0c6bSedation and Analgesia in ICU

8/3/2019 0c6bSedation and Analgesia in ICU

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Sedation and analgesiain ICUAHMAD F. MADY MD

Lecturer of Anesthesia &ICU,

Tanta university hospitals,Tanta,Egypt

Senior registrar,ICU,KSMC


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Objectives

Algorithm for Sedation TechniqueApplication

Clinical practice guidelines for the sustained use of sedatives and

analgesics in the critically ill adult


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introduction

In critically ill patients there are three rationales for adequateanalgesia and sedation (A&S).

Firstly,A&S ensure an optimal level of comfort; the patient should have no

more than moderate pain and should be calm and alert. Secondly,

A&S are thought to reduce the stress response that is relatedto inflammation and trauma.

Thirdly,

A&S facilitate diagnostic and therapeutic procedures, as well asnursing care.


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Analgesia is the act of blunting pain,through administration of drugs, but also through positioning ofthe patient, stabilising fractures and minimising harmful physical

stimulation .

4582% of critically ill patients suffer from pain depending ontheir degree of activity . They are exposed to numerous noxiousstimuli

Bernhard Walder, Martin R. TramrSWISS MEDWKLY 2004;134:333346 www.smw. c h

Sedation in critical care is the act of calming,especially through administration of centrally acting drugs, but

also through reassurance, information and music.

71% of critically ill patients have been shown to suffer fromanxiety, confusion and agitation


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INDICATIONS FOR A&S

1- Pain, MV. trauma, invasive operations, routine nursing care, ETTsuctioning, and prolonged immobility.

2- Anxiety & agitation life-threatening illness, Inadequatelycontrolled pain, sleep deprivation, isolation, and the presence ofinvasive tubes and catheters are frequently listed as sources of

stress and anxiety3- Delirium:

4- Facilitate Patient Care

5- Decrease Oxygen Consumption particularly important in patientssuffering from acute lung injury or shock.

6- Reduction of seizures: Sedation appears to be an attractive optionin reducing seizures in the NICU


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7-amnesia

Some studies have shown that patients with a greater recallof adverse experiences may be likely to developposttraumatic stress disorder (PTSD), leading some tosuggest that deep sedation be routinely used to bluntpatient awareness of the ICU experience

More recently,investigators have demonstrated thatpatients who were most awake, or the most unresponsive,

during mechanical ventilation had the lowest PTSD-likesymptoms.

Weinert CR, Sprenkle M. Post-ICU consequences of patient wakefulness and sedative

exposure during mechanical ventilation. Intensive Care Med 2008; 34(1):8290.


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8- Weaning from Mechanical Ventilation It is now well known that patients being weaned from MV require

appropriate sedation for a successful outcome.

Non pharmacologic intervention at the time of weaning may relievemild anxiety. Such interventions include changing the environment,

using relaxation techniques, reassuring the patient, and providingadequate rest and psychological support. However, for patientswho do not respond to these interventions, pharmacologic therapyshould be instituted

Cohen IL, Gallagher TJ, Pohlman AS, Dast JF, Abraham E, Papadakos PJ:Themanagement of the agitated ICU patient. Crit Care Med 2002; 30: 97125.


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GOALS FOR S&A

To minimise physical discomfort or pain for procedures To control behaviour, particularly movement

To minimise psychological disturbance & distress To maximise the potential for amnesia

To guard patient safety


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Clinical practice guidelines for the sustaineduse of sedatives and analgesics in the

critically ill adult(1995,2002,2005)

American College of Critical Care Medicine (ACCM)

the Society of Critical Care Medicine (SCCM)

the American Society of Health-System Pharmacists (ASHP)

the American College of Chest Physicians

Judith Jacobi, PharmD, FCCM, BCPS; Gilles L. Fraser, PharmD, FCCM; Douglas B. Coursin, MD;Richard R. Riker, MD; Dorrie Fontaine, RN, DNSc, FAAN; Eric T. Wittbrodt, PharmD; Donald B.Chalfin, MD, MS, FCCM; Michael F. Masica, MD, MPH; H. Scott Bjerke, MD; William M. Coplin, MD;David W. Crippen, MD, FCCM; Barry D. Fuchs, MD; Ruth M. Kelleher, RN; Paul E. Marik, MDBCh,FCCM; Stanley A. Nasraway, Jr, MD, FCCM; Michael J. Murray, MD, PhD, FCCM; William T. Peruzzi,MD, FCCM; Philip D. Lumb, MB, BS, FCCM


