Transcript Slide 1

Connee Sloman
CRNA, MSN
Assessing and Managing Sedation
Connee L. Sloman, CRNA
Certified Registered Nurse Anesthetist
Associated Anesthesiologist
Springfield, Illinois
Faculty Disclosure
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person with a relevant financial or other relationship from participating in
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can base their own judgments. The France Foundation has identified and
resolved any and all conflicts of interest prior to the release of this activity.
Connee Sloman, CRNA, has received grant/research support from the
AANA.
Learning Objectives
• Manage adult patients who need sedation and
analgesia while receiving ventilator support according
to current standards and guidelines
• Use validated scales for sedation, pain, agitation and
delirium in the management of these critically ill
patients
• Assess recent clinical findings in pain, agitation, and
delirium management and incorporate them into the
management of ICU patients
Need for Sedation and Analgesia
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Prevent pain and anxiety
Decrease oxygen consumption
Decrease the stress response
Patient-ventilator synchrony
Avoid adverse neurocognitive sequelae
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Depression
PTSD
Delirium
Anxiety
• Avoid post-intensive care syndrome
Rotondi AJ, et al. Crit Care Med. 2002;30:746-752.
Weinert C. Curr Opin in Crit Care. 2005;11:376-380.
Kress JP, et al. Am J Respir Crit Care Med. 1996;153:1012-1018.
Characteristics of an Ideal Sedative
• Rapid onset of action allows rapid recovery after
discontinuation
• Effective at providing adequate sedation with
predictable dose response
• Easy to administer
• Lack of drug accumulation
• Few adverse effects
• Minimal adverse interactions with other drugs
• Cost-effective
• Promotes natural sleep
1. Ostermann ME, et al. JAMA. 2000;283:1451-1459.
2. Jacobi J, et al. Crit Care Med. 2002;30:119-141.
3. Dasta JF, et al. Pharmacother. 2006;26:798-805.
4. Nelson LE, et al. Anesthesiol. 2003;98:428-436.
Consider Patient Comorbidities When
Choosing a Sedation Regimen
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Chronic pain
Organ dysfunction
CV instability
Substance abuse/withdrawal
Respiratory insufficiency
Obesity
Obstructive sleep apnea
Potential Drawbacks of Sedative
and Analgesic Therapy
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Impede assessment of neurologic function
Increase risk for delirium
Numerous agent-specific adverse events
Vital signs alone do not tell the amount of pain
Need for objective measures of brain function to
adjunctively monitor level of consciousness
especially with NDNMB (BIS)
Kollef MH, et al. Chest. 1998;114:541-548.
Pandharipande PP, et al. Anesthesiology. 2006;104:21-26.
A Word About the 2013 PAD Guidelines
(Evidence-based)
• Supporting organizations
– American College of Critical Care Medicine (ACCM)
– Society of Critical Care Medicine (SCCM)
– American Society of Health-System Pharmacists (ASHP)
• Suggest preemptively treating pain with analgesics and/or
non-pharmacologic treatment
• Use opioids as first-line therapy for treatment of nonneuropathic pain
• Use non-opioid analgesics in conjunction with opioids to
decrease opioid requirements and side effects
Improper Sedation
30.6%
•
Continuous sedation carries the risks
associated with oversedation and may
increase the duration of mechanical
ventilation (MV)1
•
MV patients accrue significantly more
cost during their ICU stay than non-MV
patients2
15.4%
– $31,574 versus $12,931, P < 0.001
54.0%
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Sedation should be titrated to achieve a
cooperative patient and daily wake-up,
a JC requirement1,2
Undersedated3
Oversedated
On Target
1. Kress JP, et al. N Engl J Med. 2000;342:1471-1477.
2. Dasta JF, et al. Crit Care Med. 2005;33:1266-1271.
3. Kaplan LJ, Bailey H. Crit Care. 2000;4(suppl 1):P190.
Pain, Agitation, and Delirium
Are Interrelated
Delirium
Barr J, et al. Crit Care Med. 2013;41:263-306.
ICU Delirium
• Develops in ~2/3 of critically ill patients
• Hypoactive or mixed forms most common
• Increased risk
– Benzodiazepines
– Extended ventilation
– Immobility
• Associated with weakness
• Undiagnosed in up to 72% of cases
Vasilevskis EE, et al. Chest. 2010;138(5):1224-1233.
