Transcript Sedation and analgesia in the ICU

Sedation and analgesia in the ICU
Dr Jeju Nath Pokharel, MD
Sr consultant anesthesiologist and
Head Dept of Anesthesiology
SGNHC, Bansbari, Kathmandu, Nepal
Some definitions
 Pain – It is an unpleasant sensory and emotional experience
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associated with actual or potential tissue damage.
Analgesia - is defined as the blunting or absence of sensation of
pain or noxious stimuli. (ACCM 2002)
Anxiety - a sustained state of apprehension with accompanying
autonomic arousal in response to a real or perceived threat.
Delirium – an acute, potentially reversible impairment of
consciousness and cognitive function that fluctuates in severity.
Agitation – it is characterized by extreme arousal,irritability,
excess motor activities driven by internal sense of discomfort such
as disease, pain, anxiety and delirium.
Background
 One third of all patients in intensive care units (ICUs)worldwide are
mechanically ventilated.
 Common conditions in mechanically ventilated, critically ill, trauma
patients are acute pain, anxiety, and delirium.
 ICU patients frequently experience pain and physical discomfort from
obvious factors, such as pre-existing diseases, invasive procedures, or
trauma. Pain and discomfort also can be caused by:
- monitoring and therapeutic devices such as catheters, drains, and
endotracheal tubes
- performing routine nursing care (e.g., airway suctioning, physical
therapy, dressing changes, patient mobilization)
-prolonged immobility.
Background
 unrelieved pain may contribute to inadequate sleep and
disorientation, and evoke a stress response, decreased cell
repair cellular immunity.
 Severely ill patients in a stressful environment for prolonged
periods may also experience delirium.
 Delirium itself is attributed to increased length of hospital
stay, increased health care costs, and higher mortality.
 Additionally, the ICU patient may experience heart, lung,
liver, and kidney complications, Post Traumatic Stress
Disorder (PTSD), and long-term cognitive decline.
Background
 Safe and effective management of an ICU patient’s pain and
anxiety demands a delicate balance of analgesia and sedation
protocols while managing delirium.
Why sedation and analgesia is
required ?
 To improve patient comfort.
 Reduce stress.
 Facilitate interventions.
 Allow effective ventilation/oxygenation.
 Encourage natural sleep.
 ?? Prevent post-ICU psychosis.
• Sedation comes from the Latin word sedare.
• Sedare = to calm or to allay fear
Hypnosis
Analgesia
± Muscle
Relaxation
Balancing Pain and Anxiety Treatment
PROMOTE NATURAL SLEEP CYCLE
 Allow natural sleep at night
 Stick to the schedule for sleep.
 Avoid frequent waking tasks and prevent
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interruptions.
Use back massage to relax the patient for sleep.
Create a quiet, dark environment conducive to sleep as much as
possible, lessen outside lighting, turn off lights including flashing
indicators, and reduce human and mechanical noise.
Use natural sleep cues ( lighting, noise, smells, room with
windows which can mimic 24 hour day to regulate day light
/darkness.
Use music therapy to encourage sleep.
Facilitate patient’s familiarity with environment.
Employ comfort measures:
• Provide complementary holistic therapies
• Encourage family to stay at bedside
• Remove unnecessary lines and tubes
• Remove or minimize restraints
• Encourage family to be at the bedside and engage the patient
in activities as well as sitting quietly with the patient to
promote rest
PATIENT ASSESSMENT
PATIENT ASSESSMENT
Pain
 Pain is an unpleasant sensory or emotional experience that is
associated with tissue damage or described in terms of tissue
damage. (International Association for the Study of
Pain,www.iasp-pain.org).
 All critically ill patients have the right to adequate analgesia
and management of their pain.
 A patient’s pain experience in the ICU need not be
memorable given effective attention and application of pain
management and amnesic agents.
Self reporting pain assessment scale:
Wong –Baker FACES Pain rating scale
Non – verbal reporting of pain:
10 point non – verbal pain scale.
Non verbal reporting of pain:
The Critical-Care Pain Observation Tool
(CPOT)
Pain management algorithm
Some analgesics
Sedation
 Sedatives are drugs that calm a patient down, easing agitation and
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permitting sleep.
Sedatives generally work by modulating signals within the central
nervous system.
The appropriate target level of sedation is a calm patient that can be
easily aroused with maintenance of the normal sleep-wake cycle
(SCCM).
Advantage/disadvantage
Robinson et al (2008) found continuous sedative infusions for critically
ill patients have been shown to increase the duration of mechanical
ventilation and length of intensive care stay, despite perceived
advantages.
coordinated daily interruption of sedative infusions with objective retitration in critically ill patients has been shown to decrease the
durations of mechanical ventilation and length of ICU stay.
