Sedation, analgesia & paralysis in ICU

Pain is a more terrible lord of mankind than death itself - Albert Schweitzer

What is the need?

• Patient’s comfort• Alley pain & anxiety• Patient- ventilator synchrony• Allow oxygenation

• Atleast 50% patients discharged from ICU remember pain as worst experience

Can Anaesth Soc J 1979;26:173-80

Analgesia- sedation- delirium protocol improves outcome in ICU

And it’s cost saving too!

P-A-D approach

Outcome

Delirium treatment

& prevention

Treatment of agitation Pain management

P-A-D guidelines 2013

• Routine assessment of pain in all adult ICU patients by self reporting NRS (0-10)

• Behavioral Pain Scale (BPS) and the Critical-Care Pain Observation Tool (CPOT) are the most valid and reliable behavioral pain assessment tools

• Vital signs (or observational pain scales that include vital signs) be used alone for pain assessment in adult ICU patients, but as a cue to further assess pain.

Behavioral pain scale

Crit Care Med 2001; 29:2258-63

Critical care Pain Observation Tool (CPOT)

Am J Crit Care 2006; 15:420-7

Regular pain assessment improves outcome

P-A-D guidelines 2013

• IV opioids as first-line drug to treat nonneuropathic pain.

• All IV opioids, when titrated to similar pain intensity endpoints, are equally effective.

• Enteral gabapentin or carbamazepine in addition to IV opioid for neuropathic pain are RECOMMENDED

• Non-opioid analgesics may reduce dose or need for IV opioids

P-A-D guidelines 2013

• Sedation using non-benzodiazepine sedatives (propofol or dexmedetomidine) over benzodiazepines (midazolam/lorazepam) to improve clinical outcomes in mechanically ventilated ICU patients

Compared with traditional sedatives, long-term sedation using dexmedetomidine in critically ill adults reduced the duration of mechanical ventilation and ICU length of stay.

Dexmedetomidine might be associated with lower ICU stay when compared with traditional sedative agents. The included studies showed that dexmedetomidine was associated with a shorter period of mechanical ventilation than the compared groups.

Dexmedetomidine was associated with decrease in the risk of delirium.

Bradycardia was reported in higher rates in dexmedetomidine groups than comparators

Monitoring sedation• The RASS and SAS are the most valid and

reliable sedation assessment tools for measuring quality and depth of sedation in adult ICU patients

• PAD guidelines do not recommend objective measures of brain function (AEP, BIS, Narcotrend, PSI, or state entropy) be used as the primary method to monitor depth of sedation in non-comatose, non-paralyzed critically ill adult patients.

Sedation-Agitation Scale: SAS

Richmond Agitation-Sedation Scale: RAAS

“RASS demonstrated excellent interrater reliability and criterion, construct, and face validity. This is the first sedation scale to be validated for its ability to detect changes in sedation status over consecutive days of ICU care, against constructs of level of consciousness and delirium, and correlated with the administered dose of sedative and analgesic medications”

• Analgesia-first sedation be used in adult ICU patients who are mechanically ventilated

• Light levels of sedation is associated with improved clinical outcomes

Protocol vs non-protocol sedation• protocol-directed sedation can reduce the

duration of mechanical ventilation, ICU stay and hospital lengths of stay, and the need for tracheostomy among critically ill patients with acute respiratory failure.

DSI: No increase in ICU recall

A recent Cochrane review

There is currently insufficient evidence to evaluate the effectiveness of protocol-directed sedation. Results from the two RCTs were conflicting, resulting in the quality of the body of evidence as a whole being assessed as low. Further studies, taking into account contextual and clinician characteristics in different ICU environments, are necessary to inform future practice. Methodological strategies to reduce the risk of bias need to be considered in future studies.

Daily sedation interruption?

We have not found strong evidence that DSI alters the duration of mechanical ventilation, mortality, length of ICU or hospital stay, adverse event rates, drug consumption, or quality of life for critically ill adults receiving mechanical ventilation compared to sedation strategies that do not include DSI.

PAD guidelines 2013: Delirium

• Delirium is associated with: increased mortality in adult ICUprolonged ICU and hospital lengths of stay indevelopment of post-ICU cognitive

impairment in adult ICU patients

• Routine monitoring for delirium with the CAM-ICU or the Intensive Care Delirium Screening Checklist (ICDSC) - the most valid and reliable delirium monitoring tools in adult ICU patients is recommended.

ICU Delirium Screening Checklist

CAM-ICU

Delirium prevention

• PAD guidelines provide no recommendation for:

the use of dexmedetomidine to prevent delirium.

pharmacological or non-pharmacological delirium prevention.

• PAD guidelines do not suggest that haloperidol or atypical antipsychotics be administered to prevent delirium in ICU patients.

• Recommend that early mobilization be performed to reduce the incidence and duration of delirium

Haloperidol decreases delirium after non-cardiac surgery

Quitapine?• Quetiapine added to as-needed haloperidol results in faster

delirium resolution, less agitation, and a greater rate of transfer to home or rehabilitation.

Dexmedetomidine vs Haloperidol

Dexmedetomidine significantly shortened median time to extubation (P = 0.016) and decreased ICU length of stay (P = 0.004)

Dexmedetomidine vs Midazolam

At comparable sedation levels, dexmedetomidine-treated patients spent less time on the ventilator, experienced less delirium, and developed less tachycardia and hypertension. The most notable adverse effect of dexmedetomidine was bradycardia.

Rivastigmine? No

Opioid used in ICU

Paralysis in ICU: When to do?

• Facilitate mechanical ventilation if patients can’t tolerate even with appropriate sedation

• non-conventional ventilatory strategies such as permissive hypercapnia, prone positioning, use of high levels of PEEP, and high frequency oscillatory ventilation.

NMBA: Improved survival in ARDS

Properties of NMBA

Which NMBA?

• At present, there are limited data to support the use of one NMBA over another in critically ill patients.- Crit Care Med 2004;32(11 Suppl):S554-S561

• Pancuronium/ vecuronium- prolonged in hepatic/ renal dysfunction

• Atracurium- histamine release & seizure due to laudonosine after prolonged infusion

• Steroidal NMBA- concern of myopathy when used along with corticosteroids-

• Cautious use is recommended in asthmatics

Paralysis: What to monitor

• Depth of paralysis: TOF-• Usefulness is controversial