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Grades of Recommendations(A) Methods strong, results consistent, prospective, randomized,

controlled trials, no heterogeneity

(B) Methods strong, results inconsistent, prospective, randomized,controlled trials, heterogeneity present

(C) Methods weak, observational studies


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ANALGESIAICU patients commonly have pain and physical discomfort fromobvious factors, such as

preexisting diseases,

Invasive procedures, or trauma.

Monitoring and therapeutic devices (such as catheters, drains,noninvasive ventilating devices, and endotracheal tubes)

Routine nursing care (such as airway suctioning, physicaltherapy, dressing changes, and patient mobilization)

prolonged immobility


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Unrelieved pain may contribute to

inadequate sleep, possibly causing exhaustion and disorientation.

Agitation.

Stress response characterized by tachycardia, increased

myocardial oxygen consumption, hypercoagulability,immunosuppression, and persistent catabolism,

pulmonary dysfunction.

Recommendation:All critically ill patients have the right to adequateanalgesia and management of their pain. (C)


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Because patients can complete the NRS by writing or speaking, andbecause it is applicable to patients in many age groups, NRS may bepreferable to VAS in critically ill patients.


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Pain Assessment The most reliable and valid indicator of pain is the patients self-

report. The location, characteristics, aggravating and alleviatingfactors, and intensity of pain should be evaluated. Assessment ofpain intensity may be performed with unidimensional tools, such as

verbal rating scale (VRS),

visual analogue scale (VAS), and numeric rating scale (NRS)

RecommendationsThe level of pain reported by the patient mustbe considered the current standard for assessment of pain andresponse to analgesia whenever possible. Use of theNRSisrecommended to assess pain.(B)


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As critically ill patients are often unable to communicate theirlevel of pain if sedated, anesthetized, or receiving neuromuscularblockade. Neither the VAS nor the NRS will resolve this problemas they rely on the patients ability to communicate with the careprovider

RecommendationsPatients who cannot communicate should be assessed throughsubjective observation of pain-related behaviors (movement, facialexpression, and posturing) and physiological indicators (heart rate,

blood pressure, and respiratory rate) and the change in theseparameters following analgesic therapy. (B)


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Recommendations:

Pain assessment and response to therapy should beperformed regularly by using a scale appropriate to thepatient population and systematically documented. (C)

The level of pain reported by the patient must beconsidered the current standard for assessment of pain and

response to analgesia whenever possible. Use of the NRS isrecommended to assess pain.(B)

Patients who cannot communicate should be assessedthrough subjective observation of pain-related behaviors(movement, facial expression, and posturing) and physiological

indicators (heart rate, blood pressure, and respiratory rate)and the change in these parameters following analgesictherapy. (B)


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Analgesia Therapy

NONPHARMACOLOGIC TREATMENT

Stabilization of fractures Encouragement of patients to communicat.

Music Minimizing irritating stimuli, such as traction on the ETT. Proper positioning of patients.

Prompt treatment of anxiety and delirium


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PHARMACOLOGIC TREATMENTopioids,

NSAIDs,

PCMIn critically ill patients opioids are most often used for acute pain treatmentOpioids mediate analgesia by interacting with a variety of central andperipheral opioid receptors and . The analgesic agents most commonly usedin ICU patients (fentanyl, morphine, and hydromorphone)


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Intravenous opiates can be delivered in three different modes:

Bolus intravenous injections are often used for moderate pain,with doses titrated to analgesic requirements and the avoidance ofrespiratory depression and hemodynamic instability .

