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1. Lars Heslet Toronto February 07 Lars HesletProfessorICU 4131National University Hospital RigshospitaletCopenhagen 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 ?
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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 analgesiaA Canadia survey
17. Lars Heslet Toronto February 07 Protocols for sedation and analgesiaA 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?
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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
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33. Lars Heslet Toronto February 07 The patient´s scale
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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
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46. Lars Heslet Toronto February 07 Protocols for sedation and analgesiaA Canadia survey - Effect of training
47. Lars Heslet Toronto February 07 Protocols for sedation and analgesiaA Canadia survey – effect of No beds
48. Lars Heslet Toronto February 07 Protocols for sedation and analgesiaA Canadia survey – Which drugs?