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Deep Sedation or No Sedation in the ICU? Where is the Comfort Zone?

Monday June 14 th 2010 Hong Kong Crit3cal Care Medicine and College of Anaesthesiologists. Michael Ramsay MD. FRCA Chairman Department of Anesthesia Baylor University Medical Center President Baylor Research Institute. Deep Sedation or No Sedation in the ICU? Where is the Comfort Zone?.

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Deep Sedation or No Sedation in the ICU? Where is the Comfort Zone?

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  1. Monday June 14th 2010 Hong Kong Crit3cal Care Medicine and College of Anaesthesiologists Michael Ramsay MD. FRCA Chairman Department of Anesthesia Baylor University Medical Center President Baylor Research Institute Deep Sedation or NoSedation in the ICU? Where is the Comfort Zone? .

  2. Speaker Disclosure • I have received research grants and honoraria from: • Hospira • CareFusion • Ikaria • Masimo

  3. “The body when asleep has no perception; but the soul when awake has cognizance of all things, sees what is visible, hears what is audible, walks, touches, feels pain, ponders. In a word, all the functions of the body and of soul are performed by the soul during sleep.” Hippocrates, Dreams.

  4. If the soul is put to sleep by pharmacological agents are our patients at increased risk for adverse events? In Hippocrates time – 460 – 380 BC, the opium poppy was used for both analgesia and sleep inducing. The notion that the unconscious patient is insensitive to pain was the foundation of anesthesia, analgesia and sedation. However, at that time, the sleep inducing substances (opium) had analgesic properties as well as sedative effects making this statement true. However, Hippocrates did relate the loss of consciousness in a critically ill patient with a fatal outcome.

  5. ANALGO-SEDATION Good Analgesia FIRST as opposed to SEDATION first may provide the optimal comfort zone for the critically ill patient requiring mechanical ventilation. ANALGO-SEDATION techniques were indeed the first techniques described by Hippocrates and may improve outcomes today!

  6. Goals of Analgesia and Sedation • Optimize safety for acute care patients and their caregivers1,2 • Relieve pain and anxiety1-3 • Attenuate the harmful adrenergic response1,2 • Improve compliance with care1,2 • Provide comfort and safety • Facilitate communication with caregivers and family members1,2 • Avoid or reduce delirium1,2,4 • 1Blanchard AR. Postgrad Med. 2002;111:59-74. • 2Jacobi J, et al. Crit Care Med. 2002;30:119-141. • 3Dasta JF, et al. Pharmacotherapy. 2006;26:798-805. • 4Ely EW, et al. JAMA. 2004;291:1753-1762.

  7. Courtesy of M. Ramsay, MD. Sessler CN, et al. Chest. 2008;133;552-565.

  8. Sedation induced Coma in the ICU is Bad Ouimet S et al. Intensive Care Med 2007

  9. Petty TL. Suspended Life or Extending Death? Chest 1998;114:360 • “But what I see these days are sedated patients, lying without motion, appearing to be dead, except for the monitors that tell me otherwise….. By being awake and alert…they could interact with family….feel human…sustain the zest for living which is a requirement for survival”

  10. One Year Outcomes in Survivors of ARDS Herridge et al. NEMJ 2003;348:683-93 • Functional limitations 1 year later • Most patients have muscle wasting and weakness. • Neurocognitive impairments. Hopkins & Brett. Cur Opin Crit Care 2005;11:369 • Depression and memory dysfunction increased in ARDS survivors. Chest 2009;135:678

  11. Physical limitations after ARDS Herridge et al. NEMJ 2003;348:683-93 • All reported poor function due to: • Loss of muscle bulk, proximal weakness, fatigue • Alopecia in most • Persistent pain • Entrapment neuropathies • Immobility from heterotopic ossification • Trach site scar problems • Contractures/frozen shoulders

  12. Critical Care 2009, 13:216

  13. Mobile, Awake and Critically ill Margaret S. Herridge MD MPH CMAJ • March 11, 2008 • 178(6)

  14. Goals of Sedation Scales • Avoid oversedation and undersedation • Define an optimal endpoint for titration of sedation • Provide continuity of care and charting • Facilitate cost-effective use of drugs • Allow comparison of drugs • Enable precise patient management .

  15. Ramsay Sedation Scale 1 Anxious and agitated or restless or both 2 Cooperative, oriented, and tranquil 3 Responding to commands only 4 Asleep, brisk response to stimuli* 5 Asleep, sluggish response to stimuli* 6 Asleep, no response to stimuli* * light glabellar tap Ramsay, et al. Brit Med J. 1974;2(920):656-659.

  16. +4 Combative +3 Very agitated +2 Agitated +1 Restless 0 Alert and calm -1 Drowsy -2 Light sedation -3 Moderate sedation -4 Deep sedation -5 Unarousable Richmond Agitation-Sedation Scale (RASS) Sessler, et al. Sem Respir Crit Care Med. 2001;22:211-225. Sessler, et al. Am J Respir Crit Care Med. 2002;166:1338-1344.

