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Presentation given in Pace 2011
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Sedation , Analgesia & Paralysis in ICU
Dr.Venugopalan.P.PDA,DNB,MNAMS
Chief, Emergency Medicine –MIMS Site Director ,Masters program in EM
Executive director ,Angels international foundation
Objectives
Guidelines for sedation, analgesia, and chemical paralysisBenefits of daily awakening/lightening and sedation titration programsRational 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
Immediate• Patient-ventilator
dyssynchrony• Increased oxygen
consumption • Self (and health care
provider) injury• Family anxiety
Late• chronic anxiety
disorders • post-traumatic
stress disorder (PTSD)
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
SedativesCauses for Agitation
UndersedationSedatives
Causes for AgitationAgitation & anxietyPain and discomfortCatheter displacementInadequate ventilationHypertensionTachycardiaArrhythmiasMyocardial ischemiaWound disruptionPatient injury
Oversedation
Sedatives
Causes for Agitation
Prolonged sedationDelayed emergenceRespiratory depressionHypotensionBradycardiaIncreased protein breakdownMuscle atrophyVenous stasisPressure injuryLoss of patient-staff interactionIncreased 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
Yes
Reassess goal daily,Titrate and taper therapy to maintain goal,Consider daily wake-up,Taper if > 1 week high-dose therapy & monitorfor withdrawal
No
Set Goalfor
Analgesia
Hemodynamically UnstableFentanyl 25 - 100 mcg IVP Q 5-15 min, orHydromorphone 0.25 - 0.75 mg IVP Q 5 - 15 min
Hemodynamically stableMorphine 2 - 5 mg IVP Q 5 - 15 min
Repeat until pain controlled, then scheduled doses + prn
Set Goalfor
Sedation
Acute Agitation #
Midazolam 2 - 5 mg IVP Q 5 - 15 min untilacute event controlled
Ongoing Sedation #
Lorazepam 1 - 4 mg IVP Q 10-20 min untilat goal then Q 2 - 6 hr scheduled + prn , orPropofol start 5 mcg/kg/min, titrate Q 5 minuntil at goal
Set Goalfor Controlof Delirium
Haloperidol 2 - 10 mg IVP Q 20 - 30 min,then 25% of loading dose Q 6hr x 2-3 days,then taper
IVP Dosesmore often than Q
2hr?
Consider continuousinfusion opiate or
sedative
> 3 Days Propofol?(except neuro pt.)
Convert toLorazepam
Yes
Benzodiazepine or Opioid:Taper Infusion Rate by
10-25% Per Day
Yes
Dosesapproximate for
70kg adult
Rule out and Correct Reversible Causes
Use Non-pharmacologic Treament,Optimize the Environment
ALGORITHM FOR SEDATION AND ANALGESIA OF MECHANICALLY VENTILATED PATIENTS
Use Pain Scale * toAssess for Pain
Use Sedation Scale **
to Assess forAgitation/Anxiety
Use Delirium Scale *** toAssess for Delirium
Is the Patient Comfortable & at Goal?
Lorazepam viainfusion?
Use a low rate and IVPloading doses
1
2
3
4
Jacobi J, Fraser GL, Coursin D, et al. Crit Care Med. 2002;30:119-141.
Pain
Assess Pain Separately
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
RecognizePain
Ask
FindLo
ok
Treat Pain
oQuantify the pain perception oCorrect the correctable causes oUse appropriate analgesics
• Remember- most sedative agents do not provide analgesia
• Reassess
Non-pharmacologicalMethods
• Proper position of the patient• Stabilization of fractures• Elimination of irritating stimulation• Proper positioning of the ventilator
tubing to avoid traction on endotracheal tube
Yes
Reassess goal daily,Titrate and taper therapy to maintain goal,Consider daily wake-up,Taper if > 1 week high-dose therapy & monitorfor withdrawal
No
Set Goalfor
Analgesia
Hemodynamically UnstableFentanyl 25 - 100 mcg IVP Q 5-15 min, orHydromorphone 0.25 - 0.75 mg IVP Q 5 - 15 min
Hemodynamically stableMorphine 2 - 5 mg IVP Q 5 - 15 min
Repeat until pain controlled, then scheduled doses + prn
Set Goalfor
Sedation
Acute Agitation #
Midazolam 2 - 5 mg IVP Q 5 - 15 min untilacute event controlled
Ongoing Sedation #
Lorazepam 1 - 4 mg IVP Q 10-20 min untilat goal then Q 2 - 6 hr scheduled + prn , orPropofol start 5 mcg/kg/min, titrate Q 5 minuntil at goal
Set Goalfor Controlof Delirium
Haloperidol 2 - 10 mg IVP Q 20 - 30 min,then 25% of loading dose Q 6hr x 2-3 days,then taper
IVP Dosesmore often than Q
2hr?
