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Lars Heslet Professor ICU 4131 National University Hospital Rigshospitalet Copenhagen Denmark

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Lars Heslet Professor ICU 4131 National University Hospital Rigshospitalet Copenhagen Denmark

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    1. Lars Heslet Toronto February 07 Lars Heslet Professor ICU 4131 National University Hospital Rigshospitalet Copenhagen Denmark

    2. Lars Heslet Toronto February 07 Introduction What is the problem?

    3. Lars Heslet Toronto February 07 Aim of sedation for Whom? For the patient ? For the Staff ?

    4. Lars Heslet Toronto February 07

    5. Lars Heslet Toronto February 07

    6. Lars Heslet Toronto February 07 To score or not to score that is the problem

    7. Lars Heslet Toronto February 07 The ”Sedation Scale” of the Staff

    8. Lars Heslet Toronto February 07 ”Patient´s scale”

    9. Lars Heslet Toronto February 07 Objective Prospective controlled study of the effect of implementation of systematic evaluation of pain, agitation & sedation score in critically ill patients. Interventions Patients were scored twice daily. The treating physician was alerted in case of increase pain and agitation score Results Incidence of pain and agitation decreased significantly in study group: Pain 63% vs. 42% (p=.002) and agitation 29% vs. 12% (p=.002) Marked decrease in the duration of MV (17% vs. 8%, p<.05). Conclusion Systematic evaluation of pain and agitation, and analgesics and sedatives need was associated with a decrease in incidence of pain and agitation, duration of mechanical ventilation and nosocomial infections Impact of implementing numerical scoring rates (NSR)

    10. Lars Heslet Toronto February 07 The most important treatment of anxiety is Good human care – communication Removal of pain, and unpleasant and unnecessary therapies First thereafter might sedative drugs be considered But do we need a ”speedometer” ?

    11. Lars Heslet Toronto February 07 Scoring systems Pain, Anxiety, Discomfort, Withdrawal Symptoms and Delirium

    12. Lars Heslet Toronto February 07 Ramsay scale

    13. Lars Heslet Toronto February 07 The only way to be able to know whether the patient is in pain is anxious is thirsty is nauseated is uncomfortable due to e.g. the NG-tube

    14. Lars Heslet Toronto February 07 …is if the patient is awake !!

    15. Lars Heslet Toronto February 07 Effect on Morbidity of using Sedation and Analgesia Protocol

    16. Lars Heslet Toronto February 07 Objectives To characterize the utilization of sedative, analgesic, and neuromuscular blocking agents, The use of sedation scales, and daily sedative interruption in mechanically ventilated adults - To define clinical factors that influence these practices - 60% of eligible physicians responded Protocols for sedation and analgesia A Canadia survey

    17. Lars Heslet Toronto February 07 Protocols for sedation and analgesia A Canadia survey Use of sedation strategies that have been shown to improve outcome is not widespread, and tremendous variability exists in clinicians’ sedation practices throughout Canada. The results of this survey emphasize the need for further educational and research efforts in sedative/ analgesic use in the ICU.

    18. Lars Heslet Toronto February 07 * Kress JP et al .Daily interruption of sedative infusions in critically ill patients undergoing mechanical ventilation. N Engl J Med. 2000 May 18;342:1471-7. ** Brook AD et al. Effect of a nursing-implemented sedation protocol on the duration of mechanical ventilation. Crit Care Med. 1999;27(12):2609-15 Comparison of 2 randomized trials: Morbidity was reduced by using a sedation protocol

    19. Lars Heslet Toronto February 07 Breen D et al. Decreased duration of mechanical ventilation when comparing analgesia based sedation using remifentanil with standard hypnotic based sedation for up to 10 days in intensive care unit patients: a randomised trial. Critical Care 2005; 9:R200-R210. Analgesia based sedation a randomised during mechanical ventilation - Safety and Efficacy (I)

    20. Lars Heslet Toronto February 07 Breen D et al. Decreased duration of mechanical ventilation when comparing analgesia based sedation using remifentanil with standard hypnotic based sedation for up to 10 days in intensive care unit patients: a randomised trial. Critical Care 2005; 9:R200-R210.

