Sedation and Analgesia in the Intubated Patient (Adult Critical Care) (1)

8/10/2019 Sedation and Analgesia in the Intubated Patient (Adult Critical Care) (1)

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1Dr Richard Sherman and Dr Thea de Beer 10/ 2011 Review 10/2014

ADULT CRITICAL CARE GUIDELINES FOR SEDATIONAND ANALGESIA IN THE INTUBATED PATIENT

Contact name and jobtitle.

Dr T de Beer and Dr R ShermanConsultants in Intensive Care Medicine and

Anaesthesia.Critical Care, Queens Medical Centre.Mid Trent Critical Care Network.

Directorate andSpeciality

Adult Critical Care Department, NottinghamUniversity Hospitals NHS Trust.

Date of submission November 2011

Date of review November 2013

Application Adult intubated patients receiving sedation andanalgesia within adult critical care units atNottingham University Hospitals NHS Trust

Abstract This guideline describes the optimal choice ofsedative and analgesic in the intubated patient.

Key words Sedation, Analgesia, intubated patient.

Evidence base 1b plus updating of current guidelines. Based on

Intensive Care Society sedation guidelineConsultation process Critical Care Cross Town Protocol and Guideline

Group, Critical Care Directorate.

Ratification Dr D Selwyn, Head of Service Critical CareB Lawrence, Matron Critical CareCritical Care Cross Town Group

Target audience Critical care nursing and medical staff

Training Plans In local areas as required

Audit Plans Will be audited following implementation

This guideline has been registered with the trust. However, clinicalguidelines are guidelines only. The interpretation and application ofclinical guidelines will remain the responsibility of the individualclinician. If in doubt contact a senior colleague or expert. Caution isadvised when using guidelines after the review date


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ADULT CRITICAL CARE GUIDELINES FOR SEDATION AND ANALGESIA IN THEINTUBATED PATIENT

Critical Care Directorate

Nottingham University Hospitals NHS Trust

Introduction

The aims of sedation and analgesia are to facilitate patient acceptance of intubation andventilation, to provide relief from anxiety and pain and to decrease oxygen requirements

(Werret, 2003; Murdoch, Cohen, 2000)

The correct management of sedation is one of the most important aspects of Intensive Caremanagement. Unfortunately it is also one of the most difficult, mainly because patients

cannot communicate easily how they feel and what they need to feel better. Some degree ofsedation (i.e. analgesia hypnosis) is often required to allow patient co-operation with organsystem support and the associated nursing care. An agitated patient has a higher basal

metabolic rate and may reduce the efficiency of supportive care, most commonly ventilation.

While it is clear that leaving a patient agitated and distressed is detrimental to their care thisis equally true of over sedation. All sedative agents share the following problems;

i. accumulation with prolonged infusion, delaying weaning from supportive care increasingcomplications and consequently morbidity and mortality

ii. detrimental effects on the circulation leading to increased inotrope requirements

iii. detrimental effects on the pulmonary system - vasculature. increasing VQ mismatch

leading to increased ventilatory support with the consequent increase in complications, andsuppression of cough reflex reducing clearance of pulmonary secretions.

iv. tolerance during sedation and withdrawal when it is stopped

v. no sedative provides rapid eye movement (REM) sleep - i.e. useful sleep. REM sleepdeprivation is thought to be one of the most important causes of ICU psychosis

vi. reduced intestinal motility impairing establishment of enteral feeding and constipation

It is therefore vital that sedation is managed as precisely as possible and given the priorityattention that it deserves.

(ICS Guidelines 2007)

Principles of Management

A drug given by intravenous infusion will take approximately four half-lives to achieve steadystate levels. This means that it will take a significant amount of time for adequate sedation tobe achieved by starting an infusion without a loading dose. It also means that changes insedation infusion rate will take some time to be effective.

As a result there is a tendency for infusion rates to be started at a high rate in order to

achieve adequate sedation quickly. Unfortunately, this high initial rate is often continued inthe mistaken belief that it will continue to be needed. This also applies to increases in

infusion rate which tend to be too great.