  17. Daily Wake-up Study: Clinical Outcomes Wake-up Group Standard of Care Group Mechanical ventilation duration (days) 4.9 (2.5-8.6) 7.3 (3.4-16.1) ICU LOS (days) 6.4 (3.9-12.0) 9.9 (4.7-17.9) *P=.004. †P=.02 Adapted from Kress et al. N Engl J Med. 2000;342:1474.

  18. Daily Wake up In ICU • Reduced incidence of: • PTSD • Ventilator-associated pneumonia • GI tract bleeding • Bacteremia • VTE • Barotrauma • Cholestasis • Sinusitis Crit Care Med 2004;32:1272-76

  19. Girard TD, et al. ABC TrialThe Lancet 2008; 371 126-134 • Daily Awakening Sedation combined with Spontaneous Breathing Trial • Adding Respiratory Therapy to Sedation Team •  duration of MV;  ICU & Hosp LOS; Improved 1 year mortality

  20. ICU SEDATION TEAM

  21. ICU SEDATION TEAM

  22. ICU SEDATION TEAM

  23. A Randomized Trial of Early Physical & Occupational Therapy in Mechanically Ventilated, Critically Ill Patients WD Schweickert, MC Pohlman, AS Pohlman et al LANCET 2009;373:1874-82

  24. Strategy • Whole-body rehabilitation “Animation” with a highly coordinated, multidisciplinary team implementing: • Co-operative sedation • Spontaneous breathing trials • Good Analgesia • Physical and occupational therapy • RESULTS IN: Superior functional and cognitive patient outcomes

  25. ICU SEDATION TEAM

  26. Conclusions: Early exercise training in critically ill intensive care unit survivors enhanced recovery of functional exercise capacity, self-perceived functional status, and muscle force at hospital discharge. Crit Care Med 2009; 37:2499 –2505)

  27. The Lancet 2010;375:475-80

  28. The Effect of a Positive Affect • In severe illness a positive affect is related to survival in a dose-response pattern. • Positive affect can be considered a resource for medium-term survival • Scherer & Hermann-Lingen. Gen Hosp Psych 2009;31:8-13

  29. ANALGO-SEDATION Is this the future?

  30. Clinical Characteristics of Dexmedetomidine Cooperative sedation1 Analgesia2,3 NO RESPIRATORY DEPRESSION Organ protection (ie, neural, renal, cardiac)1 Anxiolysis2,3 Controls hyperadrenergic response to stress1-3 Reduces shivering3 Diuretic action4 Mimics natural sleep1,5 1Aantaa R, et al. Drugs of the Future. 1993;18:49-56. 2Kamibayashi T, et al. Anesthesiology. 2000;93:1345-1349. 3Wagner BKJ, et al. Clin Pharmacokinet. 1997;33:426-453. 4Goodman LS, et al. The Pharmacological Basis of Therapeutics. New York, NY: McGraw-Hill;2004:232-235. 5Huupponen E, et al. Acta Anaesthesiol Scand. 2008;52:289-294.

  31. a2 – Agonists and Cognitive Function There is strong evidence that a2 – agonists improve prefrontal cortical function (PFC) PFC shares reciprocal projections with: Parietal association cortex specialized for visuospatial processing Medial temporal lobe important to memory abilities Anterior cingulate cortex involved in organizing complex cognitive function Caudate nucleus that regulates motor behavior NE’s beneficial action in the PFC appear to result from stimulation of a2 (A) – receptors postjunctional to NE terminals Arnstein et el. Arch Gen Psychiatry 1996

  32. Dexmedetomidine for PCA/S • Sedation and analgesia properties • Does not cause respiratory depression • Rapid distribution (half life 6 mins) and elimination (half life 2 hours) • Pharmacokinetics are linear for doses 0.2 to 0.7 mcgs/kg/h • No active sedating metabolites

  33. Methods • Loading dose 0.5 mcgs/kg • Basal infusion 0.2 mcgs/kg/h • PCA/S patient trigger 0.25mcgs/kg q 20 mins • Nurses adjust basal infusion rate up to 0-7mcgs/kg/h or down very 2 hours based on patients trigger activity

  34. Results • 17 patients enrolled 9 females 8 males • Mean age was 47.1 years (+16.6) • Diagnoses included respiratory failure (n =4), pneumonia (n =3), ARDS (n =2), AIDS (n = 2), and n = 1 each for leukemia, COPD, interstitial pneumonitis, lymphangiomyomatosis, myasthenia gravis and pancreatitis.

  35. Acta Anaesthesiol Scand 2010; 54: 710–716

  36. Neuroprotective effects of Dexmedetomidine Inhibition of ischemia induced NE release may be associated with neuroprotection Dex prevents delayed neuronal death after focal ischemia Dex decreased total ischemic volume by 40% compared to placebo Jolkkonen J et al. Euro J Pharm 1999 Hoffman WE et al Anesthesiology 1991 Dex enhances glutamine disposal by oxydative metabolism in astrocytes Huang R et al. J Cereb Blood Metab 2000

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