of discomfort/anxiety such as hypoxemia, hypercarbia, and toxic/drug side effect. Assess co-morbidities and potential side effects of drugs chosen. Target irreversible etiologies of pain and agitation.
Strategies for Patient Comfort • Set treatment goal • Quantitate sedation and pain • Choose the right medication • Use combined infusion • Reevaluate need • Treat withdrawal
ALGORITHM FOR SEDATION AND ANALGESIA OF MECHANICALLY VENTILATED PATIENTS Yes Reassess goal daily, Titrate and taper therapy to maintain goal, Consider daily wake-up, Taper if > 1 week high-dose therapy & monitor for withdrawal No Set Goal for Analgesia Hemodynamically Unstable Fentanyl 25 - 100 mcg IVP Q 5-15 min, or Hydromorphone 0.25 - 0.75 mg IVP Q 5 - 15 min Hemodynamically stable Morphine 2 - 5 mg IVP Q 5 - 15 min Repeat until pain controlled, then scheduled doses + prn Set Goal for Sedation Acute Agitation # Midazolam 2 - 5 mg IVP Q 5 - 15 min until acute event controlled Ongoing Sedation # Lorazepam 1 - 4 mg IVP Q 10-20 min until at goal then Q 2 - 6 hr scheduled + prn, or Propofol start 5 mcg/kg/min, titrate Q 5 min until at goal Set Goal for Control of Delirium Haloperidol 2 - 10 mg IVP Q 20 - 30 min, then 25% of loading dose Q 6hr x 2-3 days, then taper IVP Doses more of ten than Q 2hr? Consider continuous infusion opiate or sedative > 3 Days Propofol? (except neuro pt.) Convert to Lorazepam Yes Benzodiazepine or Opioid: Taper Infusion Rate by 10-25% Per Day Yes Doses approximate for 70kg adult Rule out and Correct Reversible Causes Use Non-pharmacologic Treament, Optimize the Environment Use Pain Scale * to Assess for Pain Use Sedation Scale ** to Assess for Agitation/Anxiety Use Delirium Scale *** to Assess for Delirium Is the Patient Comfortable & at Goal? Lorazepam via infusion? Use a low rate and IVP loading doses 1 2 3 4 Jacobi J, Fraser GL, Coursin D, et al. Crit Care Med. 2002;30:119-141.
Assess Pain Separately Pain
Visual Pain Scales 0 1 2 3 4 5 6 7 8 9 10 No pain Worst possible pain
Signs of Pain • Hypertension • Tachycardia • Lacrimation • Sweating • Pupillary dilation
Pain Management • Anticipate • Recognize • Quantify Recognize Pain
Treat Pain oQuantify the pain perception oCorrect the correctable causes oUse appropriate analgesics • Remember- most sedative agents do not provide analgesia • Reassess
Non-pharmacological Methods • Proper position of the patient • Stabilization of fractures • Elimination of irritating stimulation • Proper positioning of the ventilator tubing to avoid traction on endotracheal tube
ALGORITHM FOR SEDATION AND ANALGESIA OF MECHANICALLY VENTILATED PATIENTS Yes Reassess goal daily, Titrate and taper therapy to maintain goal, Consider daily wake-up, Taper if > 1 week high-dose therapy & monitor for withdrawal No Set Goal for Analgesia Hemodynamically Unstable Fentanyl 25 - 100 mcg IVP Q 5-15 min, or Hydromorphone 0.25 - 0.75 mg IVP Q 5 - 15 min Hemodynamically stable Morphine 2 - 5 mg IVP Q 5 - 15 min Repeat until pain controlled, then scheduled doses + prn Set Goal for Sedation Acute Agitation # Midazolam 2 - 5 mg IVP Q 5 - 15 min until acute event controlled Ongoing Sedation # Lorazepam 1 - 4 mg IVP Q 10-20 min until at goal then Q 2 - 6 hr scheduled + prn, or Propofol start 5 mcg/kg/min, titrate Q 5 min until at goal Set Goal for Control of Delirium Haloperidol 2 - 10 mg IVP Q 20 - 30 min, then 25% of loading dose Q 6hr x 2-3 days, then taper IVP Doses more of ten than Q 2hr? Consider continuous infusion opiate or sedative > 3 Days Propofol? (except neuro pt.) Convert to Lorazepam Yes Benzodiazepine or Opioid: Taper Infusion Rate by 10-25% Per Day Yes Doses approximate for 70kg adult Rule out and Correct Reversible Causes Use Non-pharmacologic Treament, Optimize the Environment Use Pain Scale * to Assess for Pain Use Sedation Scale ** to Assess for Agitation/Anxiety Use Delirium Scale *** to Assess for Delirium Is the Patient Comfortable & at Goal? Lorazepam via infusion? Use a low rate and IVP loading doses 1 2 3 4 Jacobi J, Fraser GL, Coursin D, et al. Crit Care Med. 2002;30:119-141.
