CHANG GUNG HOSPITAL

Yu-Ting Ho

2016/03/29

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IntroductionIntroduction

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Patient in ICUPatient in ICU

One of the fundamental tenets of providing care to the critically ill and injured is to relieve suffering and assuage anxiety.

ICU survivors may sustain a type of posttraumatic stress syndrome for many months or years.

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Patient in ICUPatient in ICU

Fear arises from an innate sense of life-threatening illness from strange surroundings found in the ICU environment

Agitation is simply the motor restlessness that accompanies anxiety.

A primary goal of the care provider so as to allay patient apprehension.

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Patient in ICUPatient in ICU

Pain and discomfort amplify the experience of fear.

Pain is commonplace in every critically ill patient, not just those with wounds and surgical incisions, since a patient may be forced to lay in bed for days and weeks at a time, encumbered by all manner of indwelling catheters and hardware.

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Patient in ICUPatient in ICU

Finally, patients confined to an ICU bed for days or weeks can be expected to become sleep deprived.

† stimulation with light

† touch

† noise

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Patient in ICUPatient in ICU

As a result of this bedlam, patients become progressively sleep deprived, which further augments the state of agitation, and quite often leads to paranoia or delirium.

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• 80% of ICU patients have delirium

*may or may not be accompanied by agitation

Patient in ICUPatient in ICU

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Patient in ICUPatient in ICU

ő Goals of sedation in the ICU

◊ Patient comfort◊ Control of pain◊ Anxiolysis and

amnesia◊ Adverse autonomic

and hemodynamic responses

◊ Facilitate nursing management

◊ Facilitate mechanical ventilation

◊ Avoid self extubation

◊ Reduce oxygen consumption

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The use of optimal sedation, particularly in conjunction with analgesia, can reduce the risk of complications associated with the metabolic response to injury and can allow patients to better tolerate ICU care that is noxious, such as tracheal suctioning, invasive procedures, and dressing changes.

Patient in ICUPatient in ICU

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Patient in ICUPatient in ICU

ő The Need for Sedation

◊ Anxiety

◊ Pain

◊ Acute confusional status

◊ Mechanical ventilation

◊ Treatment or diagnostic procedures

◊ Psychological response to stress

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• The first obligation of the caregiver, before giving sedation, is to insure that underlying illness isn't manifesting as agitation or delirium

Causes of Agitation not to be Overlooked

� Hypoxia

� Hypercarbia

� Hypoglycemia

� Endotracheal tube malposition

Patient in ICUPatient in ICU

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Sedation therapySedation therapy

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GuidelinesGuidelines------SCCMSCCM--20132013

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Sedation therapySedation therapy

őő NonNon--ppharmacologic therapyharmacologic therapy:

• Good communication with regular reassurance from nursing staff

• Environmental control such as humidity, lighting, temperature, and noise

• Explanation prior to procedures

• Management of thirst, hunger, constipation, and full bladder

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ÖÖ Pharmacologic therapyPharmacologic therapyThe sedative agent should possess the following qualities

• Both sedative and analgesic properties

• Minimal cardiovascular side effects

• Controllable respiratory side effects

• Rapid onset/offset of action

• No accumulation in renal/hepatic dysfunction

• No interactions with other ICU drugs

Sedation therapySedation therapy

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Use of Sedative Medications in ICUUse of Sedative Medications in ICU

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Commonly Used Sedatives In ICUCommonly Used Sedatives In ICU

€ Benzodiazepines

€ Intravenous anesthetic agents

€ Opioids

€ Other sedatives (eg: Haloperidol)

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BenzodiazepineBenzodiazepine

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BenzodiazepineBenzodiazepine

Functions: sedation and hypnosis.

• MOA: modulating the effects of GABA, the main inhibitory neurotransmitter within the central nervous system.

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Onset Peaks Duration

Midazolam 2 – 3 min 5 – 10 min 30 – 120 min

Diazepam 2 – 5 min 5- 30 min > 20 hrs

Lorazepam 5 – 20 min 30 min 10 – 20 hrs

� MIDAZOLAM STANDARD DOSESIV bolus injection: 1-2.5 mg every two min, max 5 mg.Continuous iv infusion: 1- 10 mg/hrSE : Respiratory depression, hypotension, nausea, vomiting.

BenzodiazepineBenzodiazepine

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BenzodiazepineBenzodiazepine

Patient-related factors can affect the BZD response

– age

– concurrent pathology

– prior alcohol use

– concurrent therapy with other sedative drugs

Higher volume of distribution and slower clearance in elderly.

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PropofolPropofol

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PropofolPropofol

Intravenous anesthtic agents

Functions: Sedation and anesthetics effect

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IV bolus: 1.5-2.5 mg/kg (less in the elderly) at a rate of 20-40 mg every 10 seconds

Continuous iv infusion: 0.3- 4mg/ kg/ hr

Onset Peaks Duration

Propofol 30 – 60 sec 2 – 5 min 10 min

PropofolPropofol

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PropofolPropofol

Adverse Effects:

Propofol Infusion Syndrome

◊ Severe metabolic acidosis

◊ Rhabdomyolysis

◊ Hyperkalaemia

◊ Hypertriglyceridaemia

◊ Renal failure, hepatomegaly and cardiovascular collapse (usually occurs at doses of > 5mg/kg/hr)

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Monitor blood-lipid concentration if at risk of fat overload or if sedation used for longer than 3 days.

