Transcript NO - Society of Hospital Medicine

ABCDE implementation at
BHCS
Susan Smith, MS, RN, ACNS-BC
Clinical Nurse Specialist
Baylor University Medical Center
Critical Care Services
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SEDATION VACATION AND
SPONTANEOUS BREATHING
TRIALS
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Awakening Trial
Safety Screen (BUMC criteria)
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NO FiO2 ≥ 0.6
NO PEEP > 7.5 cm
NO neurosurgical pts.
NO ICP > 10 cm H2O
NO HR > 140 bpm
NO neuromuscular blocker
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NO open surgical abdomen/chest
NO active seizures
NO active ETOH withdrawal
NO active agitation
NO myocardial ischemia within
the past 24 hours
Hold analgesic / sedation for continuous
infusion 2 times daily. May supplement with
prn analgesic / sedative if ordered.
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Sedation Restarting Criteria
• If patient develops any of the symptoms below, resume
infusion at HALF of the previous rate prior to sedation
vacation
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–
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Agitated or combative
O2 saturation falls below 90%
Respiratory Rate is 40 or above
Worsening dyspnea
• If these symptoms persist, contact the physician
• Be sure to have prn bolus orders for pain and sedation
before beginning SAT/sedation vacation
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Spontaneous Breathing Trial
Safety Screen (BUMC)
Breathing Trial
Breathing Trial
• Patient awake and able to
• No vasopressors, HD
follow 3 of 4 commands:
stable
– Opens eyes with verbal
command
• No active agitation
– Points 2 fingers upon
• No FiO2 ≥ 0.6
instruction
– Tracks caregiver
• No RR ≥ 40
– Sticks tongue out on
• No worsening dyspnea
command
If these symptoms
Place patient on
present contact
CPAP 5 + 5 cm H2O
physician
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Spontaneous Breathing Trial
• Discontinue SBT and resume prior vent settings
for:
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–
–
RR > 35 or < 8 x 5 minutes or longer
SpO2 < 90% x 5 minutes or longer
Acute cardiac arrhythmia
HR > 130 or < 60
Accessory muscle use
Abdominal paradoxical breathing
Diaphoresis
Marked dyspnea
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Spontaneous Breathing Trial
• If SBT successful measure:
– RR and TV (more parameters may be requested)
– Call physician after 30 minutes of the trial
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Critical Care Flowsheet
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Patient Care Viewer
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Improvement Strategies
• People
– RN, RT, MD
– Others: Pharmacist
• Process
– Adult Ventilator Orderset
– Multidisciplinary Rounds
– Daily Vent Mortality Data collection
• How do we get this data to match up with our documentation?
• Technology
– EHR
– DART reports
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CHOICE OF SEDATIVE
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Treatment of Pain
Opiate
IV
PO
IV Onset
(min)
Half-life
(hours)
Fentanyl
0.1
--
1-2
2-4
Hydromorphone
1.5
7.5
5-15
2-3
Morphine
10
30
5-10
3-4
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Treatment of pain with IV
medications
Opiate
Intermittent dosing
IV infusion rate
0.35-5 mcg/kg
0.7-10 mcg/kg/hr
25-100mcg
25-250mcg/hr
Fentanyl
Other information
Most lipophillic,
accumulation w/
liver dysfunction
Hydromorphone
0.2-0.6 mg
0.5-3 mg/hr
May be better in
patients tolerant to
other agents
Morphine
2-4 mg
2-30 mg/hr
Active metabolites,
histamine release
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Opioid related side effects
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Sedation
Muscle rigidity
Respiratory depression
Decrease GI mucus secretion and increase fluid absorption
Nausea, vomiting
Pruritus
CONSTIPATION
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Adjunctive pain agents
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Local and regional anesthetics
Ketamine
Acetaminophen
NSAIDS
Gabapentin or pregabalin
Carbamazepine
Non-pharmacological management strategies
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Indications for sedation
• Treat agitation
• Promptly identify underlying causes
– Delirium, pain, hypoxemia, hypoglycemia, hypotension, alcohol
withdrawal
• Titration of sedation to light and arousable
• Sedation scales and protocols have reduced the amount of sedation
patients receive and improve outcomes
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Benzodiazepines