Sequelae of Delirium
During the
ICU/Hospital Stay
After Hospital
Discharge
• Increased mortality
• Longer intubation time
• Average 10 additional days in hospital
• Higher costs of care
• Increased mortality
• Development of dementia
• Long-term cognitive impairment
• Requirement for care in chronic care facility
• Decreased functional status at 6 months
Bruno JJ, Warren ML. Crit Care Nurs Clin North Am. 2010;22(2):161-178.
Shehabi Y, et al. Crit Care Med. 2010;38(12):2311-2318.
Rockwood K, et al. Age Ageing. 1999;28(6):551-556.
Jackson JC, et al. Neuropsychol Rev. 2004;14:87-98.
Nelson JE, et al. Arch Intern Med. 2006;166:1993-1999.
Worse Long-term
Cognitive Performance
• Duration of delirium was an independent
predictor of cognitive impairment
– An increase from 1 day of delirium to 5 days was
associated with nearly a 5-point decline in cognitive
battery scores
• Patient testimony
“One quite literally loses one’s grip on what is true and
what is false because the true and the false are
mixed together in a mess of experience.”
Girard TD, et al. Crit Care Med. 2010;38:1513-1520.
Misak CJ. Am J Respir Crit Care Med. 2004;170(4):357-359.
Consequences of Delirium
After Cardiac Operations
• Delirium after cardiac procedures is associated with
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Increased mortality (13.5% vs 2.0% in patients without)
More hospital readmissions (45.7% vs 26.5%)
Reduced quality of life
Reduced cognitive functioning, including failures in
attention, memory, perception, and motor function, and with
functional dysfunction such as independency in activities of
daily living and mobility
• Suggests we need new treatment strategies
Koster S, et al. Ann Thorac Sur. 2012;93:705-711.
ABC Trial: Objectives
• To determine the efficacy and safety of a protocol linking:
spontaneous awakening trials (SATs) &
spontaneous breathing trials (SBTs)
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Ventilator-free days
Duration of mechanical ventilation
ICU and hospital length of stay
Duration of coma and delirium
Long-term neuropsychological outcomes
Girard TD, et al. Lancet. 2008;371:126-134.
A Clinical Approach to
Improve Outcomes in Critically Ill Patients
• More than half of patients on MV in the United States
receive continuous sedation
– Risks (delirium, prolonged MV, ↑ stay ICU/hospital)
– Benzodiazepines and propofol
• DIS (daily interruption of sedation)
• Evidence suggests DIS used with assessment tools
can lead to improved outcomes
• Despite recommendations less than 33% of Medical
ICUs in the US use a sedation protocol
Berry E, Zecca H. Crit Care Nurse. 2012;32(1):43-51.
Despite Proven Benefits, Spontaneous
Awakening/Daily Interruption Trials
Are Not Standard of Practice at Most Institutions
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Canada – 40% get SATs (273 physicians in 2005)1
US – 40% get SATs (2004-05)2
Germany – 34% get SATs (214 ICUs in 2006)3
France – 40–50% deeply sedated with 90% on
continuous infusion of sedative/opiate4
1. Mehta S, et al. Crit Care Med. 2006;34:374-380.
2. Devlin J. Crit Care Med. 2006;34:556-557.
3. Martin J, et al. Crit Care. 2007;11:R124.
4. Payen JF, et al. Anesthesiology. 2007;106:687-695.
Correlating Pain Assessment With
Analgesic Administration in the ICU
• Pain scoring used in 21%
of surveyed ICUs in 20062
Assessed
100
Patients (%)
• Fewer patients assessed for
pain, more treated with
analgesics in ICUs without
analgesia protocols
compared with ICUs with
protocols1
Treated
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92
87
80
60
60
40
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25
20
0
Protocol
No Protocol
*P < 0.01 vs ICUs using a protocol
1. Payen JF, et al. Anesthesiol. 2007;106:687-695.
2. Martin J, et al. Crit Care. 2007;11:R124.
Common Agents for
Conscious Sedation
Agent
Classification
Dose
Guidelines
Side Effects
Midazolam
BZD
0.5-1 mg every
5-10 min
Respiratory depression,
somnolence
Ketamine
Dissociative
Anesthetic
200-750 mcg/kg
bolus, 5-20
mcg/kg/min
Hallucinations, delirium,
intracranial HTN,
↑ secretions
Fentanyl
Opioid agonist
25-50 mcg
Respiratory depression,
Nausea/vomiting
Mustoe TA, et al. Plast Reconstr Surg. 2010;126(4):165e-176e.