Consider continuousinfusion opiate or
sedative
> 3 Days Propofol?(except neuro pt.)
Convert toLorazepam
Yes
Benzodiazepine or Opioid:Taper Infusion Rate by
10-25% Per Day
Yes
Dosesapproximate for
70kg adult
Rule out and Correct Reversible Causes
Use Non-pharmacologic Treament,Optimize the Environment
ALGORITHM FOR SEDATION AND ANALGESIA OF MECHANICALLY VENTILATED PATIENTS
Use Pain Scale * toAssess for Pain
Use Sedation Scale **
to Assess forAgitation/Anxiety
Use Delirium Scale *** toAssess for Delirium
Is the Patient Comfortable & at Goal?
Lorazepam viainfusion?
Use a low rate and IVPloading doses
1
2
3
4
Jacobi J, Fraser GL, Coursin D, et al. Crit Care Med. 2002;30:119-141.
Address Pain
Set G oalfor
Analgesia
Hem odynam ically UnstableFentanyl 25 - 100 m cg IVP Q 5-15 m in, orHydromorphone 0.25 - 0.75 m g IVP Q 5 - 15 m in
Hem odynam ically stableMorphine 2 - 5 m g IVP Q 5 - 15 m in
Repeat until pain controlled, then scheduled doses + prn
Use Pain Scale * toAssess for Pain
Reassess goal daily,T itrate and taper therapy to m aintain goal,Consider daily wake-up,Taper if > 1 week high-dose therapy & m onitorfor withdrawal
Is the Patient Com fortable & at Goal?
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
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
Pharmacology of Selected Analgesics
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 instability
X
Equivalent doses 100 mcg 1.5 mg 10 mg
* Offset prolonged after long-term use
** Active metabolite accumulation causes excessive narcosis
Sam
ple
Anal
gesi
a Pr
otoc
olNumeric Rating Scale
ICU
SEDAT
ION
Sedation- Assessment
• Ramsay Sedation Scale (RSS)
• Sedation-agitation Scale (SAS)
• Observers Assessment of Alertness/Sedation Scale (OAASS)
• Motor Activity Assessment Scale (MAAS)
BMJ 1974;2:656-659Crit Care Med 1999;27:1325-1329J Clin Psychopharmacol 1990;10:244-251Crit Care Med 1999;27:1271-1275
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 Ramsay 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 Riker Sedation-Agitation Scale
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 GuidelinesAwake
Responds to loud commands or mild prodding/shaking
Low probability to explicit recallsUnresponsive to verbal stimuli
Burst suppression
Flat line EEG
Responds to normal voice Axiolysis
Moderatesedation
Deep Sedation
100
80
60
40
20
0
BIS
Yes
Reassess goal daily,Titrate and taper therapy to maintain goal,Consider daily wake-up,Taper if > 1 week high-dose therapy & monitorfor withdrawal
No
Set Goalfor
Analgesia
Hemodynamically UnstableFentanyl 25 - 100 mcg IVP Q 5-15 min, orHydromorphone 0.25 - 0.75 mg IVP Q 5 - 15 min
Hemodynamically stableMorphine 2 - 5 mg IVP Q 5 - 15 min
Repeat until pain controlled, then scheduled doses + prn
Set Goalfor
Sedation
Acute Agitation #
Midazolam 2 - 5 mg IVP Q 5 - 15 min untilacute event controlled
Ongoing Sedation #
Lorazepam 1 - 4 mg IVP Q 10-20 min untilat goal then Q 2 - 6 hr scheduled + prn , orPropofol start 5 mcg/kg/min, titrate Q 5 minuntil at goal
Set Goalfor Controlof Delirium
Haloperidol 2 - 10 mg IVP Q 20 - 30 min,then 25% of loading dose Q 6hr x 2-3 days,then taper
IVP Dosesmore often than Q
2hr?