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Activate GABA-A receptors in the brain
Anxiolytic, amnestic, sedating, hypnotic, and anticonvulsant effects
Potency: Lorazepam > Midazolam > Diazepam
Lipophilicity: Midazolam and Diazepam > Lorazepam
All BDZs are metabolized hepatically
Caution in elderly patients
Lorazepam, oxazepam, and temazepam are renally cleared
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Benzodiazepines
Agent
Onset
(min)
Half life
(hours)
Active
metabolites
IV infusion
rate
Midazolam
2-3
3-11
Yes
1-7 mg/hr
Lorazepam
15-20
8-15
No
1-10 mg/hr
Diazepam
2-5
20-120
Yes
Not used
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Propofol
• Exact mechanism is not known
• Binds to GABA-A, glycine, nicotinic, and muscarinic receptors
• Sedative, hypnotic, anxiolytic, amnestic, antiemetic, and
anticonvulsant
• No analgesic properties
• Highly lipid soluble
• Best for patients who need frequent awakenings
• Caution with egg and soybean allergies
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Propofol
Agent
Onset (min)
Half life
(hours)
Active
metabolites
IV infusion
rate
Propofol
1-2
3-12
No
5-50
mcg/kg/min
• Adverse effects: hypertriglyceridemia, acute pancreatitis, myoclonus,
hypotension
• Propofol infusion syndrome: metabolic acidosis, hypertriglyceridemia,
hypotension with vasopressor use, arrhythmias, acute kidney injury,
hyperkalemia, rhadbomyolysis
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Dexmedetomidine
• Selective alpha 2 receptor agonist
• Sedative, sympatholytic, and questionable analgesic properties
• Generally patients are more easily arousable with minimal respiratory
depression
• Hepatically cleared
• Adverse effects: hypotension, bradycardia
Agent
Onset
(min)
Half life
(hours)
Active
metabolites
IV infusion
rate
Dexmedetomidine
5-10
1-3
No
0.2-0.7
mcg/kg/min
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What should I do to prepare for a
sedation vacation?
• Evaluate your flowsheet checklist
• If patient doesn’t meet requirement, ask for clarification
on multidisciplinary rounds
• The most important tool you can have for a sedation
vacation is PRN pain and sedative agents. Why???
– If a patient fails vacation and patient isn’t going to be
extubated you will need PRN agents to get them under
control and to prevent dose titrations beyond their
requirements.
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What about precedex?
• This agent is typically ordered when
preparing for extubation
• Purpose of precedex is to allow the pt to
remain calm and compliant with the
ventilator without lowering respiratory
drive
• Allow the patient to prove that he/she
needs the agent when the other sedatives
are stopped
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How do I handle a sedation
vacation when the patient is
already on precedex?
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90 percent of the time, it is appropriate to keep this agent going
If the patient is only on precedex and they are overly drowsy, they may not
require this agent to remain calm for extubation, consider stopping
It is not wrong to pause this agent, in fact, the ideal patient would remain
calm with no agent on board.
If patient has had a h/o agitation and this was the reason for starting the
agent, another appropriate method would be to titrate down to minimal
requirements during the “sedation vacation”
Once the patient is extubated, stop the agent.
If agitation occurs after extubation, clarify with MD what agent to use. In
general we will use other agents after extubation to assist the patient in
remaining calm
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The patient failed the trial, how
do I proceed
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Is the patient acutely in pain?
– Give PRN Pain agent (fentanyl, dilaudid, morphine, norco, etc)
Is the patient acutely agitated?
– Give PRN Sedative agent (ativan, versed)
– If patient was on propofol gtt
What rate to I set my drips at?
– Regardless of agitation or not, restart at half the rate!
– Utilize PRN pushes to support the patient through the agitation/pain
period
– If more than one push is required, then titrate up the agent
– Let the patient prove they need more agent
– Always titrate to calmness, while trying to maintain the highest level
of alertness unless MD order specifies otherwise
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What if my patient is fully alert
on their sedation?
• Stop the agent and do a sedation vacation.
• Let them prove they need the agent to remain calm
• The agent may be frivolous at that point…why give something they do
not need?
