Sedation & Paralytic Therapy in the ICU Leanna R. Miller, RN, MN, CCRN-CSC, PCCN-CMC, CEN, CNRN, NP...
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Transcript of Sedation & Paralytic Therapy in the ICU Leanna R. Miller, RN, MN, CCRN-CSC, PCCN-CMC, CEN, CNRN, NP...
Sedation & Paralytic Therapy in the ICU
Leanna R. Miller, RN, MN, CCRN-CSC, PCCN-CMC, CEN, CNRN, NP
Education Specialist
LRM Consulting
Nashville, TN
Objectives
Identify the purpose for pain, sedation, & paralysis management in the ICU patient
Analyze and compare assessment methods for determining appropriate pain, sedation & paralysis management.
Recognize and apply the different pharmacotherapeutics used in the ICU for pain, sedation, & paralysis.
Goals of Critical Care Management
Save the salvageable and relieve suffering Peaceful & dignified death without prolonging life Curative therapy should not supplant palliation of
pain Use of state-of-the-art interventions Aggressive & fast paced therapy according to need Quality pain management mandatory for all
patients
The Balance of Analgesia, Sedation, and Paralytics to promote comfort
Consciousness/SedationConsciousness/Sedation
What is Sedation?
Several Clinical Definitions: process of establishing a state of calm promoting a sense of well-being reduction of anxiety and agitation through the
use of pharmacotherapy
Sedation is NOT analgesia 80% of Doctors and 40% of ICU nurses
answered that benzodiazepines provided analgesia (1990s)
Pathophysiology Response of Stress and Anxiety Cardiovascular
Release of systemic epinephrine and norepinephrine
Elevated HR and BP Increased cardiac O2 demand Decrease end-organ perfusion
Endocrine Release of Cortisol, Glucagon, Glucose
Hyperglycemia
Pathophysiology Response of Stress and Anxiety Neurological
Increased response and activation of peripheral pain fibers
Increased sensation to pain Release of neurotransmitters in the brain
Pain Agitation Delirium
Pathophysiology Response of Stress and Anxiety
Immune Increased levels of prostaglandins,
cortisol, glucose, cytokines, Increase anti-inflammatory response Decrease wound healing
SIGNIFICANT STRESS IN THE ICU PATIENT OVERALL CAUSES ORGAN ISCHEMIA AND DECREASED HEALING
Analgesia
Clinical Definition: The absence of pain through the use of
pharmacotherapy
Acute and chronic pain in the ICU activates the stress response
Patients with analgesia can still experience anxiety
PAIN THERAPY - Myth
“One size fits all or
Set and forget therapy.
Its essentially a maintenance therapy”
Truths
Majority of ICU patents suffer moderate/severe pain 40% are delirious & cannot communicate 50% are either physically/emotionally distressed 10-20% have no hopes of cure --- end-of-life in ICU Balance between pain relief & maintaining alertness Multidisciplinary team for multimodal therapies.
Pain in ICU Repeated episodes of acute pain localized Surgery/tissue inflammation immobility catheter/ apparatus discomfort/ nasogastric
& orogastric tubes endotracheal intubation/ suctioning/ chest
tubes phlebotomy/vascular access/physiotherapy routine turning & positioning the patient
Types of pain in ICU
Somatic – most common –localized opiates Visceral – cramping & colicky anticholinergics Neuropathic – burning / shooting antidepressants Mixed type combination therapy Sustained or chronic pain of varying degrees
Inherent Problems
difficult to differentiate due to lack of communication
untreated pain affects all body systems synergistic effect of pain on anxiety,
depression, sleep all modalities are unpredictable & have
adverse effects pain therapy to be tailored to individual
needs.
Assessment of pain in ICU
Pain as the 5th vital sign- requires frequent evaluation
Cognitive impairment/delirium markers• Behavioral (facial, FACS)• Physiological (BP, HR, RR)
Creative assessments (teaching hand movements, blinking
Subjective quantification (numeric/graphic scales –W-B faces)
Assessment of pain in ICU
Treatment of Pain treatment of perceived & prevention of
anticipated pain Opiates – principal agents in ICU
- potent / lack ceiling effects - mild anxiolytic & sedative - relieves air hunger & suppresses cough in
respiratory failure - improved patient – ventilator synchrony - effective antagonist – naloxone lack amnesic effects /additional sedatives
required
Treatment of Pain
adjuvant / non-pharmacological / multimodal therapies• Simple Relaxation – must begin preoperatively
Jaw relaxation Progressive muscle relaxation Simple imagery Music (either patient – preferred or “easy listening” are
effective in reducing mild to moderate pain• Complex Relaxation – must begin preoperatively
Biofeedback imagery
Causes of Pain in the ICU?