Sedation-Agitation Scale (SAS)
Score
State
Behaviors
7
Dangerous
Agitation
6
Very Agitated
5
Agitated
4
Calm and
Cooperative
3
Sedated
Difficult to arouse, awakens to verbal stimuli or gentle
shaking but drifts off
2
Very Sedated
Arouses to physical stimuli but does not communicate
or follow commands
1
Unarousable
Minimal or no response to noxious stimuli, does not
communicate or follow commands
Pulling at ET tube, climbing over bedrail, striking at
staff, thrashing side-to-side
Does not calm despite frequent verbal reminding,
requires physical restraints
Anxious or mildly agitated, attempting to sit up, calms
down to verbal instructions
Calm, awakens easily, follows commands
Riker RR, et al. Crit Care Med. 1999;27:1325-1329.
Brandl K, et al. Pharmacotherapy. 2001;21:431-436.
PAD Choice of Sedative
Recommendations
• We suggest that analgesia-first sedation be used in mechanically
ventilated adult ICU patients (+2B)
• We suggest that sedation strategies using nonbenzodiazepine
sedatives (either propofol or dexmedetomidine) may be preferred
over sedation with benzodiazepines (either midazolam or
lorazepam) to improve clinical outcomes in mechanically ventilated
adult ICU patients (+2B)
• We suggest that in adult ICU patients with delirium unrelated to
alcohol or benzodiazepine withdrawal, continuous IV infusions of
dexmedetomidine rather than benzodiazepine infusions be
administered for sedation to reduce the duration of delirium in these
patients (+2B)
Barr J, et al. Crit Care Med. 2013;41:263-306.
Ramsay Sedation Scale
1 - Awake and anxious, agitated, or restless
2 - Awake, cooperative, accepting ventilation, oriented,
tranquil
3 - Awake; responds only to commands
4 - Asleep; brisk response to light glabellar tap or loud
noise
5 - Asleep; sluggish response to light glabellar tap or loud
noise stimulus but does not respond to painful
stimulus
6 - Asleep; no response to light glabellar tap or loud noise
Ramsay MA, et al. Br Med J. 1974;2(5920):656-659.
GABA Agonist
Benzodiazepine (Midazolam)
Clinical Effects
• Sedation, anxiolysis, and
amnesia
• Rapid onset of action (IV)
Adverse Effects
• May accumulate with hepatic
and/or renal failure
• Anterograde amnesia
• Long recovery time
• Synergy with opioids
• Respiratory depression
• Delirium
Olkkola KT, Ahonen J. Handb Exp Pharmacol. 2008;(182):335-360.
Riker RR, et al; SEDCOM Study Group. JAMA. 2009;301(5):489-499.
Propofol
Clinical Effects
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Sedation
Hypnosis
Anxiolysis
Muscle relaxation
Mild bronchodilation
Decreased ICP
Decreased cerebral metabolic rate
Antiemetic
Adverse Effects
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Pain on injection
Respiratory depression
Hypotension
Decreased myocardial contractility
Increased serum triglycerides
Tolerance
Propofol infusion syndrome
Prolonged effect with high adiposity
Seizures (rare)
Ellett ML. Gastroenterol Nurs. 2010;33(4):284-925.
Lundström S, et al. J Pain Symptom Manage. 2010;40(3):466-470.
a2 Agonist Dexmedetomidine
Clinical Effects
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Antihypertensive
Sedation
Analgesia
Decreased shivering
Anxiolysis
Patient arousability
Potentiate effects of opioids,
sedatives, and anesthetics
• Decrease sympathetic activity
Kamibayashi T, et al. Anesthesiol. 2000;93:1345-1349.
Bhana N, et al. Drugs. 2000;59(2):263-268.
Adverse Effects
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Hypotension
Hypertension
Nausea
Bradycardia
Dry mouth
Peripheral vasoconstriction at
high doses
Benzodiazepines vs Propofol
Better Outcomes With Propofol
Study/Year
Population
Outcome Improved
Cardiac surgery
Faster awakening
Aitkenhead et al 1989
General ICU
More consistent awakening, faster weaning
McMurray et al 1990
Cardiac surgery
Faster awakening
Carrasco et al 1993
General ICU
More accurate sedation, faster awakening,
lower costs
Roekaerts et al 1993
Cardiac surgery
Faster awakening, earlier extubation
Ronan et al 1995
Surgical ICU
Faster awakening
Sherry et al 1996
Cardiac surgery
Lower costs
Chamorro et al 1996
General ICU
Better ventilator synchrony, faster
awakening
Barrientos-Vega et al 1997
General ICU
Earlier extubation
Weinbroum et al 1997
General ICU
Faster awakening
Sanchez-Izquierdo-Riera et al 1998
Trauma ICU
Faster awakening
McCollam et al 1999
Trauma ICU
Less oversedation
Mixed ICU
More accurate sedation, earlier extubation
Medical ICU
Fewer ventilator days
Grounds et al 1987
Hall et al 2001
Carson et al 2006
Ely EW, et al. Chest. 2012;142(2);287-289.