The correct way to initiate sedation is thus to administer a loading dose which istitrated to effect and then to start an infusion. Increases in sedative infusion rate

should follow the same principle, i.e. a bolus, titrated to effect, should be administeredand the infusion rate increased by a small increment.


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A commonly used analogy to simplify the understanding of these principles is that of theleaking bucket. In order to fill the bucket a bolus of water is required. The size of this bolus

is1independent of the size of the leak. However in order to keep the bucket full an infusionrate which is equal to the size of the leak is required. If the infusion is started with no bolus

then the bucket will never fill.

It is important to remember that combinations of sedatives that act via different mechanisms

are more effective than single agents at high dose. In addition, tolerance to sedativesdevelops more quickly at high doses. Alternative sedative agents may need to be

considered.(ICS Guidelines 2007)

The ideal sedative agent should possess the following qualities:

Both sedative and analgesic Minimal cardiovascular side effects Controllable respiratory side effects

Rapid onset/ offset of action No accumulation in renal/ hepatic dysfunction

Inactive metabolites Cheap/ cost-effective

Minimal interactions with other drugs (Werret, 2003)

Choice of SedativeThe choice of sedation in critically ill patients in critical care is determined by several factorsincluding the patients diagnosis, route and method of ventilation, liver and kidney functionand changes in the patients condition. Propofol and Midazolam are sedative agents that arewidely used within critical care

Propofol

Propofol is a widely used agent for maintenance of sedation in the critically ill. It has a rapid

onset and offset even after prolonged infusion. Propofol has inactive metabolites. It ishowever comparatively expensive.

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).

Other adverse effects include:Myoclonic movements and convulsionsBradycardia

Green urine

Cautions:Not suitable for patients less than seventeen years of ageLipid disordersEgg allergy (egg albumin is a component of Propofol)

Standard Dose:Induction of anaesthesia by intravenous bolus injection:

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

Sedation in critical care by continuous intravenous infusion 0.3- 4mg/ kg/ hourMonitor 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 loweringagents.(British National Formulary, 2010)


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Midazolam

Midazolam is a benzodiazepine sedative used in critical care. When given as bolus doses ithas a short elimination half-life (1-4 hours), rapid onset, and short duration of action. Its

active metabolite, alpha-hydroxy-midazolam can accumulate leading to prolonged sedationin patients following infusion, and especially in patients with a reduced GFR.

Adverse EffectsGastrointestinal disturbances Laryngospasm

Bronchospasm Respiratory depression and apnoeaAtaxia Hallucinations

Involuntary movements DysarthriaVisual disturbances Increased appetite

Jaundice HypotensionCardiac arrest Thrombosis

Anaphylaxis

Cautions

Hepatic impairment PregnancyRenal impairment Breastfeeding

Cardiac disease Respiratory diseaseEnhanced effects in older person HypovolaemiaVasoconstriction

Standard DoseAs an adjunct to induction of anaesthesia by slow intravenous bolus injection

30-300 mcg/kg in steps of 1-2.5 mg every two minutes

Sedation in critical care by continuous intravenous infusion

200 mcg/kg/hour or 1-10 mg/hr

If patient has been exposed to midazolam for more than 7 days do not stop abruptly,

unless there is a good clinical indication. Decrease dose, or start equivalent doses ofalternative benzodiazepine and wean appropriately.

(British National Formulary, 2010)

Other Sedatives used in ICUOther sedative agents are used occasionally in ICU, usually under special circumstances.

Clonidine

Clonidine, a centrally acting alpha receptor agonist, is often used to aid weaning fromprolonged opioid sedation, when withdrawal features such as hypertension and tachycardiamay be problematic.

Ketamine

Ketamine is a phencyclidine derivative. It has potent sedative, analgesic and bronchodilatorproperties. It is occasionally used in patients with acute severe asthma for its sedative and

bronchodilator activity, and for patients with burn injuries undergoing dressings changes forits analgesic properties. If used as the sole sedative agent Ketamine frequently leads tounpleasant dreams/hallucinations. It should therefore only be prescribed in conjunction with abenzodiazepine (Midazolam) infusion.