Continuous intravenous infusions of opiates are used for moderate-to-severe pain which is poorly controlled with repeated bolusinjections. After an initial bolus dose, a low continuous infusion

rate is set with subsequent adjustment for adequate analgesia .

Patient-controlled analgesia (PCA) may be preferable in consciouspatients, particularly in the postoperative setting.This techniqueallows self-dosing with opiates up to a predetermined limit set bythe clinician.


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Recommendations: A therapeutic plan and goal of analgesia should beestablished for each patient and communicated to all caregivers toensure consistent analgesic therapy. (Grade of recommendation C)

If intravenous doses of an opioid analgesic are required, fentanyl,hydromorphone, and morphine are the recommended agents.(Grade of recommendation C)

Scheduled opioid doses or a continuous infusion is preferred over an

as needed regimen to ensure consistent analgesia. A PCA devicemay be utilized to deliver opioids if the patient is able tounderstand and operate the device. (Grade of recommendation B)

Fentanyl is preferred for a rapid onset of analgesia in acutelydistressed patients. (Grade of recommendation C)

Fentanyl or hydromorphone are preferred for patients withhemodynamic instability or renal insufficiency. (Grade of

recommendation C)Morphine and hydromorphone are preferred for intermittent therapy

because of their longer duration of effect. (Grade ofrecommendation C)


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Recommendations: NSAIDs or acetaminophenmay be used as adjuncts toopioids in selected patients. (Grade ofrecommendation B)

Ketorolac therapy should be limited to amaximum of five days, with close monitoringfor the development of renal insufficiencyor gastrointestinal bleeding.Other NSAIDs may be used via the enteral

route in appropriate patients.(Grade of recommendation B)


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SEDATION

Sedation in critical care is the act of calming,

especially through administration of centrally acting drugs, butalso through reassurance, information and music.

71% of critically ill patients have been shown to suffer fromanxiety, confusion and agitation

Bernhard Walder, Martin R. TramrSWISS MED WKLY 2004;134:333346


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GOALS

the optimal depth of sedation (or sedation score) must beindividualized. Some patients can be well ventilated withoutsedation or analgesia, while others require deep sedation to avoidventilator asynchrony or significant agitation.

The optimal target sedation score is best established by frequent

assessments while titrating the sedative dose downward. Theguiding principle should be to provide just enough medication tominimize patient discomfort, agitation, and ventilator asynchrony.


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GOALS

The appropriate target level of sedation will primarily depend on apatients acute disease process and any therapeutic and supportiveinterventions required.

A common target level of sedation in the ICU is a calm patient thatcan be easily aroused with maintenance of the normal sleep-wakecycle, but some may require deep levels of sedation to facilitate MV.

The desired level of sedation should be defined at the start oftherapy and reevaluated on a regular basis as the clinical condition ofthe patient changes.


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Goals

those ventilated by a spontaneous breathing mode neededsignificantly less midazolam and sufentanil compared with those oncontrolled mechanical ventilation.

Patients with spontaneous breathing also had a significantly

shorter mean duration of ventilation (15 vs 21 days) and of ICUstay (23 vs 30 days).

Putensen C, Zech S, Wrigge H, Zinserling J, Stuber F, Von Spiegel T, et al. Long-term effects ofspontaneous breathing during ventilatory support in patients with acute lung injury. Am J Respir CritCare Med 2001;164:439.


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GOALS

Mechanical ventilation

Pressure support ventilation, CPAP, SIMV good pt cooperation Ramsay 2, GCSC 13-15, SAS 4, RASS 0

Assisted controlled Ramsay 3, GCSC 8-12, SAS 3, RASS -1~-3

Pressure controlled Ramsay 4-5, GCSC 8-12, SAS 2, RASS -4

Agitation and delirium Ramsay 2-3, SAS 3-4, RASS 0~-2

IICP

Ramsay 5, SAS 1, RASS -5


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On-target sedation:

Decreases weaning period

Is not associated with muscular atrophy1

Decreases LOS and cost2

Provides cardiovascular1 and intraoperative

hemodynamic stability3

Improves patient safety1,3

Facilitates neurological assessment 1McGaffigan PA. Crit Care Nursing. 2002;Feb Suppl:29-36. 2Dasta et al. Pharmacotherapy. 2006;26:798-805.