Address Pain Is the Patient Comfortable & at Goal? Set Goal for Analgesia Hemodynamically Unstable Fentanyl 25 - 100 mcg IVP Q 5-15 min, or Hydromorphone 0.25 - 0.75 mg IVP Q 5 - 15 min Hemodynamically stable Morphine 2 - 5 mg IVP Q 5 - 15 min Repeat until pain controlled, then scheduled doses + prn Use Pain Scale * to Assess for Pain Reassess goal daily, Titrate and taper therapy to maintain goal, Consider daily wake-up, Taper if > 1 week high-dose therapy & monitor for withdrawal
Opiates Benefits •Relieve pain or the sensibility to noxious stimuli •Sedation trending toward a change in sensorium
Opiates - Risks •Respiratory depression •NO amnesia •Pruritus •Ileus •Urinary retention
Opiates- Risks • Histamine release - morphine •Morphine metabolites which accumulate in renal failure . • Meperidine should be avoided due to neurotoxic metabolites which accumulate in renal failure
Pharmacology of Selected Analgesics Agent Dose (iv) Half-life Metabolic pathway Active metabolites Fentanyl 200 g 1.5-6 hr Oxidation None Hydromorphone 1.5 mg 2-3 hr Glucuronidation None Morphine 10 mg 3-7 hr Glucuronidation Yes (Sedation in RF) Meperidine 75-100 mg 3-4 hr Demethylation & hydroxylation Yes (neuroexcitation in RF) Codeine 120 mg 3 hr Demethylation & Glucuronidation Yes ( analgesia, sedation) Remifentanil 3-10 min Plasma esterase None Keterolac 2.4-8.6 hr Renal None
Opiate Analgesic Options: Fentanyl, Morphine, Hydromorphone Fentanyl Hydromorphone Morphine Rapid onset X Rapid offset X* Avoid in renal disease X** Preload reduction X Avoid in hemodynamic X instability Equivalent doses 100 mcg 1.5 mg 10 mg * Offset prolonged after long-term use ** Active metabolite accumulation causes excessive narcosis
Numeric Rating Scale Sample Analgesia Protocol
Sedation- Assessment • Ramsay Sedation Scale (RSS) • Sedation-agitation Scale (SAS) • Observers Assessment of Alertness/Sedation Scale (OAASS) • Motor Activity Assessment Scale (MAAS) BMJ 1974;2:656-659 Crit Care Med 1999;27:1325-1329 J Clin Psychopharmacol 1990;10:244-251 Crit Care Med 1999;27:1271-1275
The Ramsay Scale Scale Description 1 Anxious and agitated or restless, or both 2 Cooperative, oriented, and tranquil 3 Response to commands only 4 Brisk response to light glabellar tap or loud auditory stimulus 5 Sluggish response to light glabellar tap or loud auditory stimulus 6 No response to light glabellar tap or loud auditory stimulus
The Riker Sedation-Agitation Scale Score Description Definition 7 Dangerous agitation Pulling at endotracheal tube, trying to strike at staff, thrashing side to side 6 Very agitated Does not calm despite frequent verbal commands, biting ETT 5 Agitated Anxious or mildly agitated, attempting to sit 4 Calm and cooperative Calm, awakens easily, follows commands 3 Sedated Difficult to arouse, awakens to verbal stimuli, follows simple commands 2 Very sedated Arouse to physical stimuli, but does not communicate spontaneously 1 Unarousable Minimal or no response to noxious stimuli
The Motor Activity Assessment Scale Score Description Definition 6 Dangerous agitation Pulling at endotracheal tube, trying to strike at staff, thrashing side to side 5 Agitated Does not calm despite frequent verbal commands, biting ETT 4 Restless and cooperative Anxious or mildly agitated, attempting to sit 3 Calm and cooperative Calm, awakens easily, follows commands 2 Responsive to touch or name Opens eyes or raises eyebrows or turns head when touched or name is loudly spoken 1 Responsive only to noxious stimuli Opens eyes or raises eyebrows or turns head with noxious stimuli 0 Unresponsive Does not move with noxious stimuli
What sedation Scale do? •Provide a semi quantitative “score” •Standardize treatment endpoints •Allow review of efficacy of sedation •Facilitate sedation studies •Help to avoid over sedation
But scales Do not .... • Assess anxiety • Assess pain • Assess sedation in paralyzed patients • Predict outcome • Agree with each other
BIS Monitoring Used to asses Sedation levels
BIS Range Guidelines Awake Responds to normal voice Axiolysis Responds to loud commands or mild prodding/shaking Low probability to explicit recalls Unresponsive to verbal stimuli Burst suppression Flat line EEG Moderate sedation Deep Sedation 100 80 60 40 20 0 BIS
ALGORITHM FOR SEDATION AND ANALGESIA OF MECHANICALLY VENTILATED PATIENTS Yes Reassess goal daily, Titrate and taper therapy to maintain goal, Consider daily wake-up, Taper if > 1 week high-dose therapy & monitor for withdrawal No Set Goal for Analgesia Hemodynamically Unstable Fentanyl 25 - 100 mcg IVP Q 5-15 min, or Hydromorphone 0.25 - 0.75 mg IVP Q 5 - 15 min Hemodynamically stable Morphine 2 - 5 mg IVP Q 5 - 15 min Repeat until pain controlled, then scheduled doses + prn Set Goal for Sedation Acute Agitation # Midazolam 2 - 5 mg IVP Q 5 - 15 min until acute event controlled Ongoing Sedation # Lorazepam 1 - 4 mg IVP Q 10-20 min until at goal then Q 2 - 6 hr scheduled + prn, or Propofol start 5 mcg/kg/min, titrate Q 5 min until at goal Set Goal for Control of Delirium Haloperidol 2 - 10 mg IVP Q 20 - 30 min, then 25% of loading dose Q 6hr x 2-3 days, then taper IVP Doses more of ten than Q 2hr? Consider continuous infusion opiate or sedative > 3 Days Propofol? (except neuro pt.) Convert to Lorazepam Yes Benzodiazepine or Opioid: Taper Infusion Rate by 10-25% Per Day Yes Doses approximate for 70kg adult Rule out and Correct Reversible Causes Use Non-pharmacologic Treament, Optimize the Environment Use Pain Scale * to Assess for Pain Use Sedation Scale ** to Assess for Agitation/Anxiety Use Delirium Scale *** to Assess for Delirium Is the Patient Comfortable & at Goal? Lorazepam via infusion? Use a low rate and IVP loading doses 1 2 3 4 Jacobi J, Fraser GL, Coursin D, et al. Crit Care Med. 2002;30:119-141.
Set Goal for Sedation Address Sedation Acute Agitation # Midazolam 2 - 5 mg IVP Q 5 - 15 min until acute event controlled Ongoing Sedation # Lorazepam 1 - 4 mg IVP Q 10-20 min until at goal then Q 2 - 6 hr scheduled + prn, or Propofol start 5 mcg/kg/min, titrate Q 5 min until at goal IVP Doses more often than Q 2hr? Consider continuous infusion opiate or sedative > 3 Days Propofol? (except neuro pt.) Convert to Lorazepam Benzodiazepine or Opioid: Taper Infusion Rate by 10-25% Per Day Use Sedation Scale ** to Assess for Agitation/Anxiety Lorazepam via infusion? Use a low rate and IVP loading doses Yes Reassess goal daily, Titrate and taper therapy to maintain goal, Consider daily wake-up, Taper if > 1 week high-dose therapy & monitor for withdrawal Is the Patient Comfortable & at Goal?
