This document discusses sedation practices in the ICU. It covers topics like sedation scores, problems with over and under sedation, pharmacology of sedative drugs, delirium monitoring and prevention. It recommends using non-benzodiazepine sedatives like propofol and dexmedetomidine for short-term sedation. Maintaining a light level of sedation, daily sedation holidays, adequate pain relief and early mobilization are emphasized to improve outcomes. Valid sedation scales like RASS and SAS should be used and documented regularly.
A powerpoint explaining in detail about all the intravenous induction agents and their clinical uses, pharmacokinetics & pharmacodynamics, adverse effects and complications.
The New 2018 SCCM PADIS Guidelines: Quick Hits of Recommendations for Sedatio...Intensive Care Society
Dr. Needham is Professor of Pulmonary and Critical Care Medicine, and of Physical Medicine and Rehabilitation at the Johns Hopkins University in Baltimore, USA. He is Director of the “Outcomes After Critical Illness and Surgery” (OACIS) Research Group and core faculty with the Armstrong Institute for Patient Safety and Quality, both at Johns Hopkins. From a clinical perspective, he is an attending physician in the medical intensive care unit at Johns Hopkins Hospital and Medical Director of the Johns Hopkins Critical Care Physical Medicine and Rehabilitation program.
Dr. Needham received his MD degree from McMaster University in Hamilton, Canada, and completed both his residency in internal medicine and his fellowship in critical care medicine at the University of Toronto. He obtained his PhD in Clinical Investigation from the Bloomberg School of Public Health at Johns Hopkins University. Notably, prior to his medical training, he completed Bachelor and Master degrees in Accounting and practiced in a large international accounting firm, with a focus in the health care field.
Dr. Needham is Principal Investigator on a number of NIH research grants and has authored more than 250 publications. His research interests include evaluating and improving ICU patients’ long-term physical, cognitive and mental health outcomes, including research in the areas of sedation, delirium, early physical rehabilitation, and knowledge translation and quality improvement.
In critical care medicine the invasive life saving techniques are often employed and when all goes well such interventions will be withdrawn to all for normal physiology to resume. Identifying this point for safe withdrawal for the resumption of normal respiratory function is of utmost importance.
A powerpoint explaining in detail about all the intravenous induction agents and their clinical uses, pharmacokinetics & pharmacodynamics, adverse effects and complications.
The New 2018 SCCM PADIS Guidelines: Quick Hits of Recommendations for Sedatio...Intensive Care Society
Dr. Needham is Professor of Pulmonary and Critical Care Medicine, and of Physical Medicine and Rehabilitation at the Johns Hopkins University in Baltimore, USA. He is Director of the “Outcomes After Critical Illness and Surgery” (OACIS) Research Group and core faculty with the Armstrong Institute for Patient Safety and Quality, both at Johns Hopkins. From a clinical perspective, he is an attending physician in the medical intensive care unit at Johns Hopkins Hospital and Medical Director of the Johns Hopkins Critical Care Physical Medicine and Rehabilitation program.
Dr. Needham received his MD degree from McMaster University in Hamilton, Canada, and completed both his residency in internal medicine and his fellowship in critical care medicine at the University of Toronto. He obtained his PhD in Clinical Investigation from the Bloomberg School of Public Health at Johns Hopkins University. Notably, prior to his medical training, he completed Bachelor and Master degrees in Accounting and practiced in a large international accounting firm, with a focus in the health care field.
Dr. Needham is Principal Investigator on a number of NIH research grants and has authored more than 250 publications. His research interests include evaluating and improving ICU patients’ long-term physical, cognitive and mental health outcomes, including research in the areas of sedation, delirium, early physical rehabilitation, and knowledge translation and quality improvement.
In critical care medicine the invasive life saving techniques are often employed and when all goes well such interventions will be withdrawn to all for normal physiology to resume. Identifying this point for safe withdrawal for the resumption of normal respiratory function is of utmost importance.
Onco-Anaesthesia is an emerging sub-speciality of Anaesthesiology. The presentation describes the spectrum of sub-specialities covered in Onco-Anaesthesia.
Anaesthesia management of patient's with cardiomyopathy involves detailed evaluation, meticulous induction and intra-operative management. The presentation discusses the type of cardiomyopathies and the management of anaesthesia in each sub-type.
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Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
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18. “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”
28. RAAS & SAS >>> Most valid and reliable
sedation assessment tool in adult ICU
29. Auditory evoked potential
BIS
Narcotrend Index
Patient State index
State Entropy
Scoring scales
Not
recommended
by SCCM
30.
31. 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
32. 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
Gupta N, de Jonghe J, Schieveld J, et al: Delirium phenomenology:
What can we learn from the symptoms of delirium? J Psychosom
Res 2008; 65:215–222
40. 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 )
Early mobilization is the only proven
way to prevent ICU delirium
44. Interruption of sedation ( preferably
daily )
Assess neurological status
Restart after assessment or if
agitation increased
Shown to reduce duration of
ventilation & ICU stay
Kress JP, Pohlman AS, O’Conner MF, et al. Daily interruption of sedation
infusions in critically ill patients undergoing mechanical ventilation. N Engl J
Med 2000; 342: 1471–7
46. 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
47.
48. Protocol for addressing Pain, Agitation, Delirium in
ICU
Monitor Pain, Agitation & Delirium ( Scoring
systems )
Document SCORES
49. Use non-benzodiazepine sedative
Light level of sedation is associated with
improved clinical outcomes
Adequate analgesia for procedures
Review medications daily
50. Sedation Holiday
Early mobilization
Brain function monitoring recommended if
NDMR used
Brain function monitoring not recommended in
non-comatose patients
CONDUCIVE ENVIRONMENT IN ICU