3Arbour R. Am J Crit Care Nursing. 2004;13:66-73.


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Incidence of Inadequate

Sedation

Dasta JF, et al. Crit Care Med. 2005;33:1266-1271.


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Recommendation: Sedation ofagitated

critically ill patients should be started only after providing adequateanalgesia and treating reversible

physiologicalcauses. (Grade of recommendationC)


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Pain control in ICU


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An ideal sedation scale Good reliability and validity determination of the degree of sedation and

agitation,

behavioral descriptors, Applicability

require minimal training

easy to score For diverse patient populationguide the titration of therapy to a defined

sedation endpoint

Man scales are available but a true


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The Ramsay Scale The Glasgow Coma Scale modified by Cook and

Palma, GCSC

The Sedation Agitation Scale, SAS The Richmond Agitation and Sedation Scale,RASS

The Bloomsbury sedation scale

the Adaptation to the Intensive Care Environment(ATICE) scale

The Avripas sedation scale the Comfort scale for pediatric patients.

Subjective methods


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Objective Assessment of

Sedation


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Ramsay Scale The most commonly scale used today


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BIS Recommending results good relationship with subjective monitoring tools a decreased use of opioids and analgesics using BIS-

guided sedation therapy

Conflicting results poor correlation with subjective monitoring tools intra-individual variation in BIS values even in chemically

paralyzed patients underestimation of sedation in non-chemically paralyzed

patients.

the use of the BIS monitor in the ICU is stillunclear.


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Recommendations: A sedation goal or

endpoint should be established and regularlyredefined for each patient. Regularassessment and response to therapyshould be systematically documented.(Grade of recommendation C)The use of a validated sedation assessmentscale (SAS, MAAS, or VICS) isrecommended. (Grade of recommendationB)

Objective measures of sedation, such asBIS, have not been completely evaluatedand are not yet proven useful in the ICU.(Grade of recommendation C)


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Sedation Therapy BenzodiazepinesPropofol.

Central-Agonists


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Pharmacology of selected

sedatives


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Rapid onset of action Easily titratable level of adequate sedation Short acting, allowing patient assessment, rapid recovery following discontinuation, easy weaning from MV, and early extubation. No or few adverse effects. No anaphylaxis or allergic reaction. No nausea, vomiting, or phlebitis. Minimal metabolism; not dependent on normal hepatic, renal, or pulmonary function Minimal respiratory depression. Minimal effect on cardiovascular function No pain on injection.

No active or toxic metabolites. No suppression of cortisol production by the adrenal cortex. No or minimal interactions with other commonly prescribed ICU drugs Ease of administration. Lack of accumulation with prolonged administration Does not promote growth of pathogens. No tolerance and withdrawal of pathogens Cost effective. Easily prepared and long shelf-life. Safe for all ages with no age-related changes in pharmacokinetics. Provides facilitation of ventilator synchrony and the performance of various procedures and nursing interventions Lack of abuse potential

Cohen et al., 2002)


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Recommendations: Midazolam or diazepamshould be used for rapid sedationof acutely agitated patients.(Grade of recommendation C)Propofol is the preferred sedative whenrapid awakening (e.g., for neurologicassessment or extubation) is important.(Grade of recommendation B)Midazolam is recommended for shorttermuse only, as it produces unpredictable

awakening and time to extubationwhen infusions continue longerthan 4872 hours. (Grade of recommendationA)Lorazepam is recommended for the sedationof most patients via intermittenti.v. administration or continuousinfusion. (Grade of recommendationB)The titration of the sedative dose to adefined endpoint is recommended withsystematic tapering of the dose or

daily interruption with retitration tominimize prolonged sedative effects.(Grade of recommendation A)Triglyceride concentrations should bemonitored after two days of propofolinfusion, and total caloric intake fromlipids should be included in the nutritionsupport prescription. (Grade ofrecommendation B)The use of sedation guidelines, an algorithm,or a protocol is recommended.(Grade of recommendation B