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Choice of AnalgesiaOpioid analgesics are generally used to provide analgesia for intubated and ventilated

patients as they also provide a degree of sedation. However, some patients in critical caremay not require opioid analgesia examples include some medical patients, and post-

operative patients with other forms of analgesia such as an epidural infusion. Morphine,Fentanyl, Alfentanil and Remifentanil are the most commonly used opioid analgesics withincritical care. As with sedative drugs initial loading of the opioid is needed until patient is

comfortable and then followed by low dose infusion of said opioid.

Morphine

Morphine is a widely used opioid analgesic utilised in critical care. It is metabolised in the

liver to water-soluble renally excreted compounds including morphine-6-glucuronide (M6G)

and morphine-3-glucuronide (M3G). In patients with renal failure accumulation of M6G will

lead to prolonged narcosis. Following bolus dosing the peak effect of morphine is achieved

after 15 minutes and its duration of action is 2-3 hours. Prolonged infusion leads to

accumulation with prolonged narcosis.

Adverse Effects:

As above and:Histamine Release HypotensionTachycardia TolerancePulmonary oedema

Standard Dose:Intravenous bolus injection

2.5-5 mg every 15 minutes

Continuous Intravenous Infusion

1-12 mg/ hr

If patient has been exposed to morphine for more than 7 days do not stop abruptly, unlessthere is a good clinical indication. Decrease dose, or start equivalent doses of alternative

opioids and wean appropriately.(British National Formulary, 2010)

Alfentanil

Alfentanil has a short duration of action and a rapid, predictable recovery even followinginfusion. It is hepatically metabolised to inactive substances and has a small volume of

distribution. It is useful in patients with renal failure, but may accumulate in patients with liverfailure. It is comparatively expensive.

Adverse EffectsRespiratory depression and apnoea Bradycardia

Hypotension Nausea and vomitingConstipation Biliary spasm

Delayed gastric emptying Chest wall rigidity

Standard DoseInduction of anaesthesia by intravenous bolus injection

50 - 100mcg/kg bolus

Maintenance of anaesthesia by continuous intravenous infusion 0.5-10 mg/hr (up to1mcg/kg/min)

(British National Formulary, 2010)


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Daily Sedation Holds GuidelinesCritical Care Directorate


Introduction

Administration of sedatives by continuous infusion may prolong the duration of mechanical

ventilation and the length of stay in critical care (Kress et al, 2000; Kollef et al, 1998).

Performing daily sedation holds on patients receiving a continuous infusion of sedativeagents has been shown to prevent over sedation, reduce the amount of time spent on

mechanical ventilation and reduce time spent in critical care (Kress et al, 2000; Kollef et al,1998).

Indications

Patients who are being mechanically ventilated and who are receiving a continuoussedation infusion.

Contra-indications Patients receiving neuromuscular blocking agents

Traumatic brain injury patients with raised intra cranial pressure

Patients requiring FiO2 ! 60% , or PEEP > 10 cmH20 or, inverse ratio or,prone ventilation

Patients with uncleared spines, until discussion with medical team.

Haemodynamically unstable patients.

Locally acting chemotherapy drugs that require immobilisation of patient

No airway trained personnel immediately available on the unit.

Patients receiving compassionate care

Procedure for Sedation Holds

The need for daily sedation hold should be assessed by Critical Care Consultant on themorning ward round and documented on the daily review sheet

If recommended by the Critical Care Consultant, the bedside nurse should perform thedaily sedation hold at a convenient time in the morning, as described below:

1. Sedation infusion should be discontinued

2. When the patient can follow commands or becomes agitated (sedation score +2 orabove) bolus should be given and the sedation infusion should be recommenced at

half the original infusion rate. (See Appendix 2)

3. Sedation infusion should then be adjusted until optimal level of sedation is achieved

using the guidelines in appendix 2


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Appendix 1

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Patients receiving neuromuscular blocking agents

Traumatic brain injury patients with raised intra cranial pressure

Patients requiring FiO2 ! 60% , or PEEP > 10 cmH20 or, inverse ratio or, proneventilation

Patients with uncleared spines, until discussion with medical team.