Consider continuousinfusion opiate or
sedative
> 3 Days Propofol?(except neuro pt.)
Convert toLorazepam
Yes
Benzodiazepine or Opioid:Taper Infusion Rate by
10-25% Per Day
Yes
Dosesapproximate for
70kg adult
Rule out and Correct Reversible Causes
Use Non-pharmacologic Treament,Optimize the Environment
ALGORITHM FOR SEDATION AND ANALGESIA OF MECHANICALLY VENTILATED PATIENTS
Use Pain Scale * toAssess for Pain
Use Sedation Scale **
to Assess forAgitation/Anxiety
Use Delirium Scale *** toAssess for Delirium
Is the Patient Comfortable & at Goal?
Lorazepam viainfusion?
Use a low rate and IVPloading doses
1
2
3
4
Jacobi J, Fraser GL, Coursin D, et al. Crit Care Med. 2002;30:119-141.
Set G oalfor
Sedation
Acute Agitation #
Midazolam 2 - 5 m g IVP Q 5 - 15 m in untilacute event controlled
Ongoing Sedation #
Lorazepam 1 - 4 m g IVP Q 10-20 m in untilat goal then Q 2 - 6 hr scheduled + prn, orPropofol start 5 m cg/kg/m in, titrate Q 5 m inuntil at goal
IVP Dosesm ore often than Q
2hr?
Consider continuousinfusion opiate or
sedative
> 3 Days Propofol?(except neuro pt.)
Convert toLorazepam
Benzodiazepine or Opioid:Taper Infusion Rate by
10-25% Per Day
Use Sedation Scale **
to Assess forAgitation/Anxiety
Lorazepam viainfusion?
Use a low rate and IVPloading doses
Yes
Reassess goal daily,T itrate and taper therapy to m aintain goal,Consider daily wake-up,Taper if > 1 week high-dose therapy & m onitorfor withdrawal
Is the Patient Com fortable & at Goal?
Address Sedation
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
Option1
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
PROBLEMS
Propofol
Pharmacology: GABA agonistPharmacokinetics/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
PROBLEMS
• 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
POPOFOL
INFUSION
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
DexmedetomidineAlpha-2-
adrenergic agonist Decrease the
need for other sedation
Useful while decreasing other sedatives to prevent withdrawal
Rapid onset
No Respiratory depression
Sympatholytic action
Benefits
Option -3
Dexmedetomidine
No Amnesia
Excessive awareness
Bradycardia ,Hypotension
PROBLEMS
Alpha-2 Receptors
Brain(locus ceruleus)
Spinal Cord
Peripheral vasculature
SedationAnxiolysis
Sympatholysis
Analgesia
Vasoconstriction
DEX: Dosing
Loading infusion0.25-1 g/kg(10-20 min)
Maintenance infusion0.2-0.7 g/kg/hr
Sedation-agitation Scale
Riker RR et al. Crit Care Med. 1999;27:1325.
Sample Sedation Protocol
Use Continuous and Combined Infusion
Plasma Level
Load
Maintenance
Repeated Bolus
Plasma levels
Choose the Right Drug
Sedation Analgesia
Amnesia AnxiolysisHypnosis
Propofol
Patient ComfortBenzodiazepines
-2 agonists
Opioids
ICUChemical Paralysis
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
NMBLimited 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• Non depolarizersTwo classes
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 depolarizersCompetitive 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
Agents Are Very
Special
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
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: ICURoutine 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
HaloperidolThe 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
unknownLess movement disorders than haloperidolEnhanced effects on both positive (agitation) and negative (quiet) symptoms
Quetiapine OlanzapineRisperidoneZiprasidone
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:
Issue
s
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
www.drvenu.net,www.emergencymedicinemims.com,
www.angelsindia.org
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