Benzodiazepines vs Propofol
Study/Year
Population
Outcome Improved
Searle et al, 1997
Cardiac surgery
None
Kress et al, 2000
Medical ICU
None
Cardiac surgery
None
Trials finding no differences in outcomes
Huey-Ling et al, 2008
Trials finding better outcomes
with benzodiazepine: None
Ely EW, et al. Chest. 2012;142(2);287-289.
Benzodiazepines vs Dexmedetomidine
Study/Year
Population
Outcome Improved
Pandharipande et al, 2007
Mixed ICU
More accurate sedation, more
delirium/coma-free days
Riker et al, 2009
Mixed ICU
Ruokonen et al, 2009
Mixed ICU
Lower prevalence of delirium, earlier
extubation
Shorter duration of mechanical ventilation
Maldonado et al, 2009
Cardiac surgery
Lower incidence and duration of delirium
Esmaoglu et al, 2009
Eclampsia
Shorter ICU length of stay
Dasta et al, 2010
Mixed ICU
Lower ICU costs
Jakob et al, 2012
General ICU
Lighter sedation, fewer ventilation days
Trials finding better outcomes with dex
Trials finding no differences in outcomes: None
Trials finding better outcomes with the BZD: None
Ely EW, et al. Chest. 2012;142(2);287-289.
MENDS: Dexmedetomidine vs Lorazepam
• Double-blind RCT of dex (0.15–1.5 mcg/kg/hr) vs lorazepam (1–10 mg/hr)
• Titrated to sedation goal (using RASS) established by ICU team
• Dexmedetomidine resulted in more time spent within sedation goals than
lorazepam (P = 0.04). Differences in 28-day mortality and delirium-free days were
not significant
• While incidence of HR ≤ 60 was greater with Dex (17 vs 4%, P = 0.03, the
incidence of HR ≤ 40 was not different (2 vs 2%)
Pandharipande PP, et al. JAMA. 2007;298(22):2644-2653.
SEDCOM: Dexmedetomidine vs Midazolam
• Double-blind, randomized, multicenter trial comparing long-term (> 24 hr)
dexmedetomidine (n = 244) with midazolam (n = 122)
• Sedatives (DEX 0.2-1.4 μg/kg/hr or MDZ 0.02-0.1 mg/kg/hr) titrated for light
sedation (RASS -2 to +1), administered up to 30 days
• All patients underwent daily arousal assessments and drug titration Q 4 hours
Midazolam
(N = 122)
DEX
(N = 244)
PValue
Time in target sedation range, %
75.1
77.3
0.18
Duration of sedation, days
4.1
3.5
0.01
Time to extubation, days
5.6
3.7
0.01
Patients receiving open-label, %
midazolam
49
63
0.02
18.9
42.2
0.001
0.8
4.9
0.07
Outcome
Bradycardia, %
Bradycardia requiring intervention, %
Riker RR, et al. JAMA. 2009;301(5):489-499.
Physiology of a2 Adrenoceptors
a2A
Anxiolysis
a2A
a2C
X
? a2B
a2A
a2B
X
a2A
? a2B
Adapted from Kamibayashi T, Maze M. Anesthesiology. 2000;93:1346-1349.
Applications for a2 Agonist
• Surgical
– Bariatric surgery
– CV surgery
– Neurosurgery
• Endoscopic
– Bronchoscopy
– Fiberoptic intubation
– Colonoscopy
MAC with Dexmedetomidine
• Randomized, prospective, double-blind, placebo-controlled,
multicenter
• 326 pts undergoing MAC for surgery (orthopedic,
ophthalmic, vascular, excision of lesions, others < 10%)
• All patients sedated
– Observer’s Assessment of Alertness/Sedation Scale (OAA/S ) to < 4
• Sedation with
– Dexmedetomidine ± rescue midazolam
– Placebo + rescue midazolam
• Fentanyl PRN for pain
MAC = Monitored anesthesia care
Candiotti KA, et al; MAC Study Group. Anesth Analg. 2010;110(1):47-56.
