sedation and delirium management

1. SEDATION and DELIRIUMMANAGEMENT Regina Pillai, MD; Shannon Geddes, MD; Rebecca Logiudice, RN, MS; Carey Thomson, MD, MPH for the Critical Care Committee Critical Care Services, Mount Auburn Hospital

3. Case Vignette Mr. R is a 46 y.o admitted to the ICU with pancreatitis. Intubated on hospital day 4 for acute respiratory distress and SIRS. Mr. R remains intubated for 19 days. He develops MSOF, delirium, and agitation. He receives continuous IV fentanyl, propofol and prn benzodazipines for sedation.

4. Case Vignette On ICU day 14 (10 days intubated), Mr. R opens his eyes spontaneously, but is not able to focus or follow commands. He is biting his ET tube, kicking his legs, and pulling at his restraints. Evaluate his sedation based on this description.

5. Case VignetteICU Day 14 Sedation Orders Ativan 1 mg IV q 1 hour, prn CIWA > 10 Ativan 2 mg IV q 1 hour, prn CIWA > 20 Ativan 1 mg fq 4 hours, prn agitation, hold for deep sedation Haldol 1mg IM, q 4 hours prn agitation Benadryl 50 mg, q 8 hours, prn Fentanyl drip 25 � 100 mcg/min � titrate for sedation/pain Propofol drip 20 � 50 mcg/kg/min � titrate to sedation

8. Acquiring A Common Language Agitation: excessive activity associated with internal tension Pain: unpleasant sensory or emotional experience with actual or potential tissue damage Anxiety: sustained state of apprehension with autonomic arousal in response to real or perceived threat Delirium: acute, potentially reversible global impairment of consciousness and cognitive function that fluctuates in severity

11. Optimizing Sedation & Sedation Guideline Multidisciplinary process that incorporates expertise from physicians, nurses, pharmacy, and others Allows routine monitoring and improves communication Optimizes sedation, treatment of pain and discomfort and monitors response Avoids oversedation & undersedation -reduces VAP, LOS, Vent days, Trach, reintubation Standard of care in ICUs

12. Richmond Agitation Sedation Scale (RASS) Introduced by Sessler in 2002 Easy to use by all clinicians Rapid to perform 10 point scale that addresses level of sedation Easy to recall by the negative and positive numbers

13. Richmond Agitation Sedation Scale (RASS) 4+ Combative Overtly combative, violent, immediate danger to staff 3+ Very agitated Pulls or removes tube(s) or catheter(s); aggressive 2+ Agitated Frequent non-purposeful movement, fights ventilator +1 Restless Anxious but movements not aggressive vigorous 0 ALERT & CALM ? GOAL

14. Richmond Agitation Sedation Scale (RASS) -1 Drowsy Not fully alert, but has sustained awakening (eye-opening/contact) to voice (> or = to 10 secs) -2 Light sedation Briefly awakens with eye contact to voice (<10 seconds) -3 Moderate sedation Movement or eye opening to voice (but no eye contact) -4 Deep sedation No response to voice, but movement or eye opening to physical stimulation -5 Unarousable No response to voice or physical stimulation

15. Treatment for Agitation GOAL sedation level MUST BE SET prior to ordering medications Etiology based approach to therapy Goal is to define and treat different components of agitation COMBINATION THERAPY ADDS SYNERGY AND HAS DOSE-SPARING EFFECT

16. Pain Most common cause of agitation in ICU Difficult to assess in sedated and non-verbal patients Methods to assess pain: Facial expressions: patient points to Wong-Baker face 0-10 numeric scale: patient describes per number FRACC (face,respiration,activity,audibility,consolibility) for non-verbal patients based on CLASSIC TRIAD (physiologic indicators) of pain: HR, BP, RR) and facial expressions.

