Transcript Reasons for a sedation vacation

Daily Awakenings
Leanne Current, PharmD, BCPS
January 2014
Reasons for a sedation vacation
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Goal of sedation vacations
• Shorter length of time on the vent
• Less ICU delirium
– Delirium associated with prolonged sedation
– Delirium associated with benzodiazepines
• Prevent PTSD after hospital discharge
• Shorter ICU length of stay
• Less morbidity
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Why do we need to have a sedation
vacation?
• Tissue accumulation
• Change in patient needs
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More tolerable ventilator settings
Better oxygenation (hypoxia=agitation)
No longer in pain
Trached and more comfortable
Delirium better managed
Change in Renal or liver function
Delayed response to doses and over titration
Half life of medication causes overshooting of goals
Reminder that drips are titratable down just as they are titratable up
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Goal sedation
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Days
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Appropriateness for a sedation vacation
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Reasons to Avoid Sedation Vacation
• Stopping agent will cause more harm than good
• Patient’s ventilator settings do not allow
extubation in the near future
• Other medical reasons trump need to minimize
sedation
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Flowsheet Outline
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FiO2 >60
PEEP > 7.5cm
ICP >10
HR >140
MI within 24 hours
Surgery scheduled
ECMO
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Open abdomen
Neurosurgical patient
Active Agitation issues
On NMBA
Active EtOH withdrawal
Active End of life
Physician requested
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What if the patient doesn’t seem appropriate
and the MD wants a vacation anyway?
• An MD order trumps all items listed in the flow sheet
• If an MD requests a sedation vacation and the patient doesn’t
meet criteria, please stop the line and clarify with the MD
– “The patient’s current FiO2 is higher than the protocol
allows for a sedation vacation, do you still want to do a
sedation vacation?”
– “The patient’s heart rate is 150bmp. Criteria for a sedation
vacation indicates a heart rate less than 140bpm. How
should I proceed?”
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Drug Properties for pain and
sedation
Treatment of pain
Opiate
IV
PO
IV Onset
(min)
Half-life
(hours)
Fentanyl
0.1
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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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Richmond Agitation and Sedation
Scale (RASS)
Score
Agitation
Description
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Combative
Violent, dangerous to staff
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Very agitated
Removes tubes/catheters, aggressive
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Agitated
Frequent non-purposeful movement, fights
ventilator
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Restles
Anxious, not aggressive
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Alert and calm
-1
Drowsy
Not fully alert, but has sustained awakening
-2
Light sedation
Briefly awakens to voice
-3
Moderate
sedation
Movement to voice
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Deep sedation
No response to voice, but response to physical
stimuli
-5
Unarousable
No response to voice or physical stimuli
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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
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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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Awakening time
• Would you expect the patient to wake up fairly quickly
based on its drug properties? And what confounding
factors may slow clearance causing delayed awakening?
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Propofol
Ativan
Versed
Fentanyl
Dilaudid
Morphine
Dexmedetomidine
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Expectations of Daily
awakenings
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What does a sedation vacation mean?
• To stop intravenous pain and sedative agents
that are currently causing the patient to not
be as alert as baseline
– Propofol, Ativan, Versed
– Fentanyl, Dilaudid
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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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Utilizing boluses to prevent over
sedation
Goal Sedation
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Days
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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?
• 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
• 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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Difficult patient scenarios
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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Patient specific scenarios
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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Questions??
• Can you come up with difficult patient
scenarios we can address in this session?
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