Haemodynamically unstable patients.

Locally acting chemotherapy drugs that require immobilisation of patient

No airway trained personnel immediately available

Patients receiving compassionate care

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Appendix 2: Richmond Agitation Sedation ScaleCritical Care Directorate

Nottingham University Hospitals NHS TrustIntroduction

The patients sedation score should be assessed hourly and evaluations documented on thepatients observation chart.If patient is receiving neuromuscular blocking agents please insert P

If patient is sleeping please insert S

Richmond Agitation Sedation Scale (RASS) * and Management

Score Term Description Action

+4 Combative Overtly combative, violent, immediate

danger to staff.

+3 Very agitated Pulls or removes tube(s) or catheter(s);

Aggressive.

+2 Agitated Frequent non-purposeful movement,fights ventilator.

+1 Restless Anxious but movements not aggressivevigorous.

0 Alert and calm

-1 Drowsy Not fully alert, but has

sustained awakening(eye-opening/eye contact)

to voice (>10 seconds)

-2 Light sedation Briefly awakens with eyecontact to voice (


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Appendix 3: Pain Assessment ScaleCritical Care Directorate


IntroductionPain assessment score should be assessed hourly

This is for ventilated patients only.

Pain Score Patient Characteristics Action0 Pain free If pain free for six hours consider

reducing analgesia infusion by

1ml/hr

1 Mild pain Deliver 1ml bolus of analgesia

every 2 minutes until pain free

2 Moderate pain Deliver 2ml bolus of analgesiaevery 2 minutes until pain free

Increase analgesia infusion by1ml/hr

3 Severe pain Deliver 3ml bolus of analgesiaevery 2 minutes until pain free

Increase analgesia infusion by

1ml/hr

Reassess patient prior and following each bolus dose or infusion rate change.


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Appendix 4 - EQUALITY IMPACT ASSESSMENT

1. Name of Policy or Service

Adult critical care guideline for sedation and analgesia in intubated patients.

2. Name of Responsible Manager

Dr D Selwyn

3. Name of person completing assessment

Dr T de Beer

4. Date EIA Completed

4 November 2011

5. Description and Aims of Policy/Service (including relevance to equalities)

The purpose of this policy is supply guidance for choice of sedative and analgesic as well as

guidance on discontinuation.

8. Results of Initial Screening or Full Equality Impact Assessment:

Equality Group Assessment of ImpactAge NO RELEVANCEGender NO RELEVANCERace NO RELEVANCESexual Orientation NO RELEVANCEReligion or belief NO RELEVANCEDisability NO RELEVANCEDignity and Human Rights NO RELEVANCEWorking Patterns NO RELEVANCESocial Deprivation NO RELEVANCE

9. Decisions and/or Recommendations (including supporting rationale)

This guideline is a guide to rationalise sedation and analgesia in the intubated critically illpatient. It aims to improve choice of agents to initiate sedation and facilitate analgesia. Basedon guidelines from the ICS and BNF.

10. Equality Action Plan (if required)

N/A

11. Monitoring and Review Arrangements (including date of next full review)

It is recommended that this policy and EIA be reviewed annually in order to assess itsfunctionality.


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Equality Area

(Protected

Characteristics)

Is this policy or

service RELEVANT

to this equalityarea?

YES / NO

Assessment of Potential

Impact:HIGH

MEDIUMLOW

NOT KNOWNpositive (+) negative (-)

Age NO LOW LOWDisability NO LOW LOWGenderReassignment

NO LOW LOW

Race NO LOW LOWReligion or Belief NO LOW LOW

Sex NO LOW LOWSexual Orientation NO LOW LOWMarriage & CivilPartnership

NO LOW LOW

Pregnancy &Maternity

NO LOW LOW

Social Deprivation NO LOW LOWDignity and HumanRights

NO LOW LOW

Working Patterns NO LOW LOW

Sedation and Analgesia in the Intubated Patient (Adult Critical Care) (1)

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