How to Sedate ? • Benzodiazepines • Propofol • -2 agonists Sedatives- Options
Benzodiazepines (Midazolam & Lorazepam) Anxiolysis Amnesia Sedation Pharmacokinetics/dynamics •Lorazepam: onset 5 - 10 minutes, half-life 10 hours, glucuronidated •Midazolam: onset 1 - 2 minutes, half-life 3 hours, metabolized by cytochrome P450, active metabolite (1- OH) accumulates in renal disease Benefits
Benzodiazepines (Midazolam & Lorazepam) • Delirium • NO analgesia • Excessive sedation: especially after long-term sustained use • Propylene glycol toxicity (parenteral lorazepam) - Significance uncertain - Evaluate when a patient has unexplained acidosis - In alcoholics (due to doses used) and renal failure • Respiratory failure (concurrent opiate use) • Withdrawal
Propofol Pharmacology: GABA agonist Pharmacokinetics/ dynamics: onset 1 - 2 minutes, terminal half-life 6 hours, duration 10 minutes, hepatic metabolism Benefits Rapid onset &Offset Hypnotic and Antiemetic Reduce ICP OPTION 2
Propofol • No amnesia- especially at low doses • NO analgesia! • Hypotension • Hypertriglyceridemia; lipid source (1.1 kcal/ml) • Respiratory depression • Propofol Infusion Syndrome
• Cardiac failure, rhabdomyolysis, severe metabolic acidosis, and renal failure • Caution : at a doses > 80 mcg/kg/min for more than 48 hours • Problematic when used simultaneously in patient receiving catecholamines and/or steroids P O P O F O L I N F U S I O N Syndrome
Propofol Dosing • 3-5 g/kg/min antiemetic • 5-20 g/kg/min anxiolytic • 20-50 g/kg/min sedative hypnotic • >100 g/kg/min anesthetic
Dexmedetomidine Alpha-2- adrenergic agonist Decrease the need for other sedation Useful while decreasing other sedatives to prevent withdrawal Rapid onset Benefits No Respiratory depression Sympatholytic action Option -3
Dexmedetomidine No Amnesia Excessive awareness Bradycardia ,Hypotension
Alpha-2 Receptors Brain (locus ceruleus) Spinal Cord Peripheral vasculature Sedation Anxiolysis Sympatholysis Analgesia Vasoconstriction
DEX: Dosing Maintenance infusion 0.2-0.7 g/kg/hr
Sample Sedation Protocol Sedation-agitation Scale Riker RR et al. Crit Care Med. 1999;27:1325.
Use Continuous and Combined Infusion Plasma Level Load Maintenance
Repeated Bolus Plasma levels
Choose the Right Drug Sedation Analgesia Amnesia Hypnosis Anxiolysis Propofol BenPzaotideinatz eCpoinmefsort -2 agonists Opioids
Neuromuscular Blockade (NMB) Caution • NO ANALGESIC or SEDATIVE properties • Add sedation with amnestic effect . • Analgesic as needed • Never use without the ability to establish and/or maintain a definitive airway with ventilation • If administering for prolonged period (> 6 - 12 hours), use an objective monitor to assess degree of paralysis. Used most often acutely (single dose) to facilitate intubation or selected procedures
NMB Limited use because of risk of prolonged weakness and other complications Maximize sedative/analgesic infusions as much as possible prior to adding neuromuscular blockade Current concepts
NMB • Facilitate mechanical ventilation [abdominal compartment syndrome, high airway pressures, and dyssynchrony] • High Frequency Ventilation, Prone ventilation • Elevated intracranial pressures • Reduce oxygen consumption • Prevent muscle spasm [neuroleptic malignant syndrome, tetanus, etc.] • Protect surgical wounds or medical device placement When to Use it?
NMB agents •Depolarizers Two classes •Non depolarizers
NMB agents • Succhinylcholine is the only drug in this class • Depolarization (fasciculations) and desensitization of the motor endplate • Motor Paralysis Depolarizers Prolonged binding to acetylcholine receptor
NMB Agents • Benzylisoquinoliniums • Curare Atracurium, Cisatracurium, Mivacurium, Doxacuronium • Aminosteroids • Pancuronium, Vecuronium, Rococuronium Non depolarizers Competitive inhibitors of postsynaptic receptors
NMB Agents for intubation Rocuronium • Onset -45 seconds • Nondepolarizer with about an hour duration and 10% renal elimination • Dose is 1.2 mg/kg Succinylcholine • Onset 30 seconds • Duration of 10 minutes • All or none train of four after administration due to desensitization • prolonged in patients with abnormal plasma cholinesterase • Dose is 1 - 2 mg/kg Need rapid onset paralysis Not usually used for continuous maintenance infusions
Succinylcholine Severe K+ releases • Denervation injury • Stroke • Trauma • Burns of more than 24 hours Problems •Potassium release- 0.5 to 1 meq/liter •Bradycardia •Increases intra gastric, ocular and cranial pressures •Anaphylaxis •Muscle pain
NDMR •Pancuronium - tachycardia •Vecuronium - renally excreted active metabolites •Elimination of cisatracurium is not affected by organ dysfunction Infusion doses •Pancuronium 0.05 - 0.1 mg/kg/h •Vecuronium 0.05 - 0.1 mg/kg/h •Cisatracurium 0.03 - 0.6 mg/kg/h
Monitoring NMBAs Methods: •NMBA dose reduction or cessation once daily if possible • Clinical evaluation: Assess skeletal muscle movement and respiratory effort •Peripheral nerve stimulation To prevent prolonged weakness associated with excessive NMBA administration
Monitoring NMBAs • Train of four response consists of four stimulae of 2 Hz, 0.2 msec in duration, and 500 msec apart. • Comparison of T4 (4th twitch) and T1 with a fade in strength means that 75% of receptors are blocked. • Only T1 or T1 and 2 is used for goal in ICU and indicates up to 90% of receptors are blocked. Peripheral nerve stimulation
Complications of NMB Agents Associated with inactivity: • Muscle wasting, deconditioning, decubitus ulcers, corneal drying Associated with inability to assess patient: • Recall, unrelieved pain, acute neurologic event, anxiety
Complications of NMB Agents Associated with loss of respiratory function: • Asphyxiation from ventilator malfunction or accidental extubation, atelectasis, pneumonia Other: • Prolonged paralysis or acute NMBA related myopathy - Related to decreased membrane excitability or even muscle necrosis - Risk can be compounded by concurrent use of steroids.
