Sedation practice in ICU.ppt Sedation practice in ICU

Presented by: Dr. Kishor Jhunjhunwala
Consultant Anesthesiologist
Ford Hospital & Research Centre
Patna
Training & Development Team-Ford Hospital & Research Centre -Patna
Prepared by: Clinical Team
Patna

 Sedation scores
 Problems of sedation
 To evolve a sedation protocol
 Emphasize on documentation

 Pharmacology of drugs
 Dosing
 Preparation/ storage etc

 Tube tolerance
 Ventilator synchronization
 Reduce agitation ( withdrawal etc)
 Pain relief
 Facilitate interventions

 Sleep deprivation
 Increased stress
 Increased inflammatory mediators

Over-sedation
Vs
Under-sedation

 Prolongs ICU stay
 Prolongs weaning
 Risk factor for delirium ( BZDs )
 ?CIPN
 Hemodynamic disturbances

Undersedation:
 hyper-catabolism
 immunosuppression
 Hyper-coagulability
 increased sympathetic activity
 Accidental extubation
 Hyperglycemia
 PTSD

 Counselling ( family, primary, nursing staff )
 Psychologist
 Psychiatrist
 Music
 Feeding
 Adequate hydration
NOT FOR VENTILATED PATIENTS

 Short acting ( plasma t 1/2 & context sensitivity )
 Amnesia
 Analgesia
 Less accumulation in peripheral tissues
 Hemodynamically stable
 No withdrawal effects
 No respiratory depression
 Bronchodilator
 CHEAP

 Narcotics
 Benzodiazepines
 Miscellaneous

Vasodilation
Respiratory
depression
Confusion
Gut
motility depression
Opioids

Propofol
Hypertriglyceridemia
CVS depression
Hypotension
2-agonists
Hypotension
Bradycardia
Hypertension
Secretions
Dysphoria
Over sedation
Delayed
awakening/extubation
Benzodiazepines
Hypotension Respiratory
depression Agitation/Confusion
Ketamine
General

“the inability to communicate verbally does not negate
the possibility that an individual is experiencing pain
and is in need of appropriate pain-relieving
treatment”

 Suctioning
 Positioning/ bed making
 Procedures ( including removals )

 Ramsay sedation score
 Bloomsbury sedation score
 RASS
 Sedation Agitation Scale

 RAAS & SAS >>> Most valid and reliable
sedation assessment tool in adult ICU

 Auditory evoked potential
 BIS
 Narcotrend Index
 Patient State index
 State Entropy
 Scoring scales
Not
recommended
by SCCM

 Brain function monitoring not recommended
for non- comatose, non-paralysed patients
 Brain function monitoring recommended along
with sedation scores in patients who are
paralysed in ICU
 EEG monitoring recommended in patients with
non-convulsive seizure activity, suspected seizure
activity

  Syndrome characterized by the acute onset of
cerebral dysfunction with a change or fluctuation in
baseline mental status, inattention, and either
disorganized thinking or an altered level of
consciousness
 Up to 80 % adults on ventilator experience
delirium
 Costly affair

 Prolonged ICU stay
 Prolonged sedation
 Benzodiazepines
 Alcoholics, Chronic smokers
 Elderly
 Organ dysfunction

 Acutely fluctuating mental status
 Inattention
 Disorganized thinking
 Altered mentation
 With/ without agitation

DELIRIUM Hyperactive
Hypoactive

 Neuroleptic agents ( No evidence )
 α 2 agonists ( limited evidence )
 Treat the cause
 SCCM doesn’t support or recommend use of
prophylactic methods to prevent ICU delirium (
No evidence )
Earlymobilizationis theonlyproven
way topreventICUdelirium

 Propofol / Dexmedetomidine : Short duration
sedation( 24-48 hours )
 Fentanyl ( long duration, > 48 hours )
 Avoid BZD infusion
 SEDATION HOLIDAY

 Interruption of sedation ( preferably
daily )
 Assess neurological status
 Restart after assessment or if
agitation increased
 Shown to reduce duration of
ventilation & ICU stay

 > 48 hours
 ? High dose
 metabolic acidosis, rhabdomyolysis
 Arrhythmias
 myocardial & renal failure
 hepatomegaly
 Death

 Pain/ sedation assessment infrequently done
 Implementation of recommendations not
possible ( although discussed )
 No documentation of scores
 Scores not addressed??
 Sedation Holiday is practiced most of the
times

 Protocol for addressing Pain, Agitation, Delirium in
ICU
 Monitor Pain, Agitation & Delirium ( Scoring
systems )
 Document SCORES

 Use non-benzodiazepine sedative
 Light level of sedation is associated with
improved clinical outcomes
 Adequate analgesia for procedures
 Review medications daily

 Sedation Holiday
 Early mobilization
 Brain function monitoring recommended if
NDMR used
 Brain function monitoring not recommended in
non-comatose patients
 CONDUCIVE ENVIRONMENT IN ICU

Prepared by: Clinical Team
Patna

Sedation practice in ICU.ppt Sedation practice in ICU

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