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Recommendation: The potential foropioid, benzodiazepine, and propofolwithdrawal should be considered after

high doses or more than approximatelyseven days of continuous therapy.Doses should be tapered systematicallyto prevent withdrawal

symptoms. (Grade of recommendationB)


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Recommendations : A therapeutic plan and goal of analgesia should be established for each patients and communicated to all

caregivers to ensure consistent analgesic therapy. ( Grade of recommendation = C ) If intravenous doses of opioid analgesic are required, fentanyl, hydromorphone, and morphine are the recommended agents.

( Grade of recommendation = C ) Scheduled opioid doses or a continuous infusion is preferred. A PCA device may be utilized to deliver opioid if patient is able to understand and operated the device. ( Grade of recommendation = B )


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Fentanyl is preferred for a rapid onset of analgesic in acutely distressed patients. ( Grade of recommendation = B )>>>>>c

Fentanyl or hydromorphone are preferred for patients with hemodynamic instability or renal insufficiency ( Grade of recommendation = B )>>>>>>>>>>>>>>c Morphine and hydromorphone are preferred for intermittent therapy because of their longer duration of

effect. ( Grade of recommendation = B )>>>>>>>>>>>>c


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NSAIDs or acetaminophen may be used as adjuncts to opioids in selected patients. ( Grade of recommendation = B ) Ketorolac therapy should be limited to a maximum of

5 days, with close monitoring for the development of renal insufficience or GI bleeding. Other NSAIDs may be used via the enteral route in appropriate patients. ( Grade of recommendation = B )


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A sedation goal or endpoint should be established and regularly refined for each patient. Regular assessment and response to therapy should be systematically documented. ( Grade of recommendation = C )

The use of a validated sedation assessment scale ( SAS, MAAS, or VICS ) is recommended. ( Grade of recommendation = B ) Objective measures of sedation, such as BIS, have not been completely evaluated and are not yet proven useful in the

ICU. ( Grade of recommendation = C )


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RAMSAY SEDATION SCORE Ramsay Sedation Scale Addenbrookes Sedation Scale Rikers Sedation-Agitation Scale SAS

Motor Activity Assessment Scale MAAS Level Response 1 Anxious, and agitated or restless, or both 2 Co-operative, orientated and tranquil 3 Responds to commands only

4 Asleep, but brisk response to glabellar tap or low auditory stimulation 5 Asleep, sluggish response to glabellar tap or loud auditory stimulus 6 No response


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Recommendations : Midazolam or diazepam should be used for rapid sedation of acutely agitated patients. ( Grade of recommendation = C )

Propofol is the preferred sedative when rapid awakening ( e.g. for neurologic assessment) is importment. ( Grade of recommendation = B ) Midazolam is recommended for short term use only, as it produces unpredictable awakening and time to extubation

when infusions continue longer than 48-72 hours. ( Grade of recommendation = A ) Lorazepam is recommended for the sedation of most patients via intermittent i.v. administration or continuous infusion. ( Grade of recommendation = B )


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The potential for opioid, benzodiazepine, and propofol withdrawal should be considered after high doses or more than approximately 7 days of continuous therapy. Doses should be tapered systematically to prevent

withdrawal symptoms. ( Grade of recommendation = B )


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an acute, reversible organic mental syndrome with disorder ofattention and cognitive function, increased or decreasedpsychomotor activity, and a disordered sleep-wake cycle


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Delirium is an acute confusional state characterized by analteration of consciousness with cognitive function. characterizedby increased vigilance along with psychomotor and autonomic

overactivity; these features are reflected in clinicalmanifestations such as agitation, tremulousness, and hallucinations. The most risk factors are underlying brain diseases such as

dementia, stroke, or Parkinson disease, advanced age and sensoryimpairment (hearing and vision loss). Elderly patients are at thehighest risk for delirium.

Factors that may precipitate delirium include polypharmacy(particularly psychoactive drugs), infection, metabolicdisturbances, dehydration, immobility, malnutrition.