Monitoring Sedation During Paralysis • Bispectral index • Titrating to appropriate sedation to the least amount required, not proven to achieve the goal. • Potential for baseline neurologic deficit and EEG interference in ICU patients
Monitoring Sedation During Paralysis… No randomized controlled studies to support reliable use in ICU. Other neuromonitoring (awareness) modalities are likely to be developed. Cessation of NMB as soon as safe in conjunction with other patient parameters should be a daily consideration.
Sample NMBA Protocol
ICU Delirium Seen in > 50% of ICU patients Three times higher risk of death by six months Four times greater frequency of medical device removal Nine times higher incidence of cognitive impairment at hospital discharge
Delirium 1.Acute onset of mental status changes or a fluctuating course & 2. Inattention & or Courtesy of W Ely, MD 3. Disorganized Thinking 4. Altered level of consciousness
Risk Factors for Delirium Primary CNS Dx Infection Metabolic derangement Pain Sleep deprivation Age Substances including tobacco (withdrawal as well as direct effect)
Diagnostic Tools: ICU Routine monitoring recommended • Confusion Assessment Method (CAM-ICU) or Delirium Screening Checklist (DSC) Requires Patient Participation • Cognitive Test for Delirium • Abbreviated Cognitive Test for Delirium • CAM-ICU Ely. JAMA. 2001;286: 2703-2710.
Delirium Screening Checklist No Patient Participation • Delirium Screening Checklist Bergeron. Intensive Care Med. 2001;27:859.
Treatment of Delirium Correct inciting factor Control symptoms? • No evidence that treatment reduces duration and severity of symptoms • Typical and atypical antipsychotic agents • Sedatives? - Particularly in combination with antipsychotic and for drug/alcohol withdrawal delirium No treatment FDA approved
Haloperidol The good: • Hemodynamic neutrality • No effect on respiratory drive The bad: • QTc prolongation and torsades de pointes • Neuoroleptic malignant syndrome • Extrapyramidal side effects
Atypical Antipsychotics: Mechanism of action unknown Less movement disorders than haloperidol Enhanced effects on both positive (agitation) and negative (quiet) symptoms Quetiapine Olanzapine Risperidone Ziprasidone
Efficacy = haloperidol? • Lack of available IV formulation • Troublesome reports of CVAs, hyperglycemia, NMS • Titratability hampered QTc prolongation with ziprasidone IM - Hypotension with olanzapine IM Atypical Antipsychotics:
Summary • Patient discomfort in ICU should be addressed appropriately and seriously • Protocol based practice will bring up excellent results. • Assess and Manage Sedation and Analgesia • Paralysis should be restricted to indicated cases • Address delirium and withdrawals
Thank you for your patient listening

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Sedation , analgesia & paralysis

  • 1.
    Sedation , Analgesia& Paralysis in ICU Dr.Venugopalan.P.P DA,DNB,MNAMS Chief, Emergency Medicine –MIMS Site Director ,Masters program in EM Executive director ,Angels international foundation
  • 2.
    Objectives Guidelines forsedation, analgesia, and chemical paralysis Benefits of daily awakening/lightening and sedation titration programs Rational pharmacologic strategy based on treatment goals and co morbidities
  • 3.
    What We KnowAbout ICU Agitation/Discomfort? Prevalence • 50% incidence in those with length of stay > 24 hours Primary causes • Unrelieved pain • Delirium • Anxiety • Sleep deprivation.
  • 4.
  • 5.
    Recall in theICU Some degree of recall occurs in up to 70% of ICU patients. • Anxiety, fear, pain, panic, agony, or nightmares reported in 90% of those who did have recall. Potentially cruel: • Up to 36% recalled some aspect of paralysis. Associated with PTSD in ARDS? • 41% risk of recall of two or more traumatic experiences. Associated with PTSD in cardiac surgery
  • 6.
    Appropriate Recall Maybe Important Factual memories help to put ICU experience into perspective Delusional memories cause panic attacks and PTSD The optimal level of sedation for most patients - Offers comfort while allowing for interaction with the environment.
  • 7.
    Why sedation inICU? • Anxiety • Pain • Acute confusional status • Mechanical ventilation • Treatment or diagnostic procedures • Psychological response to stress
  • 8.
    Sedation Goal •Patient comfort • Control of pain • Anxiolysis and amnesia • Blunting adverse autonomic and hemodynamic responses • Facilitate nursing management • Facilitate mechanical ventilation • Avoid self-extubation • Reduce oxygen consumption
  • 9.
    Ideal sedation agents • No respiratory depression • Analgesia • Rapid onset, titratable, with a short elimination half-time • Sedation with ease of orientation and arousability • Anxiolytic • Hemodynamic stability
  • 10.
    The Challenges •Assessment of sedation • Altered pharmacology • Tolerance • Delayed emergence • Withdrawal • Drug interaction
  • 11.
    Sedation Causes forAgitation Sedatives
  • 12.
    Undersedation Sedatives Causesfor Agitation Agitation & anxiety Pain and discomfort Catheter displacement Inadequate ventilation Hypertension Tachycardia Arrhythmias Myocardial ischemia Wound disruption Patient injury
  • 13.