17. Treatment of Pain: Opioids

18. Treatment for Pain NSAIDS Pain in hemodynamically compromised patients is difficult to treat Narcotics can compromise hemodynamics and ventilation NSAIDS do not cause hypotension NSAIDS side effects: GI bleeding, renal failure Use H2 Blockers with NSAIDS

19. Sedation Goal sedation level must be set Patient must be assessed frequently to determine sedation level Use of the RASS to increase consistency SEDATIVE AGENTS Have amnestic properties, NO analgesia Blunt patient�s perception of distress Side effects of most agents include: Delirium Hypotension Increased tolerance with withdrawal syndromes Risk of seizures if stopped abruptly Difficult to assess neurologic status

20. Medications for Sedation Benzodiazepines Onset midazolam<diazepam<lorazepam Duration diazepam>lorazepam>midazolam Elimination renal failure: active metabolites accumulate for midazolam and diazepam cirrhosis: prolongation of metabolism to active metabolites for midazolam & diazepam

21. Medications for Sedation Dosing for Benzodiazepines Begin with 1-2 mg bolus Ativan (Lorazepam)* if goal not met, give 2nd dose (1-2 x 1st dose) in 5-10 min if goal still not met, give 3rd dose (1-2x2nd dose) in 5-10min Once sedated give prn dosing at the level of last dose given If goal still not met, consider continuous infusion at 0.5-8mg/hr *Dosing increased for Versed (Midazolam)

22. Medications for Sedation Propofol Sedative hypnotic with mild amnestic properties, NO analgesia, ($$$$) Rapid induction (30-40sec), rapid recovery Dosing: Start dose at 5mcg/kg/min Titration by 5-10mcg/kg/min q5 min Side Effects: Hypotension 1/3 of all patients, Bradycardia, arrhythmia, Lipemia, hypertriglycerdemia, Pancreatitis, Infection Risk Propofol Infusion Syndrome: acute refractory bradycardia and metabolic acidosis, rhabdomyolysis, hyperlipidemia or an enlarged fatty liver Limit 2-3 days sedation therapy

23. Medications for Sedation Dexmedatomidine (Precedex) Short acting alpha 2 agonist(8-10x increased binding than clonidine) Anxiolytic, anesthetic, hypnotic and analgesic with single agent Rapid onset: 6 min Elimination: 2 hours Pts can be arousable/alert with stimulation Sedation with less lethargy & less reduction in level of arousal Dose: loading infusion for 1mg/kg for 10 min maintenance of 0.2 to 0.7 mcg/kg/hr Side effects: Hypotension Bradycardia High doses can have alpha 1 agonist effect

24. Delirium Assessment tool: CAM-ICU �Confusion Assessment Method for the ICU 4 features (Yes/No) Fluctuation in mental status Inattention Disorganized thinking (and/or) Altered Level of consciousness

25. Treatment for Delirium Haloperidol Preferred agent for treatment of delirium Dosing: 2 mg bolus IV, doubling dose every 10-15 min until desired effect Side effects: Minimal respiratory or hemodynamic effects Rigidity QTc prolongation in patients at risk (must monitor at high doses)

26. Daily Wake-Ups Allows patients to �wake up� by stopping drug infusion Clinicians are able to assess neurological status & examine patient while awake (calm or agitated) Sedative doses are subsequently decreased Daily interruption of sedative drug infusions result in: Decrease duration of mechanical ventilation Decrease length of ICU stay Less nosocomial infections/VAP Improves hemodynamics/allows weaning of vasopressos and fluids

27. Transition of Sedatives Think ahead to predicted extubation Perform daily wake-ups Once patient stable, reduce sedatives by max of 25% a day and use prns as needed (much less given overall) Use Haldol for agitation resulting from reduction in medications if delirium is an issue Consider withdrawal as an issue if long term meds used

29. Summary Assess frequently Use a scale to assess pain, sedation, delirium Communicate along common terms Understand cause of agitation and focus treatment Avoid increased tolerance and withdrawal syndromes Perform daily wake-ups Wean medications prior to extubation