The Messengers of Pain
• Direct tissue damage stimulates pain fibers• Local Inflammatory mediators
• Bradykinin, Prostaglandins, Cytokines• Tissue Injury
• Histamine• Serotonin• TNF
WHY IS THIS IMPORTANT?
Common Analgesic Drugs in the CVICU
A Focus on Morphine
First narcotic to be used Narcotic standard Relies on good kidney function for excretion Stimulates mast cells to release histamine
Itching Rash Hypotension Acute Asthma episode
No longer used frequently due to newer drugs
A Focus on Fentanyl
100x stronger then Morphine Fastest metabolizing narcotic used in the
CVICU Chest Wall Rigidity
can cause shortness of breath and difficulty weaning
occurs most often with high IV bolus doses Decreases BP and HR
A Focus on Remifentanil
Newest synthetic narcotic derived from Fentanyl Eliminated by plasma esterases
Metabolism not dependent on liver or kidney function Elimination not dose dependent
Advantages Organ independent metabolism Lack of accumulation Provides analgesia and sedation in ventilated patient
Disadvantages Expensive Severe withdrawal Rebound hyperalgesia
A Focus on Toradol
Is a potent IV/IM NSAID Decreases sternal incision pain and
inflammation Like many NSAIDs can be nephrotoxic
Know your patients BNP and Creatinine Can cause GI bleeding Usually not given if the patient is…
Age >75 Elevated creatinine Chest tube bleeding Low platelets
Sedation in ICU
used in the agitated, ventilated & for procedure discomfort
to avoid self extubation & removal of catheters
NM blockade mandates analgesia & sedation
control of pain before sedation all have side effects – dose dependent analgesics are not sedatives/ Sedatives
are not analgesics
Common Sedatives in the ICU
A Focus on Precedex
Only sedative used that does not cause respiratory depression
Patients can be weaned and extubated while on Precedex
Usual titration range 0.2 – 0.7mcg/kg/hr MD order >0.7mcg/kg/hr
Titrate by 0.1-0.2mcg/kg/hr q30-45min Can cause SEVERE bradycardia and
hypotension Very expensive!
A Focus on Ketamine
dissociative anesthetic light sedation & amnesia
used as an adjunct for patients with uncontrolled pain or inadequately sedated
rarely used in the CVICU due to myocardial depressant properties
monitor for hallucinations and vivid dreams
Assessment of Pain and Sedation
Sedation scoring systems
Assess levels to vary according to course of ICU stay
Observational scales - 4 levels – min, mod, deep, GA
Addenbrooke sedation scale 0-7 (vocal, tracheal suction)
Ramsay sedation scale 1-6 (vocal, glabellar tap)--aim for 3-4
Direct information- ideal to assess analgesia & sedation
BIS – for deep sedated & paralyzed
RASS ASSESSMENT
+4 Combative, violent, danger to self/staff +3 Very agitated, pulls lines, tubes, aggressive +2 Agitated frequent non-purposeful movement, fights the vent +1 Restless / Anxious but not aggressive or vigorous 0 Alert and calm -1 Drowsy, not fully alert but can stay awake, eyes open to voice for >10sec -2 Light sedation, wake and makes eye contact for < 10 sec -3 Moderate sedation, moves/opens eyes to voice but no eye contact -4 Deep sedation, no response to voice but moves or opens eyes to physical
stimulation -5 Unarousable, no response to stimuli
BIS monitor
BIS Monitoring
BIS Monitor
BIS monitor utilizes EEG waveforms. reading is monitored from the patient’s
forehead. excessive muscle activity can interfere with
EEG detection
Bispectral Index
BIS – an attempt to objectively monitor patients sedation
processed EEG measurement that gives a score to help determine the patient’s response to sedation
useful to help titrate medication proper sensor placement is key to
accurate monitoring
Sensor ApplicationSensor Application
Apply sensor on forehead at angle
Circle #1: Centered, 2 inches above nose
Circle #4: Directly above eyebrow
Circle #3: On temple, between corner of eye and hairline
Press around the edges of each circle to assure adhesion
Press each circle for 5 seconds
BIS Placement
Make sure the forehead is clean and dry!
Label the sensor with date/time Replace sensor every 24 hours and
PRN
BIS Monitor
implement BIS monitoring on all patients with paralytic drips infusing
purpose of BIS monitor is to provide a direct measurement of the SEDATIVE effects on the brain.
goal for BIS Monitoring will be 40 – 60. studies have indicated that this is a safe range
for no memory recall.
BIS Monitoring
Troubleshooting the BIS
If the BIS increases suddenly or is higher than expected: Consider:
Is the sedative dose sufficient? Is there an increase in stimulation? When was the last analgesic given? Is the patient adequately paralyzed? TOF? Is the patient having a seizure
Troubleshooting the BIS
If the BIS decreases suddenly or is lower than expected: Consider:
Has there been a decrease in stimulation or increase in sedation/analgesia?