    Oversedation Sedatives Causesfor Agitation Prolonged sedation Delayed emergence Respiratory depression Hypotension Bradycardia Increased protein breakdown Muscle atrophy Venous stasis Pressure injury Loss of patient-staff interaction Increased cost
  • 14.
    Reversible Causes ofAgitation • Full bladder • Uncomfortable bed position • Inadequate ventilator flow rates • Mental illness • Uremia • Drug side effects • Disorientation • Sleep deprivation • Noise • Inability to communicate
  • 15.
    Life threatening Causes • Hypoxia • Hypercarbia • Hypoglycemia • Endotracheal tube malposition • Pneumothorax • Myocardial ischemia • Abdominal pain • Drug and alcohol withdrawal
  • 16.
    Daily Goal is Arousable, Comfortable Sedation Effect of this strategy on outcomes: • One- to seven-day reduction in length of sedation and mechanical ventilation needs • 50% reduction in tracheostomies • Three-fold reduction in the need for diagnostic evaluation of CNS Sedation needs to be protocolized and titrated to goal: •Lighten sedation to appropriate wakefulness daily.
  • 17.
    Protocols and AssessmentTools Sedation o Validated sedation assessment tools (Ramsay Sedation Scale [RSS], o Sedation-Agitation Scale [SAS] o Richmond Sedation-agitation Scale [RSAS] No evidence that one is preferred over another Pain o Numeric rating scale [NRS] o Visual analogue scale [VAS] Pain assessment tools - none validated in ICU
  • 18.
    Sedation/Analgesia ICU Ruleout reversible causes of discomfort/anxiety such as hypoxemia, hypercarbia, and toxic/drug side effect. Assess co-morbidities and potential side effects of drugs chosen. Target irreversible etiologies of pain and agitation.
  • 19.
    Strategies for PatientComfort • Set treatment goal • Quantitate sedation and pain • Choose the right medication • Use combined infusion • Reevaluate need • Treat withdrawal
  • 20.
    ALGORITHM FOR SEDATIONAND ANALGESIA OF MECHANICALLY VENTILATED PATIENTS Yes Reassess goal daily, Titrate and taper therapy to maintain goal, Consider daily wake-up, Taper if > 1 week high-dose therapy & monitor for withdrawal No Set Goal for Analgesia Hemodynamically Unstable Fentanyl 25 - 100 mcg IVP Q 5-15 min, or Hydromorphone 0.25 - 0.75 mg IVP Q 5 - 15 min Hemodynamically stable Morphine 2 - 5 mg IVP Q 5 - 15 min Repeat until pain controlled, then scheduled doses + prn Set Goal for Sedation Acute Agitation # Midazolam 2 - 5 mg IVP Q 5 - 15 min until acute event controlled Ongoing Sedation # Lorazepam 1 - 4 mg IVP Q 10-20 min until at goal then Q 2 - 6 hr scheduled + prn, or Propofol start 5 mcg/kg/min, titrate Q 5 min until at goal Set Goal for Control of Delirium Haloperidol 2 - 10 mg IVP Q 20 - 30 min, then 25% of loading dose Q 6hr x 2-3 days, then taper IVP Doses more of ten than Q 2hr? Consider continuous infusion opiate or sedative > 3 Days Propofol? (except neuro pt.) Convert to Lorazepam Yes Benzodiazepine or Opioid: Taper Infusion Rate by 10-25% Per Day Yes Doses approximate for 70kg adult Rule out and Correct Reversible Causes Use Non-pharmacologic Treament, Optimize the Environment Use Pain Scale * to Assess for Pain Use Sedation Scale ** to Assess for Agitation/Anxiety Use Delirium Scale *** to Assess for Delirium Is the Patient Comfortable & at Goal? Lorazepam via infusion? Use a low rate and IVP loading doses 1 2 3 4 Jacobi J, Fraser GL, Coursin D, et al. Crit Care Med. 2002;30:119-141.
  • 21.
  • 22.
    Visual Pain Scales 0 1 2 3 4 5 6 7 8 9 10 No pain Worst possible pain
  • 23.
    Signs of Pain • Hypertension • Tachycardia • Lacrimation • Sweating • Pupillary dilation
  • 24.
    Pain Management •Anticipate • Recognize • Quantify Recognize Pain
  • 25.
    Treat Pain oQuantifythe pain perception oCorrect the correctable causes oUse appropriate analgesics • Remember- most sedative agents do not provide analgesia • Reassess
  • 26.
    Non-pharmacological Methods •Proper position of the patient • Stabilization of fractures • Elimination of irritating stimulation • Proper positioning of the ventilator tubing to avoid traction on endotracheal tube
  • 27.
    ALGORITHM FOR SEDATIONAND ANALGESIA OF MECHANICALLY VENTILATED PATIENTS Yes Reassess goal daily, Titrate and taper therapy to maintain goal, Consider daily wake-up, Taper if > 1 week high-dose therapy & monitor for withdrawal No Set Goal for Analgesia Hemodynamically Unstable Fentanyl 25 - 100 mcg IVP Q 5-15 min, or Hydromorphone 0.25 - 0.75 mg IVP Q 5 - 15 min Hemodynamically stable Morphine 2 - 5 mg IVP Q 5 - 15 min Repeat until pain controlled, then scheduled doses + prn Set Goal for Sedation Acute Agitation # Midazolam 2 - 5 mg IVP Q 5 - 15 min until acute event controlled Ongoing Sedation # Lorazepam 1 - 4 mg IVP Q 10-20 min until at goal then Q 2 - 6 hr scheduled + prn, or Propofol start 5 mcg/kg/min, titrate Q 5 min until at goal Set Goal for Control of Delirium Haloperidol 2 - 10 mg IVP Q 20 - 30 min, then 25% of loading dose Q 6hr x 2-3 days, then taper IVP Doses more of ten than Q 2hr? Consider continuous infusion opiate or sedative > 3 Days Propofol? (except neuro pt.) Convert to Lorazepam Yes Benzodiazepine or Opioid: Taper Infusion Rate by 10-25% Per Day Yes Doses approximate for 70kg adult Rule out and Correct Reversible Causes Use Non-pharmacologic Treament, Optimize the Environment Use Pain Scale * to Assess for Pain Use Sedation Scale ** to Assess for Agitation/Anxiety Use Delirium Scale *** to Assess for Delirium Is the Patient Comfortable & at Goal? Lorazepam via infusion? Use a low rate and IVP loading doses 1 2 3 4 Jacobi J, Fraser GL, Coursin D, et al. Crit Care Med. 2002;30:119-141.