    21. Lars Heslet Toronto February 07 Breen D et al. Decreased duration of mechanical ventilation when comparing analgesia based sedation using remifentanil with standard hypnotic based sedation for up to 10 days in intensive care unit patients: a randomised trial. Critical Care 2005; 9:R200-R210.

    22. Lars Heslet Toronto February 07 Breen D et al. Decreased duration of mechanical ventilation when comparing analgesia based sedation using remifentanil with standard hypnotic based sedation for up to 10 days in intensive care unit patients: a randomised trial. Critical Care 2005; 9:R200-R210.

    23. Lars Heslet Toronto February 07 What are the therapeutic options? What is the price?

    24. Lars Heslet Toronto February 07

    25. Lars Heslet Toronto February 07 Comparison of opioids for ICU analgesia

    26. Lars Heslet Toronto February 07 Comparison of sedatives in the ICU

    27. Lars Heslet Toronto February 07 How do we do it? The end

    28. Lars Heslet Toronto February 07 How we do it - A 3 step model

    29. Lars Heslet Toronto February 07 Conclusion I Daily wake-up call important, avoid long acting drugs - (Morphine & Midazolam) Optimal: shift to Remifentanil Analgesics/Sedatives induce increased morbidity: LOS in ICU/prolonged MV difficult weaning/complications tracheostomy and VAP Reduce use of sedative. Ensure analgesia before sedation Measure and use score systems to define objective goals VAS/ sedation scores with predefined score values.

    30. Lars Heslet Toronto February 07 Conclusion II Daily wake up calls i.e. use short acting analgesics with wakeup time independent on state of metabolism (renal and/or hepatic dysfunction) The optimal analgesics and sedatives are the most expensive? shift to Remifentanil 2-3 days before expected extubation Abstinence regimes Use protocols and NRS evaluation for sedation & analgesia reduces i.e. on Morbidity: LOS, MV, VAP-incidence

    31. Lars Heslet Toronto February 07 Pain and sedation must be current standard for assess-ment using numerical Rating Scales (NRS) (Grade B) Use dose titration to defined endpoint with systematic tapering of the dose or daily interruption to minimize prolonged effects. (Grade A) Use pain & sedation guidelines (Grade B) Doses of opioids and sedatives tapered to prevent withdrawal symptoms until 7 days after continuous therapy (Grade B) Clinical practice guidelines for use of sedatives & analgesics in the critically ill

    32. Lars Heslet Toronto February 07

    33. Lars Heslet Toronto February 07 The patient´s scale

    34. Lars Heslet Toronto February 07

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    42. Lars Heslet Toronto February 07 How to improve sedation practice in daily care ? Effects of reinforcement of an existing sedation protocol

    43. Lars Heslet Toronto February 07 Control group (100 pt´s) scored with Behavioral Pain Scale, Numeric Rating Scale and Richmonds Agitation Sedation Scale twice daily in 21 weeks by interdependent observers 4 weeks of training and education Intervention group (130 pt´s) scored by nurses in 29 weeks. The treating physician was alerted in case of pain or NRS >3 or in case of agitation

    44. Lars Heslet Toronto February 07 Decreased incidence of pain and agitation in the interventionGroup 63% vs. 42% (p .002) and 29% vs. 12% (p .002), respectively. Decreased rate of severe pain and agitation events defined by NRS >6 and RASS >2. Significantly more therapeutic changes in the intervention group in the way of an escalation but also in the way of a de-escalation for analgesic and psychoactive drugs. A marked decrease in the duration of mechanical ventilation120 (8–312) vs. 65 (24 –192) hrs, (p = 0 .01) A marked decrease in nosocomial infections rate 17% vs. 8%, (p < =.05) There was no significant difference in median length of stay and mortality in ICU

    45. Lars Heslet Toronto February 07

    46. Lars Heslet Toronto February 07 Protocols for sedation and analgesia A Canadia survey - Effect of training

    47. Lars Heslet Toronto February 07 Protocols for sedation and analgesia A Canadia survey – effect of No beds

    48. Lars Heslet Toronto February 07 Protocols for sedation and analgesia A Canadia survey – Which drugs?

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