Is the patient significantly hypothermic? Has there been a sudden significant drop in BP?
BIS Monitoring
Always consider the overall picture of the patient Ex: if nothing significant has changed with
patient and BIS number suddenly reflects very different readings then fall back to your overall assessment of the patient
REMEMBER!
Look at the BIG PICTURE!
Do Not Forget
You are treating a patient not just the number
“Sedation Vacation”
Assess for daily awakening• Exclusions
Increased ICP Neuromuscular blockade Significant ventilation support CABG, immediate post-op
“Sedation Vacation”
Is patient awake and calm?• SAS 3 – 4• RASS 0 to -1
If no, restart sedation @ ½ previous dose
If yes, proceed to spontaneous breathing trial (SBT)
“Sedation Vacation”
Assess for SBT• Calm & co-operative• Hemodynamically stable• PEEP < 8• FiO2 < 0.60
• pH > 7.34• SpO2 > 90%
“Sedation Vacation”
SBT Termination Criteria• RR > 35/min for > 5 minutes• SpO2 < 90% for > 2 minutes
• New ectopy• HR change 20% from baseline• BP change 20% from baseline• Accessory muscle use• Increased anxiety/diaphoresis
“Sedation Vacation”
Conduct SBT for 1 minute• Mode CPAP• PEEP = 0• PS @ least 5 – 10• FiO2 unchanged
Paralytics in the ICU
Paralysis – the loss of voluntary muscular function due to the administration of a paralytic
Neuromuscular Blockade Agent (NMB) – Drugs that obstruct transmission of nerve impulses to the muscle
Neuromuscular Blockade agents DO NOT BLOCK THE TRANSMISSION OF PAIN!!!!
Paralytics in the CVICU
Sedation and Analgesics must always be given FIRST
Must use sedatives with an Amnesic affect Benzodiazepines (VERSED) High dose Propofol
Paralytics are always given LAST
Why Do We Paralyze?
Decreases O2 demand ARDS
Prevent Patient-Ventilator dysynchrony VDR ventilators BiVent
Prevents Shivering in hypothermia patients Shivering increases O2 demand Raises patients temperature
Open chest
Checklist for chemical paralysis
Must be adequately sedated first before paralytic administered
Must have anxiolytic drip that has amnesic properties
Must have analgesic drip infusing Must have lubrication for eyes/eye bubbles
Common CVICU Paralytics
Drug Dose Onset Peak Duration
Vecuronium .08 - .1 mg/kg 1 min 3-5 min 15-25 min
Pancuronium .04 -.1 mg/kg 30-45 sec 3-4 min 35-65 min
Succinylcholine .6 mg/kg 30-60 sec 1-2 min 4-10min
Nimbex 3 mcg/kg/min 1-2 min 2-5 min 25-44 min
A Focus on Vecuronium
A non-depolarizing NMB Will NOT increase K+ Full recovery from paralytic 25-40min Frequently used in the CVICU for intubation
or as a bolus drug before Nimbex Rarely used as a drip in the absence of
Nimbex 0.8-1.2mck/kg/min
A Focus on Succinylcholine
A depolarizing NMB Can increase K+ ~ 0.5-1mEq/L
KNOW YOUR PATIENTS K+ before administering
Does your patient have any renal disease? Metabolized by plasma cholinesterase
Very rapid metabolism ~5min Does not rely on kidney or liver function
A Focus on Nimbex
Is our primary titrating NMB used in the CVICU
Is also metabolized in the blood Standard dose is 3mcg/kg/min
Titrate range: 0.5-5mcg/kg/min Metabolism ~45min
Changes with hypothermia?
Successful Paralysis: How do we know? Assessment
Movement Spontaneous Breaths Peripheral Nerve Stimulator
Peripheral Nerve Stimulators
Peripheral Nerve Stimulator – A device that delivers a determine electrical current to create a muscular contraction
Used to determine the amount of neuromuscular blockade a patient has
An increase in NMB will show a decrease response to a peripheral nerve stimulator at a set current
Train of Four
Train of Four – 4 consecutive impulses generated from the peripheral nerve stimulator resulting in 4 muscular twitches
# of twitches seen = degree of NMB No blockade – 4 twitches Total blockade – 0 twitches GOAL IS 1-2 TWITCHES
Increase drip by 10% if >2 twitches Decrease drip by 10% if <1 twitch
Train of Four: Facial Nerve
Place one electrode on the face at the outer canthus of the eye (positive/red electrode)
Place the second electrode 2 cm below and parallel with the tragus of the ear (negative/black electrode)
Watch and feel for facial nerve contraction
Train of Four: Ulnar Nerve
Train of Four
Must have 2x baseline TOFs before starting NMBs
Ulnar nerve is more preferred but facial nerve is easier to see/assess
Use alcohol pad to wipe clean and dry the skin before applying electrode
Electrodes must be changed 24 hrs Possibly inaccurate in hypothermia patients…
Helpful tips for TOF
If checking the thumb – ensure the leads are placed on the ulnar side of the arm(this is where the nerve lies)
Be careful with applying maximum MA’s when leads are placed on the face – this can lead to burns/scarring
Check your battery Change your electrodes q24h
Putting it all Together
1. start BIS Monitoring
2. get a Baseline TOF on two locations
3. start Sedation and Analgesic Drips
4. titrate medication up until BIS 40-60
5. bolus paralytic
6. start paralytic drip
7. check TOF q30min until 1-2 twitches
8. monitor TOF and BIS and titrate drips to endpoints
***** CRUCIAL POINT ******
Prior to the administration of any paralytic agent - sedation MUST be administered first. If paralytic will be continued as an infusion, sedation MUST also be continued.
