Mazen kherallah, MD, FCCP

Stress in ICU?Stress in ICU?

Psychological Stress in ICU

Psychological Stress in ICU

Loss of control Fear of death or serious illness Fear of pain Overwhelming isolation Feelings of helplessness Loss of normal circadian rhythms The disruption of normal sleep

patterns Sleep deprivation Disorientation and panic

Can the patient whom we thing is sedated on the ventilator hear and think?

Listen to this…

Alien, sensory rich environmentAlien, sensory rich environment

Environmental Stress in ICU

Environmental Stress in ICU

Foreign environments Room temperatureRoom temperature Continuous ambient lightingContinuous ambient lighting Family not continuously available for

comfort Significant noise from personnel and

medical equipment

12

12

Physical Stress in ICU

Attached to equipments with tubes or wires

Intubated and ventilated Treatment or diagnostic procedures Confined (restricted) to bed Uncomfortable bed and pillow Unable to control stool habit

+ Inability to communicate+ Inability to communicate

Frustration and Anger

Excessive stimulation Excessive stimulation in ICU

• MonitoringMonitoring

• CleaningCleaning

• SuctioningSuctioning

• Dressing changesDressing changes

• MobilizationMobilization

• Physical therapyPhysical therapy

Anxiety, sleep deprivationAnxiety, sleep deprivation

71% of patients in a medical 71% of patients in a medical surgical ICU get agitated at surgical ICU get agitated at

least once (46% severe agitation) least once (46% severe agitation)

Pharmacotherapy 2000; 20: 75-82Pharmacotherapy 2000; 20: 75-82

Delirium in 87%Delirium in 87%

with fluctuating mental status,with fluctuating mental status, inattention, disorganizedinattention, disorganized thinking with or without thinking with or without

agitationagitationJAMA 2001; 286: 2703-2710JAMA 2001; 286: 2703-2710

Recall in the ICURecall in the ICU

• Questionnaire to 80 survivors of ARDSQuestionnaire to 80 survivors of ARDS

• 80% remembered an adverse experience e.g. 80% remembered an adverse experience e.g. nightmares, anxiety, pain, respiratory distressnightmares, anxiety, pain, respiratory distress

• 28% met criteria for PTSD28% met criteria for PTSD

- 41% with recall of - 41% with recall of 2 frightening 2 frightening experiencesexperiences

• Other reports suggest 4-15% PTSD in ICU Other reports suggest 4-15% PTSD in ICU survivorssurvivors

Crit Care Med 2000; Crit Care Med 2000;

28: 86-9228: 86-92 Crit Care Med Crit Care Med

1998;18:651-6591998;18:651-659

Sedation GoalSedation Goal

ICU Sedation GoalICU Sedation Goal

• Stabilize hemodynamics & modulate Stabilize hemodynamics & modulate stress responsestress response

• Reduce motor activity – tolerance of Reduce motor activity – tolerance of procedures, facilitate nursing procedures, facilitate nursing managmentmanagment

• Facilitate mechanical ventilationFacilitate mechanical ventilation

• Facilitate sleep patternsFacilitate sleep patterns

UndersedationUndersedationUnderdosing Underdosing ToleranceToleranceWithdrawalWithdrawal

OversedationOversedationOverdosingOverdosingDrug accumulationDrug accumulationImpaired eliminationImpaired elimination

Drug interactions Drug interactions Adverse side effectsAdverse side effects

Incidence of Inappropriate Incidence of Inappropriate SedationSedation

Over-sedation

On Target

Under-sedation

54%

15.4%

30.6%

Kaplan L and Bailey H. Critical Care. 2000; 4(1):S110.

Olson D et al. NTI Proceedings. 2003; CS82:196.

10%20%

70%

Kaplan L. and Bailey H. Kaplan L. and Bailey H. 20002000

Olson D. et al.Olson D. et al.20032003

Sedation

SedativesCauses for Agitation

Undersedation

SedationCauses for Agitation

Agitation & anxietyPain and discomfortCatheter displacementInadequate ventilationHypertensionTachycardiaArrhythmiasMyocardial ischemiaWound disruptionPatient injury

Oversedation

Sedation

Causes for Agitation

Prolonged sedationDelayed emergenceRespiratory depressionHypotensionBradycardiaIncreased protein breakdownMuscle atrophyVenous stasisPressure injuryLoss of patient-staff interactionIncreased cost

So, we want appropriate So, we want appropriate sedation, but how? sedation, but how?

Sedation Depth

ComplicationsCostsAdverse Outcomes

Complications Adverse Outcomes

BEST OUTCOMES

ADEQUATE/OPTIMALOVERDOSING UNDERDOSING

Is Your Patient Comfortable and Is Your Patient Comfortable and at Goal ?at Goal ?

Pain Assessment by Family?Pain Assessment by Family?