ICU-related factors contributing to the development of delirium include sleepdeprivation, sensory overload, lack of meaningful verbal or cognitive stimulation, andimmobilization. inadequate analgesia ,Withdrawal of drugs such as opioids,sedatives,


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An interesting characteristic of delirium is that the behavior ofthe patient can change dramatically within hours or even minutes.Drowsiness and lethargy can change to alertness and lucidity for atime, and then can quickly change to agitation and aggression


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Deliriummay be associated with confusionand different motoric subtypes: hypoactive,hyperactive, or mixed (179, 180).Hypoactive delirium, which is associatedwith the worst prognosis, is characterizedby psychomotor retardationmanifested by a calm appearance, inattention,decreased mobility, and obtundationin extreme cases. Hyperactivedelirium is easily recognized by agitation,combative behaviors, lack of orientation,

and progressive confusion after sedative therapy.

The confusion assessment method for the


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The confusion assessmentmethod for thediagnosis of delirium in the ICU (CAM-ICU)

(182, 185)


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Recommendation: Routine assessmentfor the presence of delirium is

recommended.

(The CAM-ICU is a promisingtool for the assessment of delirium inICU patients.) (Grade of recommendation

B)


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Suggested Criteria for DischargeFollowing Sedation and Analgesia (1,2022,34)1. Patients should be easily aroused, alert and oriented, or returned to their baselinestatus (i.e. infants, cognitive impairment).2. Vital signs should be stable and within acceptable limits3. Patient is not at risk for resedation (i.e., sufficient time has elapsed since

administration

of reversal agents)4. The patients protective reflexes have returned, and there is no risk for airwayobstruction or aspiration5. Pain is minimal and can be easily controlled in the post-discharge setting6. Nausea is controlled and can be managed in the post-discharge setting7. Outpatients should be discharged into the care of a responsible adult8. Outpatients must be provided with written instructions regarding medications,

activity, and emergency phone contacts


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Delirium (acute, reversible) Dementia (chronic, irreversible) Depression (chronic, usually reversible)


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Prevention of Delirium Consider developing protocolized approach Treat underlying infection and CHF Correct metabolic disturbances and hypoxemia

Frequent reorientation of patient by nurse and family Goal directed sedation/analgesia and /or daily wake-up Stop the ventilator (SBT) each day to test readiness Early mobilization and physical therapy Attention to optimizing sleep pattern


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Treatment of Delirium Identify etiologies Modify Risk Factors 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


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Haloperidol Clinical Effects Hypnotic agent with antipsychotic properties1 For treatment of delirium in critically ill adults1

Does not cause respiratory depression Haloperidol Adverse Effects Dysphoria Adverse CV effects include QT interval prolongation,

extrapyramidal symptoms, neuroleptic malignant syndrome (rare) Metabolism altered by drug-drug interactions


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A l i d li i d ti t l f iti ll ill


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An analgesia-delirium-sedation protocol for critically illtrauma patients reduces ventilator days and hospital

length of stay

Pain visual/objective pain assessment scale

Agitation Richmond Agitation-Sedation Scale RASS

Delirium Confusion Assessment Method CAM-ICU.

CONCLUSION: An objective assessment- based protocol

without daily interruption of medication infusion decreases

ventilator days and hospital length of stay in critically ill trauma

patients .

Robinson BR, J Trauma. 2008 Sep;65(3):517-26

Remifentanil-propofol analgo-sedation shortens
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Robinson%20BR%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlushttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Robinson%20BR%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlus


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e e ta p opo o a a go sedat o s o te sduration of ventilation and length of ICU stay

compared to a conventional regimen.15 Dutch hospitals,Patient cohorts were randomised to remifentanil

based regimen (n = 96) with propofol as required, for a maximum of10 days, or to conventional regimens (n = 109) of propofol,

midazolam or lorazepam combined with fentanyl or morphine .