  • 28.
    Address Pain Isthe Patient Comfortable & at Goal? Set Goal for Analgesia Hemodynamically Unstable Fentanyl 25 - 100 mcg IVP Q 5-15 min, or Hydromorphone 0.25 - 0.75 mg IVP Q 5 - 15 min Hemodynamically stable Morphine 2 - 5 mg IVP Q 5 - 15 min Repeat until pain controlled, then scheduled doses + prn Use Pain Scale * to Assess for Pain Reassess goal daily, Titrate and taper therapy to maintain goal, Consider daily wake-up, Taper if > 1 week high-dose therapy & monitor for withdrawal
  • 29.
    Opiates Benefits •Relievepain or the sensibility to noxious stimuli •Sedation trending toward a change in sensorium
  • 30.
    Opiates - Risks •Respiratory depression •NO amnesia •Pruritus •Ileus •Urinary retention
  • 31.
    Opiates- Risks •Histamine release - morphine •Morphine metabolites which accumulate in renal failure . • Meperidine should be avoided due to neurotoxic metabolites which accumulate in renal failure
  • 32.
    Pharmacology of SelectedAnalgesics Agent Dose (iv) Half-life Metabolic pathway Active metabolites Fentanyl 200 g 1.5-6 hr Oxidation None Hydromorphone 1.5 mg 2-3 hr Glucuronidation None Morphine 10 mg 3-7 hr Glucuronidation Yes (Sedation in RF) Meperidine 75-100 mg 3-4 hr Demethylation & hydroxylation Yes (neuroexcitation in RF) Codeine 120 mg 3 hr Demethylation & Glucuronidation Yes ( analgesia, sedation) Remifentanil 3-10 min Plasma esterase None Keterolac 2.4-8.6 hr Renal None
  • 33.
    Opiate Analgesic Options:Fentanyl, Morphine, Hydromorphone Fentanyl Hydromorphone Morphine Rapid onset X Rapid offset X* Avoid in renal disease X** Preload reduction X Avoid in hemodynamic X instability Equivalent doses 100 mcg 1.5 mg 10 mg * Offset prolonged after long-term use ** Active metabolite accumulation causes excessive narcosis
  • 34.
    Numeric Rating Scale Sample Analgesia Protocol
  • 36.
    Sedation- Assessment •Ramsay Sedation Scale (RSS) • Sedation-agitation Scale (SAS) • Observers Assessment of Alertness/Sedation Scale (OAASS) • Motor Activity Assessment Scale (MAAS) BMJ 1974;2:656-659 Crit Care Med 1999;27:1325-1329 J Clin Psychopharmacol 1990;10:244-251 Crit Care Med 1999;27:1271-1275
  • 37.
    The Ramsay Scale Scale Description 1 Anxious and agitated or restless, or both 2 Cooperative, oriented, and tranquil 3 Response to commands only 4 Brisk response to light glabellar tap or loud auditory stimulus 5 Sluggish response to light glabellar tap or loud auditory stimulus 6 No response to light glabellar tap or loud auditory stimulus
  • 38.
    The Riker Sedation-AgitationScale Score Description Definition 7 Dangerous agitation Pulling at endotracheal tube, trying to strike at staff, thrashing side to side 6 Very agitated Does not calm despite frequent verbal commands, biting ETT 5 Agitated Anxious or mildly agitated, attempting to sit 4 Calm and cooperative Calm, awakens easily, follows commands 3 Sedated Difficult to arouse, awakens to verbal stimuli, follows simple commands 2 Very sedated Arouse to physical stimuli, but does not communicate spontaneously 1 Unarousable Minimal or no response to noxious stimuli
  • 39.
    The Motor ActivityAssessment Scale Score Description Definition 6 Dangerous agitation Pulling at endotracheal tube, trying to strike at staff, thrashing side to side 5 Agitated Does not calm despite frequent verbal commands, biting ETT 4 Restless and cooperative Anxious or mildly agitated, attempting to sit 3 Calm and cooperative Calm, awakens easily, follows commands 2 Responsive to touch or name Opens eyes or raises eyebrows or turns head when touched or name is loudly spoken 1 Responsive only to noxious stimuli Opens eyes or raises eyebrows or turns head with noxious stimuli 0 Unresponsive Does not move with noxious stimuli
  • 40.
    What sedation Scaledo? •Provide a semi quantitative “score” •Standardize treatment endpoints •Allow review of efficacy of sedation •Facilitate sedation studies •Help to avoid over sedation
  • 41.
    But scales Donot .... • Assess anxiety • Assess pain • Assess sedation in paralyzed patients • Predict outcome • Agree with each other
  • 42.
    BIS Monitoring Usedto asses Sedation levels
  • 43.
    BIS Range Guidelines Awake Responds to normal voice Axiolysis Responds to loud commands or mild prodding/shaking Low probability to explicit recalls Unresponsive to verbal stimuli Burst suppression Flat line EEG Moderate sedation Deep Sedation 100 80 60 40 20 0 BIS
  • 44.