• Surrogates were able to assess presence or Surrogates were able to assess presence or absence of pain in 73.5% of patientsabsence of pain in 73.5% of patients

• Degree of pain correctly assessed in only Degree of pain correctly assessed in only 53% of patients53% of patients

*Crit Care Med 2002;30:119-141*Crit Care Med 2002;30:119-141

Signs of PainSigns of Pain

Hypertension Tachycardia Lacrimation Sweating Pupillary dilation

Patients who cannot communicate should be assessed through Patients who cannot communicate should be assessed through

subjective observation of pain-related behaviors (movement, facial subjective observation of pain-related behaviors (movement, facial

expression, and posturing) and physiological indicators (HR, BP, RR) expression, and posturing) and physiological indicators (HR, BP, RR)

and the change in these parameters following analgesic therapyand the change in these parameters following analgesic therapy

Grade B recommendationGrade B recommendation

Motor Activity Assessment Scale Motor Activity Assessment Scale (MAAS)*(MAAS)*

Seven categories to describe the patient’s Seven categories to describe the patient’s reaction to stimulationreaction to stimulation

*Devlin et al. Crit Care Med 1999;27:1271-1275*Devlin et al. Crit Care Med 1999;27:1271-1275

ScoreScore DescriptionDescription DefinitionDefinition

00 UnresponsiveUnresponsive Does not move with noxious Does not move with noxious

stimulus*stimulus*

11 Responsive only toResponsive only to Open eyes OR raises eyebrows OR Open eyes OR raises eyebrows OR

turns turns noxious stimulinoxious stimuli head toward stimulus OR moves head toward stimulus OR moves limbs limbs with noxious stimuliwith noxious stimuli

22 Response to touchResponse to touch Opens eyes OR raises eyebrows Opens eyes OR raises eyebrows

OR turns OR turns or nameor namehead towards stimulus OR moves limbs head towards stimulus OR moves limbs

when touched or name is loudly spokenwhen touched or name is loudly spoken

33 Calm and cooperativeCalm and cooperative No external stimulus is required to No external stimulus is required to

elicit elicit movement AND patient is movement AND patient is adjustingadjusting sheets or clothes sheets or clothes purposefully andpurposefully and follows follows commandscommands

*Noxious stimuli = Suctioning OR 5 sec of vigorous orbital, sternal, *Noxious stimuli = Suctioning OR 5 sec of vigorous orbital, sternal, or nail bed pressure or nail bed pressure

ScoreScore DescriptionDescription DefinitionDefinition

44 Restless andRestless and No external stimulus is required to No external stimulus is required to

elicit elicit cooperativecooperative movement AND patient is movement AND patient is picking at sheets picking at sheets or tubes or uncovering or tubes or uncovering self and follows self and follows commandscommands

55 AgitatedAgitated No external stimulus is required to No external stimulus is required to

elicit elicit movement AND attempting movement AND attempting to sit up OR to sit up OR moves limbs out of bed moves limbs out of bed AND does not AND does not consistently follow consistently follow commands (e.g. will lie commands (e.g. will lie down when asked but down when asked but soon reverts back to soon reverts back to attempts to sit up or move attempts to sit up or move limbs out of bedlimbs out of bed

66 Dangerously agitatedDangerously agitated No external stimulus is required to No external stimulus is required to

elicit elicit UncooperativeUncooperative movement AND patient is movement AND patient is pulling at tubes pulling at tubes or catheters OR thrashing side to or catheters OR thrashing side to side or side or striking at staff OR trying striking at staff OR trying to climb out of to climb out of bed AND does not calm bed AND does not calm down when askeddown when asked

Objective assessment of sedation during:

BIS in the ICU: Key ApplicationsBIS in the ICU: Key Applications

? Mechanical Ventilation

Neuromuscular Blockade

Bedside Procedures

Drug Induced Coma

GE BIS Display / BIS SensorGE BIS Display / BIS Sensor

GE BIS Display

BIS Sensor

BIS converts BIS converts the “raw” EEG the “raw” EEG

signal to a signal to a number 0-100number 0-100

BIS = 95BIS = 95

BIS = 70BIS = 70

BIS = 50BIS = 50

BIS = 30BIS = 30

Responds to normal voice

Responds to loud commands or mild prodding/shaking

100100

BIS

8080

6060

4040

2020

00

Low probability of explicit recall

Unresponsive to verbal stimulus

Burst suppression

BIS in Deep SedationBIS in Deep Sedation

Jaspers et al. Intensive Care Medicine. 1999;25(Suppl 1):S67.

• Titration to maximal Ramsay Score of 6 (unarousable)• Blinded BIS monitoring

Results:• Ramsay Score remains the same, with significant decrease of BIS values over time. • Data suggest possible accumulation of sedatives and inherent risks of over-sedation.

0

10

20

30

40

50

60

70

80

90

100

Day 1 Day 3 Day 5

BIS

Val

ueB

IS V

alue

BIS

Ram

say Score*

Ram

say Score*

6868

4545

3131

66 66 66

23

4

56

* Mondello et al. Minerva Anestesiology. 2002;68(102):37-43.

Ramsay

BIS in Deep SedationBIS in Deep Sedation

Riker. AJRCCM 1999De Deyne. Int Care Med 1998

Unarousable

0

10

20

30

40

50

60

70

80

90

100B

isp

ectr

al I

nd

ex (

BIS

)

SAS 1 Ramsay 6

• Titration to unarousable state by subjective scale• Blinded BIS monitoring

Results: • Patients were unarousable at maximal sedation score. • All patients appeared similar clinically, but displayed wide variation in sedation level as measured objectively with BIS monitoring.

Ruling Out Reversible CausesRuling Out Reversible Causes

Sedation of agitated patients should start only Sedation of agitated patients should start only after providing adequate analgesia and treating after providing adequate analgesia and treating

reversible physiological causesreversible physiological causes

Grade C recommendationGrade C recommendation

Pain, hypoxemia, hypoglycemia, hypotension, Pain, hypoxemia, hypoglycemia, hypotension,

withdrawal from alcohol and other drugswithdrawal from alcohol and other drugs

Correctable Causes of Agitation

Sedation

SedativesCauses for Agitation

SedationSedation AnalgesiaAnalgesia

““ICU Sedation”ICU Sedation”

AmnesiaAmnesia HypnosisHypnosis AnxiolysisAnxiolysis

Patient Comfort