• It is never wrong to ask for clarification, but the majority of the time
your answer will be to stop the agent
• Remember, the ideal patient is the one tolerating the ventilator
without any continuous infusion on board. Ideally we would have no
gtts and utilize PRN agents to support them through acute pain and
agitation
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What if my patient is
complaining of pain, should I
stop the agent?
• If your pt is alert and complaining of pain, then get a clarification from
the MD.
• We do not want to cause pain that would increase respirations and
thus negatively impact their ability to be extubated.
• The patient may qualify for a transition to longer acting oral agents to
control pain
• If they aren’t alert and unable to verbalize their pain, then stop the
agent.
– Let them prove to you they need the pain medication
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HF is a 60 yoF on a ventilator now for 3 days.
Her current regimen is Fentanyl
3mcg/kg/hour and Versed 5mg/hour. She
qualifies for a sedation vacation so Sally
stops the Versed.
Has she done the correct thing?
What recommendations would you make?
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• HF is a 60 yoF on a ventilator now for 3
days. Her current regimen is Fentanyl
3mcg/kg/hour and Versed 5mg/hour. She
qualifies for a sedation vacation. After your
brilliant education, Sally stops both the
fentanyl and versed. However an hour later
the patient starts fighting the ventilator and
requires reinitiating the patient’s pain and
sedation regimen.
• How should she proceed with reinitiating
the pain and sedation on this patient?
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• MM is a 50 yoM on a ventilator for 7 days.
He was initiated on precedex
0.5mcg/kg/hour yesterday after his
propofol was stopped and he became
agitated. He is also on fentanyl at
1mcg/kg/hr. He meets requirements for a
sedation vacation.
• What other information do you need before deciding how to
proceed?
• If he is in pain how would you proceed?
• If he is drowsy how would you proceed
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Improvement Strategies
• Provide more in depth drug information to super
trainers to be able to better support staff nurses
during the SAT/SBT process
– Encourage use of pharmacists to help with guidance
• Encourage good communication
• Daily multidisciplinary rounds to discuss patient
progress
• Review of documentation daily
• Daily vent mortality data collection
– Does this match your documentation?
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DELIRIUM SCREENING AND
MANAGEMENT
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…seems like it was in a huge, empty gray
space, sort of like a monstrous underground
parking garage with no cars, only me, floating or
seeming to float, on something…
-SB
Travis Smith via Flickr
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Sarah Beth tells her story
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Confusion Assessment Method for
the ICU (CAM-ICU)
Feature 1: Acute change or
fluctuating course of mental
status
And
Feature 2: Inattention
And
Feature 3: Altered level of
consciousness
Or
Feature 4: Disorganized
thinking
Inouye, et. al. Ann Intern Med 1990; 113:941-948.1
Ely, et. al. CCM 2001; 29:1370-1379.4
Ely, et. al. JAMA 2001; 286:2703-2710.5
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Step 1: Sedation Assessment (RASS)
Sessler CN, AJRCCM 2002;166:1338-1344
Ely EW, AJRCCM 2001;163:A954
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Step 2: Content Assessment
Assess For Delirium With the
CAM-ICU
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Feature 1: Alteration/Fluctuation
in Mental Status
• Is the pt different than his/her baseline mental status?
or
• Has the patient had any fluctuation in mental status in
the past 24 hours (e.g. fluctuating RASS, GCS, previous
delirium assessments, etc)
The Feature is Present if either question is YES.
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Feature 2: Inattention
Screening for Attention– two options
Inattention Present: If >2 errors
Letter “A” test
Letters: S A V E A H A A R T
Say 10 letters and instruct the patient to squeeze on the
letter “A”
Pictures
Similar test with pictures
(instructions are in picture packets)
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Feature 3: Altered Level of
Consciousness
You already did this assessment when you did the
RASS. It was the first thing you did when you walked in
the room!
If the Actual RASS score is anything other than “0”
(zero) and alert, then altered LOC is Present
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Teaching Point
• It is only necessary to proceed to
Disorganized Thinking when a patient is
Feature 2 positive (Inattentive) and
Awake and Alert (RASS 0) at the time of
CAM-ICU evaluation.
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Feature 4: Disorganized Thinking
Yes/No Questions (Use either Set A or Set B) :
Set A
1. Will a stone float on water?
2. Are there fish in the sea?
3. Does one pound weigh more than
two pounds?