    ALGORITHM FOR SEDATIONAND ANALGESIA OF MECHANICALLY VENTILATED PATIENTS Yes Reassess goal daily, Titrate and taper therapy to maintain goal, Consider daily wake-up, Taper if > 1 week high-dose therapy & monitor for withdrawal No Set Goal for Analgesia Hemodynamically Unstable Fentanyl 25 - 100 mcg IVP Q 5-15 min, or Hydromorphone 0.25 - 0.75 mg IVP Q 5 - 15 min Hemodynamically stable Morphine 2 - 5 mg IVP Q 5 - 15 min Repeat until pain controlled, then scheduled doses + prn Set Goal for Sedation Acute Agitation # Midazolam 2 - 5 mg IVP Q 5 - 15 min until acute event controlled Ongoing Sedation # Lorazepam 1 - 4 mg IVP Q 10-20 min until at goal then Q 2 - 6 hr scheduled + prn, or Propofol start 5 mcg/kg/min, titrate Q 5 min until at goal Set Goal for Control of Delirium Haloperidol 2 - 10 mg IVP Q 20 - 30 min, then 25% of loading dose Q 6hr x 2-3 days, then taper IVP Doses more of ten than Q 2hr? Consider continuous infusion opiate or sedative > 3 Days Propofol? (except neuro pt.) Convert to Lorazepam Yes Benzodiazepine or Opioid: Taper Infusion Rate by 10-25% Per Day Yes Doses approximate for 70kg adult Rule out and Correct Reversible Causes Use Non-pharmacologic Treament, Optimize the Environment Use Pain Scale * to Assess for Pain Use Sedation Scale ** to Assess for Agitation/Anxiety Use Delirium Scale *** to Assess for Delirium Is the Patient Comfortable & at Goal? Lorazepam via infusion? Use a low rate and IVP loading doses 1 2 3 4 Jacobi J, Fraser GL, Coursin D, et al. Crit Care Med. 2002;30:119-141.
  • 45.
    Set Goal for Sedation Address Sedation Acute Agitation # Midazolam 2 - 5 mg IVP Q 5 - 15 min until acute event controlled Ongoing Sedation # Lorazepam 1 - 4 mg IVP Q 10-20 min until at goal then Q 2 - 6 hr scheduled + prn, or Propofol start 5 mcg/kg/min, titrate Q 5 min until at goal IVP Doses more often than Q 2hr? Consider continuous infusion opiate or sedative > 3 Days Propofol? (except neuro pt.) Convert to Lorazepam Benzodiazepine or Opioid: Taper Infusion Rate by 10-25% Per Day Use Sedation Scale ** to Assess for Agitation/Anxiety Lorazepam via infusion? Use a low rate and IVP loading doses Yes Reassess goal daily, Titrate and taper therapy to maintain goal, Consider daily wake-up, Taper if > 1 week high-dose therapy & monitor for withdrawal Is the Patient Comfortable & at Goal?
  • 46.
    How to Sedate? • Benzodiazepines • Propofol • -2 agonists Sedatives- Options
  • 47.
    Benzodiazepines (Midazolam &Lorazepam) Anxiolysis Amnesia Sedation Pharmacokinetics/dynamics •Lorazepam: onset 5 - 10 minutes, half-life 10 hours, glucuronidated •Midazolam: onset 1 - 2 minutes, half-life 3 hours, metabolized by cytochrome P450, active metabolite (1- OH) accumulates in renal disease Benefits
  • 48.
    Benzodiazepines (Midazolam &Lorazepam) • Delirium • NO analgesia • Excessive sedation: especially after long-term sustained use • Propylene glycol toxicity (parenteral lorazepam) - Significance uncertain - Evaluate when a patient has unexplained acidosis - In alcoholics (due to doses used) and renal failure • Respiratory failure (concurrent opiate use) • Withdrawal
  • 49.
    Propofol Pharmacology: GABA agonist Pharmacokinetics/ dynamics: onset 1 - 2 minutes, terminal half-life 6 hours, duration 10 minutes, hepatic metabolism Benefits Rapid onset &Offset Hypnotic and Antiemetic Reduce ICP OPTION 2
  • 50.
    Propofol • Noamnesia- especially at low doses • NO analgesia! • Hypotension • Hypertriglyceridemia; lipid source (1.1 kcal/ml) • Respiratory depression • Propofol Infusion Syndrome
  • 51.
    • Cardiac failure, rhabdomyolysis, severe metabolic acidosis, and renal failure • Caution : at a doses > 80 mcg/kg/min for more than 48 hours • Problematic when used simultaneously in patient receiving catecholamines and/or steroids P O P O F O L I N F U S I O N Syndrome
  • 52.
    Propofol Dosing •3-5 g/kg/min antiemetic • 5-20 g/kg/min anxiolytic • 20-50 g/kg/min sedative hypnotic • >100 g/kg/min anesthetic
  • 53.
    Dexmedetomidine Alpha-2- adrenergicagonist Decrease the need for other sedation Useful while decreasing other sedatives to prevent withdrawal Rapid onset Benefits No Respiratory depression Sympatholytic action Option -3
  • 54.
    Dexmedetomidine No Amnesia Excessive awareness Bradycardia ,Hypotension
  • 55.
    Alpha-2 Receptors Brain (locus ceruleus) Spinal Cord Peripheral vasculature Sedation Anxiolysis Sympatholysis Analgesia Vasoconstriction
  • 56.
    DEX: Dosing Maintenanceinfusion 0.2-0.7 g/kg/hr
  • 57.
    Sample Sedation Protocol Sedation-agitation Scale Riker RR et al. Crit Care Med. 1999;27:1325.
  • 58.
    Use Continuous andCombined Infusion Plasma Level Load Maintenance
  • 59.
  • 60.
    Choose the RightDrug Sedation Analgesia Amnesia Hypnosis Anxiolysis Propofol BenPzaotideinatz eCpoinmefsort -2 agonists Opioids
  • 62.
    Neuromuscular Blockade (NMB)Caution • NO ANALGESIC or SEDATIVE properties • Add sedation with amnestic effect . • Analgesic as needed • Never use without the ability to establish and/or maintain a definitive airway with ventilation • If administering for prolonged period (> 6 - 12 hours), use an objective monitor to assess degree of paralysis. Used most often acutely (single dose) to facilitate intubation or selected procedures
  • 63.
    NMB Limited usebecause of risk of prolonged weakness and other complications Maximize sedative/analgesic infusions as much as possible prior to adding neuromuscular blockade Current concepts
  • 64.