35
Dexmedetomidine Reduces Fentanyl
and Midazolam Use During MAC
150
144.4
Fentanyl Use
*
84.8
100
5
Midazolam, mg
Fentanyl, µg
200
*
83.6
4.1
4
Midazolam Use
3
*
2
1.4
50
1
0
Dex 0.5
88.9
75
*
59.0
*
42.6
50
25
0
Placebo
Dex 0.5
Placebo
Dex 1.0
Dex 1.0
Midazolam Treatment, %
Fentanyl Treatment, %
0.9
0
Placebo
100
*
100
Dex 0.5
Dex 1.0
96.8
*
59.7
75
50
*
45.7
25
0
*P < 0.001 compared with placebo,
MAC = monitored anesthesia care
Candiotti KA, et al; MAC Study Group. Anesth Analg. 2010;110(1):47-56.
Placebo
Dex 0.5
Dex 1.0
Drugs for Fiberoptic Intubation
Agent
Class
Example
Advantages
Considerations
GABA
agonist
Benzodiazepine
Midazolam
• Quick onset
• Injection not painful
• Short duration
• Not analgesic
• Airway reflexes persist
GABA
agonist
Benzodiazepine
Propofol
• Quick onset
• Respiratory depression
• Unconsciousness
• Decreased blood
pressure & CO
• Increased HR
Opioid
Fentanyl
Remifentanil
• Analgesic
• Cough suppressive
• Respiratory depression
• Pt easily arousable
• Anxiolytic
• Analgesic
• No resp depression
• Transient hypertension
• Hypotension
• Bradycardia
a2 Agonist Dexmedetomidine
Summary courtesy of Pratik Pandharipande, MD.
Dexmedetomidine Increases Comfort in AFOI
Double-blinded randomized trial
Midazolam +/- dexmedetomidine
Awake fiberoptic intubation (AFOI)
Patient comfort rated by 2 observers
Total Comfort Score (max = 35)
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n = 24
n = 31
Preoxygenation
Introduction
of scope
Bergese SD, et al. J Clin Anesth. 2010;22(1):35-40.
Introduction of ET tube
Sedation for AFOI
Conclusions
• Compared to placebo, dexmedetomidine
reduces the amount of BZD in patients with
high risk airway compromise in AFOI
• Dexmedetomidine in combination with low
doses of midazolam is more effective than
midazolam alone for sedation in AFOI
Fentanyl vs Dexmedetomidine
in Bariatric Surgery
• 20 morbidly obese patients
• Roux-en-Y gastric bypass surgery
• All received midazolam, desflurane to maintain BIS at
45–50, and intraoperative analgesics
– Fentanyl (n = 10) 0.5 µg/kg bolus, 0.5 µg/kg/h (group 1)
– Dexmedetomidine (n = 10) 0.5 µg/kg bolus, 0.4 µg/kg/h (group 2)
• Dexmedetomidine associated with
– Lower desflurane requirement for BIS maintenance
– Decreased surgical BP and HR
– Lower postoperative pain and morphine use (up to 2 h)
Feld JM, et al. J Clin Anesthesia. 2006;18:24-28.
Dexmedetomidine in Bariatric Surgery
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80 morbidly obese patients
Gastric banding or gastric bypass surgery
Prospective dose ranging study
Medication
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Celecoxib
Midazolam
Propofol
Desflurane
Dexmedetomidine
400 mg
20 µg/kg
1.25 mg/kg
4%
0, 0.2, 0.4, 0.8 µg/kg/h
Tufanogullari B, et al. Anesth Analg. 2008;106:1741-1748.
po
IV
IV
inspired
IV
Dexmedetomidine in Bariatric Surgery:
Results
• More dex 0.8 patients required rescue phenylephrine for
hypotension than control pts (50% vs 20%, P < 0.05)
• All dex groups
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–
–
–
Required less desflurane (19–22%)
Had lower MAP for 45’ post-op
Required less fentanyl after awakening (36–42%)
Had less emetic symptoms post-op
• No clinical difference
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–
–
–
Emergence from anesthesia
Post-op self-administered morphine and pain scores
Length of stay in post-anesthesia care unit
Length of stay in hospital
Tufanogullari B, et al. Anesth Analg. 2008;106:1741-1748.