4. Can you use a hammer to pound a nail?
wood?
Set B
1. Will a leaf float on water?
2. Are there elephants in the sea?
3. Does two pounds weigh
more than one pound?
4. Can you use a hammer to cut
Note: Use whatever form of communication that works
(nodding, hand squeezing, blinking, etc).
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Feature 4: Disorganized Thinking
Command
Say to patient: “Hold up this many fingers”
(Examiner holds two fingers in front of patient) “Now
do the same thing with the other hand” (Not
repeating the number of fingers).
Patient gets credit only if able to successfully
complete the entire command.
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CAM-ICU FAQs
• Patient with severe depression:
– May result in a false positive—consult psych
• Patient with dementia:
– CAM-ICU reliable in both groups of patients
– Patients can have both
– Assessment is more difficult, must know the
baseline
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CAM-ICU FAQs
• Neuro patients e.g. stroke, TBI, disease, SDH, SAH
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–
This may represent the patient’s new baseline
Look for fluctuation
Are there structural neurologic changes?
Are there reversible causes of delirium?
• Use last know baseline and adjust as more info is obtained
• Alterations and fluctuations include those caused
by us from sedatives etc.
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CAM-ICU FAQs
• ETOH withdrawal
– Can be CAM-ICU ⊕
– Also do CIWA-Ar
• Tetraplegia or Blind
– Score Feature 4 on just the questions
– Cannot make more than 1 error
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Delirium Management
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SCCM recommended approach to
management of delirium
1. Identify etiology
2. Identify risk factors
3. Consider pharmacologic treatment
So: STOP & THINK before you medicate
Jacobi J, et al. Crit Care Med 2002;30:119-141
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Risk Factors for Developing Delirium
• Age
• Sensory impairment
• History of dementia,
ETOH, smoking,
depression
• Malnutrition
• Disease processes
• Polypharmacy and
psychotropic meds
• Renal/liver
impairment
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•
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Dehydration
Sleep deprivation
Restraints/lines/tubes
Excessive noise
Day/night
disorientation
• Constipation
Any patient with
these problems
should be flagged as
high risk for delirium
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Ambien
Consult pharmacy for patients
with these drugs who are at high
risk for delirium or patients who
have delirium.
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Stop and THINK
Do any meds need to be stopped
or lowered?
• Especially consider sedatives
• Is patient on minimal amount
necessary?
– Daily sedation cessation
– Targeted sedation plan
– Assess target daily
• Do sedatives need to be changed?
• Remember to assess for pain!
Toxic Situations
• CHF, shock, dehydration
• New organ failure (liver/kidney)
Hypoxemia
Infection/sepsis (nosocomial),
Immobilization
Nonpharmacologic interventions
• Hearing aids, glasses, reorient,
sleep protocols, music, noise
control, ambulation
K+ or electrolyte problems
Consider antipsychotics after evaluating etiology & risk factors
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Elder Life Program
Targeted Risk Factor
Standardized Intervention
Cognitive impairment
Orientation & therapeutic activity protocol
(discuss current events, word games, reorient, etc)
Sleep deprivation
Sleep enhancement & nonpharm sleep protocol
(noise reduction, back massages, schedule adjustment)
Visual impairment
Early mobilization protocol
(active ROM, reduce restraint use, ambulation, remove
catheters)
Vision protocol
(glasses, adaptive equipment, reinforce use)
Hearing impairment
Hearing protocol
(amplification devices, hearing aids, earwax disimpaction)
Dehydration
Dehydration protocol
(early recognition of dehydration & volume repletion)
Immobility
Inouye, et al. NEJM. 1999;340:669-676.
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Nonpharmacologic interventions
• Early Mobility*—the only nonpharmacologic
intervention shown to reduce ICU delirium
• Other Interventions:
– Environmental changes (e.g., noise reduction)
– Sensory aids (e.g., glasses)
– Reorientation and cognitive stimulation
– Sleep preservation and enhancement
*Schweickert WD, et al. Lancet. 2009;373:1874-1882.
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Nonpharmacologic interventions
Pain:
• Monitor and manage pain using an objective scale
(e.g., FACES, BPS, VAS, CPOT, etc.)