Sedation assessment scales
 Richmond Agitation Sedation Scale (RASS)
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RASS Target Sedation = 0 to -3
Riker Sedation-Agitation Scale (SAS)
SAS Target Sedation = 3 to 4
Ramsay scale ( RS )
VICS (Vancouver Interaction and Calmness Scale)
MAAS (Motor Activity Assessment Scale)
The AVRIPAS scale
The BLOOMSBURY Scale
HS (Harris Scale)
ATICE (Adaptation to the Intensive Care Environment).
Sedation assessment scales
Sedation assessment scale
Sedation assessment scales
- RS (Ramsay Scale):
Level Response
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
Figure . The Ramsay Scale. Modified from Ramsay M, Savege T,
Simpson BRJ, et al. Controlled sedation with
alphaxalone/alphadolone. BMJ 1974;2:656–569.
Non pharmacological methods of
sedation
 environment modification,
 relaxation, back massage, and music therapy when
appropriate.
Pharmacological method of sedation
Pharmacology of selected sedatives
Daily awakening trial
 A Daily Awakening Trial (or Sedation Vacation) is titrating
down continuous infusions of sedatives or holding sedation
bolus until the patient is awake
 Once the patient is awake and responsive, an accurate
sedation, pain, and delirium assessment can be obtained
 It is recommended to couple spontaneous breathing trial
protocols with sedation protocols
 combining a spontaneous breathing trial protocol with a daily
wakening trial results in patients spending less time on
mechanical ventilation, less time in coma, and less time in
intensive care and the hospital.
Daily Awakening Trial and Spontaneous
Breathing Trial
SEDATIVE AND ANALGESIC
WITHDRAWAL
Benzodiazepines
 dysphoria,
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tremor,
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headache,
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nausea,
 sweating,
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fatigue,
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anxiety,
 agitation,
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increased sensitivity to light and sound,
 paresthesias,
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muscle cramps, myoclonus,
 sleep disturbances,
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delirium, and
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seizures.
Opioids
 dilation of the pupils
 sweating,
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lacrimation
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rhinorrhea,
 piloerection
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tachycardia,
 vomiting,
 diarrhea,
 hypertension,
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yawning,
 fever,
 tachypnea,
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restlessness,
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irritability,
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increased sensitivity to pain,
 cramps, muscle aches,
 anxiety.
DELIRIUM
 Delirium, characterized by fluctuations in mental status
such as inattention,disorganized thinking,hallucinations,
disorientation, and an altered level of consciousness, is a
frequent occurrence in the intensive care unit (ICU).
 Occurs in up to 65 percent of hospitalized patients, and up
to 87percent of patients admitted to the ICU.
Hyperactive delirium, Hypoactive delirium, Mixed
delirium
Agitation & delirium: an aide memoire
for routine use
I WATCH DEATH
 Infection
 Withdrawal
 Acute metabolic problem
 Trauma/ pain
 CNS pathology
 Hypoxia/Hypoglycemia
 Deficiencies (B1, B12)
 Endocrinopathies
 Acute vascular
 Toxins/ drugs
 Heavy metals
DELIRIUM
 Drugs
 Electrolyte abnormalities
 Lack of drugs
 Infection
 Reduced sensory input
 Intracranial problem
 Urinary retention & fecal
impaction
 Myocardial infarction
Drugs that can cause Delirium
 Anti-arrhythmics
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Lidocaine
Mexilitine
Quinidine
Antibiotics: Penicillin
Anti-cholinergics: atropine
Anti-histaminics
Beta-blockers: propranolol
Narcotics: meperidine
Morphine
Pentazocine
Delirium Assessment (CAM-ICU)
Algorithm
Intensive Care Delirium Screening
Checklist (ICDSC)
Risk Factors for Delirium
 Delirium in patients usually develops between 24 and 72
hours after admission to ICU.
 Risk factors before hospitalization: cognitive impairment,
chronic illness (including hypertension), advanced age (over
65 years), depression, smoking, alcoholism, and severity of
illness.
 Risk factors during hospitalization: Congestive heart failure,
sepsis, prolonged restraint use and immobility, withdrawal,
seizures, dehydration, hyperthermia, head trauma,
intracranial space-occupying lesions, and the use of specific
medications: LORazepam/ Midazolam, Morphine/fentanyl,
and Propofol.
Delirium Management Algorithm
Conclusion
ICU sedated pt care map
Thank you for attention !