Rozendaal FWIntensive Care Med .2009 Feb;35(2):291-8

CONCLUSIONS: In patients with an expected short-term duration ofMV, remifentanil significantly improves sedation and agitation levelsand reduces weaning time. This contributes to a shorter duration of MV

and ICU-LOS .
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Rozendaal%20FW%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlushttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Rozendaal%20FW%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlus


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The current practice of sedation and analgesia inintensive care units in Malaysian public

hospitals.A questionnaire survey sent by mail to 40 ICUs. 92.5% response rate.

35% routinely assess the degree of sedation (Ramsay scale).

A written protocol for sedation was available in only 14 centers

(38%).

36 centers (95%) routinely adjust the degree of sedation according

to patient's clinical progress,

only 10 centers (14%) interrupt sedation on a daily basis.

Ahmad N ,Tan CC , Med J Malaysia .2007 Jun;62(2):122-6
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Ahmad%20N%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlushttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Tan%20CC%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlushttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Tan%20CC%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlushttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Ahmad%20N%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlushttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Ahmad%20N%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlushttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Ahmad%20N%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlus


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the selection of agents for sedation depends on familiarity (97%),

pharmacology (97%), the expected duration for sedation (92%),

patient's clinical diagnosis (89%) and cost (73%).

Midazolam (89%) and morphine (86%)

14% frequently use NMB, mostly in head injury patients.

CONCLUSION the standard of practice could still be

improved by implementing the practice of sedation score

assessment and daily interruption of sedative infusion as

well as having a written protocol for sedation and analgesia.

Ahmad N ,Tan CC ,Balan S Med J Malaysia .2007 Jun;62(2):122-6

Sedation and analgesia assessment tools in ICU
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Ahmad%20N%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlushttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Tan%20CC%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlushttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Balan%20S%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlushttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Balan%20S%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlushttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Tan%20CC%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlushttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Ahmad%20N%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlus


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Sedation and analgesia assessment tools in ICU

patients The usefulness of the BIS in ICU for patients lightly sedated is

limited, mainly because of EMG artifact, when subjective scales

are more appropriated in this situation. On the other hand,

subjective scales are insensitive to detect oversedation in

patients requiring deep sedation.

The contribution of the BIS in deeply sedation patients, patients

under neuromuscular blockade or barbiturates has to be proved

Thuong M .Ann Fr Anesth Reanim. 2008 Jul-Aug;27(7-8):581-95
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Sedation in the intensive care unit withremifentanil/propofol versus midazolam/fentanyl

CONCLUSION: Compared with midazolam/fentanyl, a

remifentanil- based regimen for analgesia and sedation

supplemented with propofol significantly reduced the time onmechanical ventilation and allowed earlier discharge from the

ICU, at equal overall costs .

Muellejans BGermany .Crit Care 10(3:)2006 R91.

Dexmedetomidine vs midazolam for sedation of
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Muellejans%20B%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlushttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Muellejans%20B%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlus


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critically ill patients

Prospective, double-BRT conducted in 68 centers in 5 countriesbetween March 2005 and August 2007 among 375 medical/

surgical ICU patients with expected mechanical ventilation for

more than 24 hours

CONCLUSIONS: At comparable sedation levels, dex-treated

patients spent less time on the ventilator, experienced less

delirium, and developed less tachycardia and hypertension.

The most notable adverse effect of dex was bradycardia.

Riker RR USA JAMA .2009 Feb 4;301(5):489-99
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Sedation in the neurologic intensive care unit .Providing adequate sedation in NICU depends on

determination of proper goals for sedation,

adequate assessment of the level of sedation, and

appropriate choice of drug based on the patient's physiology.

The management of sedation in the ICU will influence long-term

outcome. Delirium, anxiety, and pain must be identified and treated

separately.

The use of protocols can improve compliance with publishedevidence - based recommendations.

Keegan MT. Curr Treat Options Neurol .2008 Mar;10(2):111-25
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Keegan%20MT%22[Author]&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlushttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Keegan%20MT%22[Author]&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlushttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Keegan%20MT%22[Author]&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlus


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Propofol and dexmedetomidine may be used for rapidlytitratable sedation, benzodiazepines for anxiolysis, neuroleptics

for treatment of delirium, and opiates for analgesia.