Orientation:
• Convey the day, date, place, and reason for
hospitalization
• Update the whiteboards with caregiver names
• Request placement of a clock and calendar in room
• Discuss current events
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Nonpharmacologic interventions
Sensory:
• Determine need for hearing aids and/or eye glasses
• If needed, request surrogate provide these for patient when
appropriate
Sleep:
• Noise reduction strategies (e.g. minimize noise outside the room, offer
white noise or earplugs)
• Normal day-night variation in illumination
• Use “time out” strategy to minimize interruptions in sleep
• Maintain ventilator synchrony
• Promote comfort and relaxation (e.g., back care, oral care, washing
face/hands, daytime bath, and massage)
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All ICU CAM-ICU Documentation
100%
90%
80%
67%
70%
60%
50%
56%
47%
40%
29%
30%
26%
22%
18%
20%
11%
10%
0%
CAM SN
CAM SN
CAM-ICU
Correct
CAM-ICU
Correct
CAM-ICU
Incorrect
CAM-ICU
Incorrect
CAM-ICU Not
Done
CAM-ICU Not
Done
Oct-13
Dec-13
Oct-13
Dec-13
Oct-13
Dec-13
Oct-13
Dec-13
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Oct-13 RASS
RASS vs Ramsay Use
Dec-13 RASS
Oct-13 Ramsay
Dec-13 Ramsay
100%
100% 100%
100%
100% 100%
100%
100%
100%
94%
89%
90%
80%
80%
76%
73%
70%
60%
60%
55%
48%
50%
40%
60%
35%
32%
30%
25%
18%
20%
14%
11%
10%
0%
0%
0%
0%
0%
0%
All ICU
2 South
3 North
4West
4 North
3 Truett
4 Truett
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Documentation Issues
• In many cases, the nurse had documented on both CAM and
CAM-ICU. This is problematic for several studies that
depend on data collection through chart review. It is also
unnecessary documentation.
• In the majority of cases, the CAM-ICU was incorrect
because the RASS or Ramsay was in the correct range, but
the nurse documented CAM-ICU not indicated.
• In many cases, the CAM-ICU was considered incorrect
because at some point during the shift the patient progressed
to a RASS or Ramsay in the correct range, but the nurse
never attempted a CAM-ICU during these times.
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Improvement Strategies
• People/Process
– Super trainers demo correct use of the CAM-ICU
• Provide scenarios
• Allow nurses to demo to each other and rate each others
performance
– Competency tool for all staff
– Pizza party!
• Technology
– Demonstrate correct documentation
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EARLY MOBILITY
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“Look at the patient lying long in bed.
What a pathetic picture he makes.
The blood clotting in his veins,
The lime draining from his bones,
The scybala stacking up in his colon,
The flesh rotting from his seat,
The urine leaking from his distended bladder,
And the spirit evaporating from his soul.”
Dr. Richard Asher, British Medical Journal, 1947
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"Teach us to live that we may dread
Unnecessary time in bed.
Get people up and we may save
Our patients from an early grave”
Dr. Richard Asher, British Medical Journal, 1947
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http://www.youtube.com/watch?v=0jycOFVE
624
Gary’s story
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Mobility safety screen first
• Responds to verbal stimuli
– RASS> (-4) or Ramsay <5
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•
•
•
•
FiO2 <0.6
PEEP <7.5 cmH2O
No increased dose of vasopressor
No evidence of AMI in past 24 hours
No arrhythmia requiring new anti-arrhythmic
in past 24 hours
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Mobility safety screen
Pass
Exercise/Mobility
Therapy
Active ROM
Dangle
Chair
Ambulate
Fail
Too Ill for
Exercise/Mobility
Passive ROM
Nursing: Consult PT to evaluate and treat if patient unable to perform any of the above
activities. Consult OT if patient is unable to perform ADLs once able to dangle safely.
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Improvement Strategies
• People
– Who gets patients up?
– Do your nurses know how to do this? Do they want to do
this?
– What are your MDs ordering?
• Processes
– When does PT get involved?
– What about other therapies?
• Technology
– Do you have gait belts? Chairs? Lift equipment?
– Is this being documented?
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