Fulfilling the need of icu patients

1. Mazen kherallah, MD, FCCP Fulfilling the need of icu patients

2. Stress in ICU?

4. Psychological Stress in ICU

5. Psychological Stress in ICU • Loss of control • Fear of death or serious illness • Fear of pain • Overwhelming isolation • Feelings of helplessness • Loss of normal circadian rhythms • The disruption of normal sleep patterns • Sleep deprivation • Disorientation and panic

6. Can the patient whom we thing is sedated on the ventilator hear and think?

7. Listen to this…

8. Alien, sensory rich environment

10. Environmental Stress in ICU

11. Environmental Stress in ICU • Foreign environments • Room temperature • Continuous ambient lighting • Family not continuously available for comfort • Significant noise from personnel and medical equipment

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13. Physical Stressin ICU • Attached to equipments with tubes or wires • Intubated and ventilated • Treatment or diagnostic procedures • Confined (restricted) to bed • Uncomfortable bed and pillow • Unable to control stool habit

15. + Inability to communicate

16. Frustration and Anger

17. Excessive stimulation in ICU • Monitoring • Cleaning • Suctioning • Dressing changes • Mobilization • Physical therapy

18. Anxiety, sleep deprivation 71% of patients in a medical surgical ICU get agitated at least once (46% severe agitation) Pharmacotherapy 2000; 20: 75-82

19. Delirium in 87% with fluctuating mental status, inattention, disorganized thinking with or without agitation JAMA 2001; 286: 2703-2710

20. Recall in the ICU • Questionnaire to 80 survivors of ARDS • 80% remembered an adverse experience e.g. nightmares, anxiety, pain, respiratory distress • 28% met criteria for PTSD • - 41% with recall of  2 frightening experiences • Other reports suggest 4-15% PTSD in ICU survivors • Crit Care Med 2000; 28: 86-92CritCare Med 1998;18:651-659

21. Sedation Goal

22. ICU Sedation Goal • Stabilize hemodynamics & modulate stress response • Reduce motor activity – tolerance of procedures, facilitate nursing managment • Facilitate mechanical ventilation • Facilitate sleep patterns

23. Undersedation Underdosing Tolerance Withdrawal Oversedation Overdosing Drug accumulation Impaired elimination Drug interactions Adverse side effects

24. 15.4% 10% 20% 30.6% 54% 70% Incidence of Inappropriate Sedation Olson D. et al. 2003 Kaplan L. and Bailey H. 2000 Over-sedation On Target Under-sedation Kaplan L and Bailey H. Critical Care. 2000; 4(1):S110. Olson D et al. NTI Proceedings. 2003; CS82:196.

25. Sedation Causes for Agitation Sedatives

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

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

28. BEST OUTCOMES Complications Adverse Outcomes Complications Costs Adverse Outcomes UNDERDOSING OVERDOSING ADEQUATE/OPTIMAL Sedation Depth So, we want appropriate sedation, but how?

29. Is Your Patient Comfortable and at Goal ?

31. Pain Assessment by Family? • Surrogates were able to assess presence or absence of pain in 73.5% of patients • Degree of pain correctly assessed in only 53% of patients • *Crit Care Med 2002;30:119-141

32. Patients who cannot communicate should be assessed through subjective observation of pain-related behaviors (movement, facial expression, and posturing) and physiological indicators (HR, BP, RR) and the change in these parameters following analgesic therapy Grade B recommendation Signs of Pain • Hypertension • Tachycardia • Lacrimation • Sweating • Pupillary dilation

33. Motor Activity Assessment Scale (MAAS)* Seven categories to describe the patient’s reaction to stimulation *Devlin et al. Crit Care Med 1999;27:1271-1275

34. ScoreDescriptionDefinition • 0Unresponsive Does not move with noxious stimulus* • 1Responsive only to Open eyes OR raises eyebrows OR turns noxious stimuli head toward stimulus OR moves limbs with noxious stimuli • 2Response to touch Opens eyes OR raises eyebrows OR turns or name head towards stimulus OR moves limbs when touched or name is loudly spoken • 3Calm and cooperative No external stimulus is required to elicit movement AND patient is adjusting sheets or clothes purposefully and follows commands • *Noxious stimuli = Suctioning OR 5 sec of vigorous orbital, sternal, or nail bed pressure

35. ScoreDescriptionDefinition • 4Restless and No external stimulus is required to elicit cooperative movement AND patient is picking at sheets or tubes or uncovering self and follows commands • 5Agitated No external stimulus is required to elicit movement AND attempting to sit up OR moves limbs out of bed AND does not consistently follow commands (e.g. will lie down when asked but soon reverts back to attempts to sit up or move limbs out of bed • 6Dangerously agitated No external stimulus is required to elicit Uncooperative movement AND patient is pulling at tubes or catheters OR thrashing side to side or striking at staff OR trying to climb out of bed AND does not calm down when asked

36. BIS in the ICU: Key Applications Objective assessment of sedation during: ? Mechanical Ventilation Neuromuscular Blockade Drug Induced Coma Bedside Procedures

37. GE BIS Display / BIS Sensor GE BIS Display BIS Sensor

38. BIS = 95 BIS converts the “raw” EEG signal to a number 0-100 BIS = 70 BIS = 50 BIS = 30

39. 100 BIS Responds to normal voice 80 Responds to loud commands or mild prodding/shaking 60 Low probability of explicit recall Unresponsive to verbal stimulus 40 20 Burst suppression 0

40. BIS in Deep Sedation • Titration to maximal Ramsay Score of 6 (unarousable) • Blinded BIS monitoring 2 3 68 BIS 4 6 6 6 BIS Value 5 45 6 Ramsay Ramsay Score* 31 • Results: • Ramsay Score remains the same, with significant decrease of BIS values over time. • Data suggest possible accumulation of sedatives and inherent risks of over-sedation. Jaspers et al. Intensive Care Medicine. 1999;25(Suppl 1):S67. * Mondello et al. Minerva Anestesiology. 2002;68(102):37-43.

41. SAS 1 Ramsay 6 Unarousable BIS in Deep Sedation • Titration to unarousable state by subjective scale • Blinded BIS monitoring • Results: • Patients were unarousable at maximal sedation score. • All patients appeared similar clinically, but displayed wide variation in • sedation level as measured objectively with BIS monitoring. Riker. AJRCCM 1999 De Deyne. Int Care Med 1998

42. Ruling Out Reversible Causes

43. Sedation of agitated patients should start only after providing adequate analgesia and treating reversible physiological causes Grade C recommendation  Pain, hypoxemia, hypoglycemia, hypotension, withdrawal from alcohol and other drugs

44. Correctable Causes of Agitation

45. Sedation Causes for Agitation Sedatives

46. “ICU Sedation” Sedation Analgesia Amnesia Hypnosis Anxiolysis Patient Comfort