If lipid levels high – change to alternative sedation and consider starting lipid lowering agents.

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OPIOIDSOPIOIDS

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OPIOIDSOPIOIDSFunctions: analgesia, narcosis, and anxiolysis

Opioids act at two sites:

• activating pre-synaptic opioid receptors. This leads to reduced intracellular cAMP concentration, decreased calcium ion influx and thus inhibits the release of excitatory neurotransmitters.

• At the post-synaptic level, opioid-receptor binding evokes a hyperpolarisation of the neuronal membrane which decreases probabilty of the generation of an action potential.

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MORPHINE STANDARD DOSE

Intravenous bolus injection :2.5-5 mg every 15 minutes

Continuous Intravenous Infusion: 1-12 mg/ hr

FENTANYL STANDARD DOSE

Sedation: 0.5-1 mcg/kg IV/IM q30-60min PRN

Side-effects: respiratory depression, bradycardia, and hypotension , nausea and vomiting, constipation, CNS depression.

Onset Peaks Duration

Morphine 2 min 20 min 2 – 7 hrs

Fentanyl 30 sec 5 – 15 min 30 – 60 min

OPIOIDSOPIOIDS

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Other SedativesOther Sedatives

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HaloperidolHaloperidol

Indications: Acute agitation and psychosis

MAO:Haloperidol blocks dopaminergic D1 and D2

receptors in the brain.

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Dosing: 2.5 - 5 mg IM

Contraindications:

• Allergy/hypersensitivity to dopaminergic receptor antagonists

• Parkinson’s Disease

• Coma/CNS depression

• Prolonged QT

Onset Duration

Haloperidol 5-10 minutes IM up to 20 hours

HaloperidolHaloperidol

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Neuromuscular blocking agentsNeuromuscular blocking agents

A. Nondepolarizing blockers

1. Long acting: pancuronium, doxacurium,

pipecuronium

2. Intermediate acting: atracurium,

vecuronium, cisatracuriumcisatracurium

3. Short acting: mivacurium

B. Depolarizing blockers: succinylcholine

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Indications & Uses

Adjunct to general anesthesia-induce muscle relaxation

for endotracheal intubation, mechanical ventilation

† Onset: 2.4-2.6 min (mean for 0.15-0.2 mg/kg adult dose)

† Duration: 55-65 min

Adverse Effects

Bronchospasm,Bradycardia,Flushing,Hypotension,Rash

cisatracuriumcisatracurium

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cisatracuriumcisatracurium

Neuromuscular BlockadeNeuromuscular Blockade

Initial doses: 0.15-0.2 mg/kg IV

Maintenance Dose:

�0.03 mg/kg IV

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IV Infusion (During Extended Surgery or In ICU)IV Infusion (During Extended Surgery or In ICU)

�3 mcg/kg/min post-bolus to prevent rapid spontaneous recovery of neuromuscular blockade, THEN

�1-2 mcg/kg/min for maintenance

�Reduce infusion rate by 30%-40% when given during stable isoflurane or enflurane anesthesia

cisatracuriumcisatracurium

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KetamineKetamine

◊ Ketamine : NMDA Receptor antagonist

Initial dose: IM 6.5-13 mg/kg

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BarbituratesBarbiturates

◊ Barbiturates: Thiopental

Dose:2-4mg/kg/h

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A sedation holidayA sedation holiday

A sedation holiday involves stopping the sedative infusions and allowing the patient to wake. this strategy has been shown to decrease the duration of mechanical ventilation and the length of stay in ICU

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Sedation scalesSedation scales

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What Sedation scales doWhat Sedation scales do

Standardize treatment endpoints

Allow review of efficacy of sedation

Facilitate sedation studies

Help to avoid over sedation

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Ramsay Sedation Scale

Ramsay Sedation ScaleRamsay Sedation Scale

11 Patient is anxious and agitated or restless, or bothPatient is anxious and agitated or restless, or both

22 Patient is coPatient is co--operative, oriented, and tranquiloperative, oriented, and tranquil

33 Patient responds to commands onlyPatient responds to commands only

44 Patient exhibits brisk response to light glabellar tap Patient exhibits brisk response to light glabellar tap

or loud auditory stimulusor loud auditory stimulus

55 Patient exhibits a sluggish response to light glabellar Patient exhibits a sluggish response to light glabellar

tap or loud auditory stimulustap or loud auditory stimulus

66 Patient exhibits no responsePatient exhibits no response

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Richmond AgitationRichmond Agitation--Sedation ScaleSedation Scale

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SummarySummary

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ReferenceReference

• SCCM (Society of Critical Care Medicine )

• Medscape

• http://www.drugs.com/

• ICU GUILDE BOOK

• Stanley A. Nasraway Jr., MD., FCCM, Department of Surgery, Tufts-New England Medical Center, Tufts University School of Medicine, Boston, Massachusetts Semin Respir Crit Care Med. 2001;22(2)

• Sedation in the intensive care unit Katherine Rowe MBChB MRCP FRCA Simon Fletcher MBBS FRCA FRCPE

• Clinical Practice Guidelines for the Management of Pain, Agitation, and Delirium in Adult Patients in the Intensive Care Unit

• Drugs Instruction sheet

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