Transcript Sedation and Delirium Management

Sedation and Delirium
Management
Medical Surgical Nursing II
Urden Chapter 9
Goals of Sedation and Delirium
Management

“The goal is to find a balance between
providing compassionate patient care and
avoiding the perils of over-sedation”
(Urden, 2012, p. 95).
Sedation Scales
Scoring systems to assess sedation are
strongly recommended.
 Why

◦ Individuals do not metabolize sedative
medications at the same rate.
◦ Use of a standardized scale can ensure that
continuous infusions such as proprofol or
lorazepam are titrated to a specific goal.
◦ Use of scales can be used for medications
given prn to assess response and patient
comfort.
Complications of sedation
“State of unintended patient
unresponsiveness in which the patient
resides in a state of suspended animation
similar to general anesthesia”
 Prolonged deep sedation is associated
with complications of
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◦ Pressure ulcers
◦ Thromboemboli
◦ Gastric ileus
Nosocomial pneumonia
Delayed weaning from
mechanical ventilation
Levels of Sedation
Light sedation –
 Drug induced state in which patients
respond ________ to
___________commands.
 Impaired function includes:
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Unaffected functions:
Moderate Sedation
Also used as another name for:
 Defined:
 Patients respond to _______commands.
 Or will respond to _______ ________
Commands.
No interventions are required to maintain:
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Deep Sedation and Analgesia
Drug induced depression of
consciousness during which the patients
cannot be _______ _______________.
 Respond purposefully after repeated or
____________stimulation.
 Independent ventilatory function is:
 Assistance is required to maintain:
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General anesthesia
Drug induced loss of consciousness
 Not arousable even w/painful stimulation
 Airway and ventilation are impaired
 Assistance is required, usually intubation
is required with ventilation
 Total loss of protection
 Patient is total care

Perils of Undersedation

Self extubation with complications of :
◦ Bronchospasm, aspiration, dysrhythmias,
bradycardia and death related to the inability
to establish a patent airway.
Pharmacological Management with
sedation

Sedation must always be preceded or
accompanied by analgesia if there is a
mechanism of pain or suspicion of pain
being experienced.
Benzodiazepines
Powerful amnesic properties
 Inhibit reception of new sensory
information
 Do not give pain relief
 Most frequently used are:
 Which one is used for acute, short term
agitation?

Benzodiazepines
Which drug is used for long term
sedation?
 Why is it preferred over the other?
 What are the major side effects of these
medications?
 The antidote is:
 What must be considered before an
antidote is given?
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Sedative-Hypnotics
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Propofol –
sedative/hypnotic and
general anesthetic agent.
In the critical area and in
the emergency room it
is used as a method to
ensure sedation after
intubation.
Delivered as a
continuous infusion at
the rates of 5 to 80
mcg/kg/min.
Benefit to remember:
Propofol does not
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Provide amnesia
Pain relief
So it must be given
along with other
medications to provide
the patient with these
medication actions.
Other medications to
give with this drug are
fentynl, morphine,
versed ( amnesia).
Side effects to manage with
Propofol
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Hypotension – How would
you manage this problem
Hyperlipidemia in long
term use
Infection related to high fat
content
Pancreatitis
Propofol Related infusion
syndrome PRIS
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Most common in children
Metabolic acidosis
Rhabodmyolysis
Acute kidney failure
Dysrhythymias
Propofol Infusion

Things to remember
◦ Dedicated line
◦ Do not mix with other drugs if possible
otherwise check compatibility
◦ Certain IV fluids cannot be given with
proprofol
◦ Monitor serum triglyceride levels
◦ Calories from propofol are calculated into
daily calorie counts.
Central Alpha Agonists
Dexmedetomidine or Precedex
 Approved for continuous infusion for less
than 24 hours in mechanically ventilated
patients.
 Confers sedation and analgesic effects
without respiratory depression.
 Loading dose is 1.0 mcg/kg over 10
minutes
 Continuous infusion is range 0.2 to 0.7
mcg/kg/hour.
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Central Alpha Agonists
Precedex
 Onset of action:
 Elimination from the
body:
 What condition
decreases Precedex
elimination from the
body?

Things to Remember
Choice of sedative is highly specific to the
patient and the situation
 Short term sedation - < 24 hours most
frequently used sedatives are _______ &
Propofol.
 Both drugs should or may be combined
with a short-acting opiod analgesic which
is ____________ or ______________.
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Things to remember
For long term sedation the recommended
agent is?
 Precedex
 Versed
 Lorazepam
 Morphine
 Fentynl
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Preventing sedative dependence and
withdrawal
Why this occurs? Critically ill patients are
often sedated and mechanically ventilated
are seriously ill for weeks or months.
 With time physical and psychological
dependence occurs.
 What are the symptoms of sedative
dependence and withdrawal?
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Sedation vacation
Strategy to avoid the pitfalls of sedative
dependence and withdrawal is a planned
strategy to turn off the sedation infusion
once a day.
 Shortens time to extubation
 Back up plan is needed for patients who
do not tolerate the procedure.
 The goal is to allow the stable patient to
regain consciousness for clinical
assessment – what would you use?
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Nursing Care Responsibility
Ongoing assessment of the patient’s level
of consciousness to avert complications.
 If the patient is severely agitated, consult
with the physician it is vital to consult
with the physician and pharmacist to
establish and effective treatment plan.
 Often the sedation is restarted at 50% of
the previous morning dose and titrated
upward for patient comfort.
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Delirium
Global impairment of cognitive processes
 Sudden onset
 Coupled with disorientation
 Impaired short-term memory
 Altered sensory perception(manifests as?)
 Inappropriate behavior
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Delirium
Occurs in 60% to 85% among
mechanically ventilated patients.
 Delirium is often identified in the patient
who is agitated and pulling at tubes.
 Delirium can occur in patients who are
physically calm.
 Provision of adequate _________is an
essential component of delirium
prevention.
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Management of Delirium with
Medication
Priority – medication selection of drugs
that provide sedation without withdrawal
associated agitation.
 Which drug is discussed by Urden as a
plausible choice?
 What type of delirium is this medication
used for?
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Monitoring Requirements
Use of this drug requires _____
monitoring due to the prolongation of the
QT interval which increases the risk of
ventricular dysrhythmias.
 Stabilizes cerebral function by blocking
transmission of ______mediated
neurotransmitters at the cerebral
synapses and in the basal ganglia.
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Nonpharmacological interventions
to prevent delirium
These methods are similar to those used
to relieve pain
 Back massage
 Music therapy
 Noise reduction
 Decreasing lights at night
 Clustering nursing care interventions
 Uninterrupted rest
 Speaking in a calm and gentle voice.
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AWS & Delirium Tremens
Patients w/alcohol dependency & critically
ill are at risk for alcohol withdrawal
syndrome and DT’s.
 AWS assoc w/increased risk of delirium,
hallucinations, seizures, need for
mechanical ventilation and death
 Delirium Tremens- when hyperactive
agitated delirium is caused by alcohol
withdrawal
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