Sedation MUST be a drug that has amnesic properties.
Drugs that have amnesic effects
Benzodiazepine class
Examples: Versed
Propofol (in high doses) dose will be individual to patient
Intravenous Medicines commonly used in CVICU SEDATION
Ativan * Versed * Propofol ** Precedex ***
• * Amnesic properties• ** Amnesic in high
doses only• *** DOES NOT have
amnesic properties
ANALGESIA Morphine Fentanyl Dilaudid Toradol
Case Study
You are caring for a patient that has an open chest, they are on a Nimbex, Fentanyl & Versed gtts: VS’s:
BP 160/90 HR 128 Vent Settings: SIMV 12, TV 450, PEEP 5, PS 10,
Spontaneous RR 12, 02 saturation 98%, TOF 2/4 Is anything wrong here?
Case Study
Patient has open chest, Nimbex, Fentanyl & Versed gtts: VS’s
105/68 HR 80 Paced Vent settings: SIMV 12, TV 600, PEEP 5, PS 10,
Spontaneous RR 16 TOF 2/4
Is anything wrong here?
Case Study
Patient has open chest, has experienced excessive blood loss through chest tubes, Nimbex & Propofol gtts(5 mcg/kg/hr)
VS’s BP labile 70’s to 100’s systolic HR 80’s paced Vent settings: SIMV 12, TV 400, PEEP 5,
PS 5, Spontaneous RR 14, 02 saturation 98% TOF 0/4
Is anything wrong here?
SCCM task force recommendations
Benzodiazepines most popular for sedation Short term sedation
• Midazolam <3h (amnesic/ hypotension)• propofol – infusion syndrome/ pancreatitis
Long term – lorazepam <20h /diazepam>96h (not for infusion)
Delirium – haloperidol - neuroleptic syndrome/ torsade pointes
Antagonist- flumazenil 0.2mg-1mg (withdrawal seizures)
ReCap of Key Points
Sedation: Patient may still experience pain, goal is anti-
anxiety/ – relaxation, goal is usually to give amnesia
Analgesia: Used to treat pain, no anti-anxiety properties
Paralytics: Used to decrease skeletal muscle movement,
imperative that amnesic drugs be used in combination with analgesic meds, MUST sedate before paralyzing
ReCap of Key Points
BIS Monitor: Used to strictly assess patient’s sedation level Goal is 40-60
Peripheral Nerve Stimulator: Used to strictly assess patients paralytic state TOF goal is 1-2/4
Putting it all Together
1. start BIS Monitoring
2. get a Baseline TOF on two locations
3. start Sedation and Analgesic Drips
4. titrate medication up until BIS 40-60
5. bolus paralytic
6. start paralytic drip
7. check TOF q30min until 1-2 twitches
8. monitor TOF and BIS and titrate drips to endpoints
Final Thoughts
give sedation/analgesia before paralyticsBIS assess for sedationTOF assess for adequate NMBIf in doubt it never hurts to ask!
References
Gelinas C. Management of pain in cardiac surgery ICU patients: have we improved over time? Intensive Crit Care Nurs. 2007;23(5):298-303.
Girard TD, Shintani AK, Jackson JC, et al. Risk factors for post-traumatic stress disorder symptoms following critical illness requiring mechanical ventilation: a prospective cohort study. Crit Care. 2007;11(1):R28.
Jacobi J, Fraser GL, Coursin DB, et al. Clinical practice guidelines for the sustained use of sedatives and analgesics in the critically ill adult. Crit Care Med. 2002;30(1):119-141.
Pandharipande PP, Pun BT, Herr DL, et al. Effect of sedation with dexmedetomidine vs lorazepam on acute brain dysfunction in mechanically ventilated patients: the MENDS randomized controlled trial. JAMA. 2007;298(22):2644-2653.