Unique aspects of patients with acute brain disease, such aselevated intracranial pressure or status epilepticus, requireadaptation of sedative regimens. Processed EEG monitoring

and volatile anesthetic agents have not yet proven beneficial orpractical for use in the ICU.

Keegan MT. Curr Treat Options Neurol .2008 Mar;10(2):111-25

Observational study of patient-ventilator asynchrony
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Keegan%20MT%22[Author]&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlushttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Keegan%20MT%22[Author]&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlushttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Keegan%20MT%22[Author]&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlushttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Keegan%20MT%22[Author]&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlus


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y p y y

and relationship to sedation levelMETHODS: Airway pressure and airflow were recorded for 15minutes. Patient-ventilator asynchrony was assessed by determiningthe number of breaths demonstrating ineffective triggering, doubletriggering, short cycling, and prolonged cycling. Ineffective triggeringindex (ITI) was calculated by dividing the number of ineffectively

triggered breaths by the total number of breaths (triggered andineffectively triggered). Sedation level was assessed by RASS,awake (yes or no), and CAM-ICU. Diagnosis of COPD, sedativetype or dose, MV mode, and trigger method had no effect on ITI.

CONCLUSIONS: Asynchrony is common, and deeper sedation levelis a predictor of ineffective triggering

de Wit M USA, J Crit Care .2009 Mar;24(1):74-80

A randomized trial of intermittent lorazepam versuspropofol with daily interruption in mechanically
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22de%20Wit%20M%22[Author]&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlushttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22de%20Wit%20M%22[Author]&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlushttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22de%20Wit%20M%22[Author]&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlushttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22de%20Wit%20M%22[Author]&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlushttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22de%20Wit%20M%22[Author]&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlushttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22de%20Wit%20M%22[Author]&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlus


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propofol with daily interruption in mechanicallyventilated patients.

Median ventilator days 5.8 vs. 8.4, p = .04.

hospital survivors 4.4 vs. 9.0, p = .006.

ventilator-free survival 18.5 days vs. 10.2 p = .06.

Hospital mortality was not different

CONCLUSIONS: For medical patients requiring >48 hrs of mechanical

ventilation, sedation with propofol results insignificantly fewer ventilator

days compared with intermittent lorazepam when sedatives are

interrupted daily

Carson SS ; Crit Care Med. 2006 May;34(5):1326-1332.

Daily interruption of sedative infusions and complications


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y p pof critical illness in mechanically ventilated patients

VAP; upper GIT hge; bacteremia; barotrauma; DVT; andcholestasis or sinusitis requiring surgical intervention.

daily interruption of sedatives(2.8%) vs. 26 (6.2%) in those subjected

to conventional sedation techniques (p =.04).

CONCLUSIONS: Daily interruption of sedative infusions in MV

reduces ICU-LOS and, in turn, decreases the incidence of

complications of critical illness associated with prolonged intubation

and mechanical ventilation.

Crit Care Med 2004 Jun;32(6):1272-6. University-based hospital Chicago

Daily sedative interruption in mechanically ventilated


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y p ypatients at risk for coronary artery disease .

CONCLUSIONS: Myocardial ischemia is common in critically illmechanically ventilated patients with coronary artery disease riskfactors. Daily sedative interruption is not associated with anincreased occurrence of myocardial ischemia in these patients .

Kress JP ,Crit Care Med. 2007 Feb;35(2):365-71.

Administration of Sedatives and Level of Sedation:C ti E l ti i th S d ti A it ti


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Comparative Evaluation via the Sedation-Agitation

Scale and the Bispectral Index

Conclusion Objective and subjective assessments of sedationare highly correlated. Use of continuous infusions is associatedwith deeper levels of sedation, and patients receiving continuous

infusions are more likely to be oversedated. Sedation therapyshould be guided by subjective or objective assessment.

American Journal of Critical Care. 2003;12: 343-348


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