Neurological Surgery
Desirable Properties for Sedatives
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Preservation of intracranial hemodynamics
Hemodynamic stability
Noninterference with neurophysiologic monitoring
Cooperative sedation (for functional
neurosurgery)
Controllability (rapid onset and offset of effect)
Neuroprotection
Decreased awareness (by the patient)
Decrease oxygen consumption
Characteristics of Cooperative Sedation
for Neurosurgery
• Patients easily transition from sleep to wakefulness
and task performance when aroused
• Patients can resume rest when not stimulated
• Most useful during procedures in which
communication with the patient must be maintained,
facilitates patient participation in therapeutic
maneuvers
• Reduces risk of drug-induced complications
Bekker A, et al. Neurosurgery. 2005;57(1 Suppl):1-10.
Current Sedatives for
Awake Craniotomy
Bonhomme V, et al. Eur J Anaesthesiol. 2009;26(11):906-912.
Sedation During Awake Craniotomy
Is Dex Compatible With Neurocognitive Testing?
Patient Number
Indication
Dex Load, μg/kg
Dex Infusion, μg/kg.h
Bekker 2001
Bustillo 2002
Lotto 2003
Ard 2003
Ard 2005
1
5
11
2
17
Neoplasm
AVM
Tumor, epilepsy,
aneurysm
Pediatric epilepsy
Tumor, epilepsy
1
0 or 1
1
0.4, 0.2, 0.1
0.2–0.7
0.6
2.8
1
Mean MDZ, mg
Mean Fentanyl, μg
Other Anesthesia
Cognitive Test
Test successful?
100
160
Prop, N2O, Sevo
(flumazenil)
Language
1/1
0.5
0.5, 0.2, 0.1
0.1–0.4
1.7 (in 6 pts)
100
191 (in 16 pts)
Prop
Prop, N2O, sevo
Prop, N2O, sevo
Wada
Language
Language
Language
0/5
10/11
2/2
17/17
Bekker AY, et al. Anesth Analg. 2001;92(5):1251-1253.
Bustillo MA, et al. J Neurosurg Anesthesiol. 2002;14(3):209-212.
Lotto M, et al. Anesthesiology. 2003; 99: A356.
Ard J, et al. J Neurosurg Anesthesiol. 2003;15(3):263-266.
Ard JL, et al. Surg Neurol. 2005;63(2):114-116.
AVM = arteriovenous malformation
Prop = propofol
Sevo = sevoflurane
Implanting Deep Brain Stimulator
for Parkinson’s Disease
• Sedation is demanding
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–
–
Recordings of movement-related neurons
Preservation of Parkinson’s symptoms for DBS localization
Patient cooperation
Halo restricts movement, respiratory depression problematic
• GABAergic sedatives (MDZ, propofol) not useful
– Ameliorate tremor and rigidity (precludes mapping & testing)
– Impair consciousness
– May cause respiratory depression
Rozet I, et al. Anesth Analg. 2006;103(5):1224-1228.
Implanting Deep Brain Stimulator
for Parkinson’s Disease
• Retrospective study with dexmedetomidine
– Control (no sedative)
n = 8 patients
– Dex (0.1-0.3 mcg/kg.h, more to goal [OAA/S = 4])
n = 11 patients
• Results
– Microelectrode recordings unimpaired by dex
– Surgical time shorter with dex (4 vs 6 h, P = 0.05)
– Less intraoperative use of antihypertensives (100% vs 54%, P = 0.048)
– Dex preserved clinical signs of Parkinson’s disease
 Tremor
 Rigidity
 Bradykinesia
• Study limitations
– Small
– Observational
– Only perioperative outcomes presented
Rozet I, et al. Anesth Analg. 2006;103(5):1224-1228.
Implanting Deep Brain Stimulator
for Parkinson’s Disease
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•
•
•
Retrospective analysis of 258 procedures (250 patients)
Patients with motor disorders, 68% PD
Propofol most common sedative, 91%
Propofol used almost exclusively in the first 30 to 45 minutes to
facilitate head-frame placement
Khatib R, et al. J Neurosurg Anesthesiol. 2008;20:36-40.
Neurosurgery Summary
• Neurosurgery presents special challenges for
sedation
– Preserve cerebral hemodynamic stability
– Maintain patient consciousness for some procedures
• Oversedation presents risks
– Delirium
– Increased ICU LOS
– Lack of patient interaction during procedure
• Emerging combinations of anesthetic and sedative
compounds have attractive properties for addressing
these unique requirements
Case Presentation
• 64-year-old female with pulsatile mass left
shoulder
• 67-year-old severe pump failure with poor
prognosis
• 71-year-old BZD and opioid dependent female
for MVR
Penney R. AANA J. 2010;78(6):446-450.
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