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Sedation, Analgesia and Paralysis in ICU

Sedation, Analgesia and Paralysis in ICU. Mazen Kherallah, MD, FCCP. ICU Sedation. ICU sedation is a complex clinical problem Current therapeutic approaches all have potential adverse side effects

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Sedation, Analgesia and Paralysis in ICU

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  1. Sedation, Analgesia and Paralysis in ICU Mazen Kherallah, MD, FCCP

  2. ICU Sedation • ICU sedation is a complex clinical problem • Current therapeutic approaches all have potential adverse side effects • Agitated patients are often hypertensive, increase stress hormones, and require more intensive nursing care

  3. The Need for Sedation • Anxiety • Pain • Acute confusional status • Mechanical ventilation • Treatment or diagnostic procedures • Psychological response to stress

  4. Goals of sedation in the ICU • Patient comfort and • Control of pain • Anxiolysis and amnesia • Blunting adverse autonomic and hemodynamic responses • Facilitate nursing management • Facilitate mechanical ventilation • Avoid self-extubation • Reduce oxygen consumption

  5. Characteristics of an ideal sedation agents for the ICU • Lack of respiratory depression • Analgesia, especially for surgical patients • Rapid onset, titratable, with a short elimination half-time • Sedation with ease of orientation and arousability • Anxiolytic • Hemodynamic stability

  6. The Challenges of ICU Sedation • Assessment of sedation • Altered pharmacology • Tolerance • Delayed emergence • Withdrawal • Drug interaction

  7. Sedation Causes for Agitation Sedatives

  8. Undersedation Sedatives Causes for Agitation Agitation & anxiety Pain and discomfort Catheter displacement Inadequate ventilation Hypertension Tachycardia Arrhythmias Myocardial ischemia Wound disruption Patient injury

  9. Oversedation Causes for Agitation Sedatives Prolonged sedation Delayed emergence Respiratory depression Hypotension Bradycardia Increased protein breakdown Muscle atrophy Venous stasis Pressure injury Loss of patient-staff interaction Increased cost

  10. Correctable Causes of Agitation • Full bladder • Uncomfortable bed position • Inadequate ventilator flow rates • Mental illness • Uremia • Drug side effects • Disorientation • Sleep deprivation • Noise • Inability to communicate

  11. Causes of Agitation Not to be Overlooked • Hypoxia • Hypercarbia • Hypoglycemia • Endotracheal tube malposition • Pneumothorax • Myocardial ischemia • Abdominal pain • Drug and alcohol withdrawal

  12. Altered PharmacologyMidazolam and Age Harper et al. Br J Anesth, 1985;57:866-871

  13. Delayed Emergence • Overdose (prolonged infusion) • pK derived from healthy patients • Drug interaction • Individual variation • Delayed elimination • Liver (Cp450) • Kidney dysfunction • Active metabolites

  14. Morphine Metobolism 80% 10%

  15. Withdrawal • Withdrawal from preoperative drugs • Sudden cessation of sedation • Return of underlying agitation • Hyperadrenergic syndrome • Hypertension, tachycardia,sweating • Opioid withdrawal • Salivation, yawning, diarrhea

  16. Drug InteractionsDiazepam-Morphine Interaction ED50 isobologram Righting reflex In rats Antagonism Diazepam Synergism Morphine Kissin et al. Anesthesiology. 1989, 70:689-694

  17. Strategies for Patient Comfort • Set treatment goal • Quantitate sedation and pain • Choose the right medication • Use combined infusion • Reevaluate need • Treat withdrawal

  18. Set Treatment Goal Sedation Analgesia Amnesia Hypnosis Anxiolysis Patient Comfort

  19. Quantitate Sedation & Analgesia • Subjective measure • Objective measures

  20. Sedation Scoring Scales • Ramsay Sedation Scale (RSS) • Sedation-agitation Scale (SAS) • Observers Assessment of Alertness/Sedation Scale (OAASS) • Motor Activity Assessment Scale (MAAS) BMJ 1974;2:656-659 Crit Care Med 1999;27:1325-1329 J Clin Psychopharmacol 1990;10:244-251 Crit Care Med 1999;27:1271-1275

  21. The Ramsay Scale

  22. The Riker Sedation-Agitation Scale

  23. The Motor Activity Assessment Scale

  24. What Sedation Scales Do • Provide a semiquantitative “score” • Standardize treatment endpoints • Allow review of efficacy of sedation • Facilitate sedation studies • Help to avoid oversedation

  25. What Sedation Scales Don’t Do • Assess anxiety • Assess pain • Assess sedation in paralyzed patients • Predict outcome • Agree with each other

  26. BIS Monitoring

  27. BIS Monitoring

  28. BIS Range Guidelines BIS Awake 100 Responds to normal voice Axiolysis 80 Responds to loud commands or mild prodding/shaking Moderate sedation 60 Low probability to explicit recalls Unresponsive to verbal stimuli 40 Burst suppression Deep Sedation 20 Flat line EEG 0

  29. Assess Pain Separately Pain

  30. Visual Pain Scales 0 1 2 3 4 5 6 7 8 9 10 Worst possible pain No pain

  31. Signs of Pain • Hypertension • Tachycardia • Lacrimation • Sweating • Pupillary dilation

  32. Principles of Pain Management • Anticipate pain • Recognize pain • Ask the patient • Look for signs • Find the source • Quantify pain • Treat: • Quantify the patient’s perception of pain • Correct the cause where possible • Give appropriate analgesics regularly as required • Remember, most sedative agents do not provide analgesia • Reassess

  33. Nonpharmacologic Interventions • Proper position of the patient • Stabilization of fractures • Elimination of irritating stimulation • Proper positioning of the ventilator tubing to avoid traction on endotracheal tube

  34. Choose the Right Drug • Benzodiazepines • Propofol • Opioids • -2 agonists

  35. Choose the Right Drug Sedation Analgesia Amnesia Hypnosis Anxiolysis Benzodiazepines

  36. Benzodiazepines

  37. Choose the Right Drug Sedation Analgesia Amnesia Hypnosis Anxiolysis Propofol

  38. Propofol

  39. Propofol Dosing • 3-5 g/kg/min antiemetic • 5-20 g/kg/min anxiolytic • 20-50 g/kg/min sedative hypnotic • >100 g/kg/min anesthetic

  40. Choose the Right Drug Sedation Analgesia Amnesia Hypnosis Anxiolysis Opioids

  41. Pharmacology of Selected Analgesics

  42. Opioids

  43. Opioids

  44. Problems with Current Sedative Agents

  45. Choose the Right Drug Sedation Analgesia Amnesia Hypnosis Anxiolysis -2 agonists

  46. Alpha-2 Receptors Brain (locus ceruleus) Sedation Anxiolysis Sympatholysis Spinal Cord Analgesia Peripheral vasculature Vasoconstriction

  47. DEX: Dosing Loading infusion 0.25-1 g/kg (10-20 min) Maintenance infusion 0.2-0.7 g/kg/hr

  48. Use Continuous and Combined Infusion Load Maintenance Plasma Level

  49. Repeated Bolus Plasma levels

  50. Opioid + Hypnotic Infusion Fentanyl + Midazolam or Propofol Amnesia Anxiolysis Hypnosis Analgesia

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