    NMB • Facilitatemechanical ventilation [abdominal compartment syndrome, high airway pressures, and dyssynchrony] • High Frequency Ventilation, Prone ventilation • Elevated intracranial pressures • Reduce oxygen consumption • Prevent muscle spasm [neuroleptic malignant syndrome, tetanus, etc.] • Protect surgical wounds or medical device placement When to Use it?
  • 65.
    NMB agents •Depolarizers Two classes •Non depolarizers
  • 66.
    NMB agents •Succhinylcholine is the only drug in this class • Depolarization (fasciculations) and desensitization of the motor endplate • Motor Paralysis Depolarizers Prolonged binding to acetylcholine receptor
  • 67.
    NMB Agents •Benzylisoquinoliniums • Curare Atracurium, Cisatracurium, Mivacurium, Doxacuronium • Aminosteroids • Pancuronium, Vecuronium, Rococuronium Non depolarizers Competitive inhibitors of postsynaptic receptors
  • 68.
    NMB Agents for intubation Rocuronium • Onset -45 seconds • Nondepolarizer with about an hour duration and 10% renal elimination • Dose is 1.2 mg/kg Succinylcholine • Onset 30 seconds • Duration of 10 minutes • All or none train of four after administration due to desensitization • prolonged in patients with abnormal plasma cholinesterase • Dose is 1 - 2 mg/kg Need rapid onset paralysis Not usually used for continuous maintenance infusions
  • 69.
    Succinylcholine Severe K+releases • Denervation injury • Stroke • Trauma • Burns of more than 24 hours Problems •Potassium release- 0.5 to 1 meq/liter •Bradycardia •Increases intra gastric, ocular and cranial pressures •Anaphylaxis •Muscle pain
  • 70.
    NDMR •Pancuronium - tachycardia •Vecuronium - renally excreted active metabolites •Elimination of cisatracurium is not affected by organ dysfunction Infusion doses •Pancuronium 0.05 - 0.1 mg/kg/h •Vecuronium 0.05 - 0.1 mg/kg/h •Cisatracurium 0.03 - 0.6 mg/kg/h
  • 71.
    Monitoring NMBAs Methods: •NMBA dose reduction or cessation once daily if possible • Clinical evaluation: Assess skeletal muscle movement and respiratory effort •Peripheral nerve stimulation To prevent prolonged weakness associated with excessive NMBA administration
  • 72.
    Monitoring NMBAs •Train of four response consists of four stimulae of 2 Hz, 0.2 msec in duration, and 500 msec apart. • Comparison of T4 (4th twitch) and T1 with a fade in strength means that 75% of receptors are blocked. • Only T1 or T1 and 2 is used for goal in ICU and indicates up to 90% of receptors are blocked. Peripheral nerve stimulation
  • 73.
    Complications of NMBAgents Associated with inactivity: • Muscle wasting, deconditioning, decubitus ulcers, corneal drying Associated with inability to assess patient: • Recall, unrelieved pain, acute neurologic event, anxiety
  • 74.
    Complications of NMBAgents Associated with loss of respiratory function: • Asphyxiation from ventilator malfunction or accidental extubation, atelectasis, pneumonia Other: • Prolonged paralysis or acute NMBA related myopathy - Related to decreased membrane excitability or even muscle necrosis - Risk can be compounded by concurrent use of steroids.
  • 75.
    Monitoring Sedation DuringParalysis • Bispectral index • Titrating to appropriate sedation to the least amount required, not proven to achieve the goal. • Potential for baseline neurologic deficit and EEG interference in ICU patients
  • 76.
    Monitoring Sedation DuringParalysis… No randomized controlled studies to support reliable use in ICU. Other neuromonitoring (awareness) modalities are likely to be developed. Cessation of NMB as soon as safe in conjunction with other patient parameters should be a daily consideration.
  • 77.
  • 79.
    ICU Delirium Seenin > 50% of ICU patients Three times higher risk of death by six months Four times greater frequency of medical device removal Nine times higher incidence of cognitive impairment at hospital discharge
  • 80.
    Delirium 1.Acute onsetof mental status changes or a fluctuating course & 2. Inattention & or Courtesy of W Ely, MD 3. Disorganized Thinking 4. Altered level of consciousness
  • 81.
    Risk Factors forDelirium Primary CNS Dx Infection Metabolic derangement Pain Sleep deprivation Age Substances including tobacco (withdrawal as well as direct effect)
  • 82.
    Diagnostic Tools: ICU Routine monitoring recommended • Confusion Assessment Method (CAM-ICU) or Delirium Screening Checklist (DSC) Requires Patient Participation • Cognitive Test for Delirium • Abbreviated Cognitive Test for Delirium • CAM-ICU Ely. JAMA. 2001;286: 2703-2710.
  • 84.
    Delirium Screening Checklist No Patient Participation • Delirium Screening Checklist Bergeron. Intensive Care Med. 2001;27:859.
  • 85.
    Treatment of Delirium Correct inciting factor Control symptoms? • No evidence that treatment reduces duration and severity of symptoms • Typical and atypical antipsychotic agents • Sedatives? - Particularly in combination with antipsychotic and for drug/alcohol withdrawal delirium No treatment FDA approved
  • 86.
    Haloperidol The good: • Hemodynamic neutrality • No effect on respiratory drive The bad: • QTc prolongation and torsades de pointes • Neuoroleptic malignant syndrome • Extrapyramidal side effects
  • 87.
    Atypical Antipsychotics: Mechanismof action unknown Less movement disorders than haloperidol Enhanced effects on both positive (agitation) and negative (quiet) symptoms Quetiapine Olanzapine Risperidone Ziprasidone
  • 88.
    Efficacy = haloperidol? • Lack of available IV formulation • Troublesome reports of CVAs, hyperglycemia, NMS • Titratability hampered QTc prolongation with ziprasidone IM - Hypotension with olanzapine IM Atypical Antipsychotics:
  • 89.
    Summary • Patientdiscomfort in ICU should be addressed appropriately and seriously • Protocol based practice will bring up excellent results. • Assess and Manage Sedation and Analgesia • Paralysis should be restricted to indicated cases • Address delirium and withdrawals
  • 90.
    Thank you foryour patient listening