7/25/2019 JURDING Sedation and Delirium in the Intensive Care Unit
1/35
SEDATION AND DELIRIUM
IN THE INTENSIVE CAREUNIT
7/25/2019 JURDING Sedation and Delirium in the Intensive Care Unit
2/35
PENDAHULUAN
Patients in intensive care units (ICUs) are treated wit!an" interventi#ns (!#st n#ta$%" end#trac ea%intu$ati#n and invasive !ec anica% venti%ati#n) t at are#$served #r &erceived t# $e distressin' Pain is t e !#st
c#!!#n !e!#r" &atients ave # t eir ICU sta"A'itati#n can &reci&itate accidenta% re!#va% #end#trac ea% tu$es #r # intravascu%ar cat eters used
#r !#nit#rin' #r ad!inistrati#n # %i e*sustainin'!edicati#ns C#nse+uent%", sedatives and ana%'esics are
a!#n' t e !#st c#!!#n%" ad!inistered dru's in ICUs
7/25/2019 JURDING Sedation and Delirium in the Intensive Care Unit
3/35
Ear%" intensive care &ractice ev#%ved r#!intra#&erative anest etic care at a ti!e w en!ec anica% venti%ati#n was de%ivered $" rudi!entar"!ac ines t att were n#t ca&a$%e # s"nc r#ni-in' wit&atients. res&irat#r" e #rts As a resu%t, dee& sedati#n
was c#!!#n%" used unti% a &atient was a$%e t# $reat ewit #ut assistance Deve%#&!ents #ver t e &ast /0 "ears,inc%udin' !icr#&r#cess#r*c#ntr#%%ed venti%at#rs t ats"nc r#ni-e wit &atients. #wn res&irat#r" e #rts andnew, s #rter*actin' sedative and ana%'esic !edicati#ns,
ave dra!atica%%" c an'ed t is a&&r#ac E+ua%%"i!rtant as $een t e rec#'niti#n t at &ain,#versedati#n, and de%iriu! are issues t at i undetectedand untreated are distressin' t# &atients and ass#ciatedwit increased !#r$idit" and !#rta%it"
7/25/2019 JURDING Sedation and Delirium in the Intensive Care Unit
4/35
1ust as t e c#nce&t # t e 2triad # anest esia3undersc#res t e & ar!ac#d"na!ic interacti#ns a!#n'
"&n#tics, ana%'esics, and !usc%e re%a4ants and t erec#'niti#n t at t e si!u%tane#us ad!inistrati#n #a'ents # eac c%ass &er!its t e use # %#wer d#ses #
dru's # a%% c%asses, t e c#nce&t # t e 2ICU triad3rec#'ni-es t at &ain, a'itati#n, and de%iriu! 5 andt ere #re a&&r#ac es t# t eir !ana'e!ent 5 areine4trica$%" %in6ed Acc#rdin' t# t e &rinci&%e t at it is$etter t# treat disease t an t# !as6 it, sedatives s #u%d$e used #n%" w en &ain and de%iriu! ave $eenaddressed wit t e use # s&eci ic & ar!ac#%#'ic andn#n& ar!ac#%#'ic strate'ies
7/25/2019 JURDING Sedation and Delirium in the Intensive Care Unit
5/35
PAIN, ANALGESIA, AND SEDATION IN THE ICU
The majority of patients who aretreated in ICUs have pain. Theshort-term consequences ofuntreated pain include higher
energy expenditure andimmunomodulation. Longer-termuntreated pain increases the ris!of post-traumatic stress disorder.
7/25/2019 JURDING Sedation and Delirium in the Intensive Care Unit
6/35
"hysiological indicators such ashypertension and tachycardiacorrelate poorly with moreintuitively valid measures ofpain #ut pain scales such asthe $ehavioral "ain %cale andthe Critical Care "ain
servation Tool providestructured and repeata#leassessments and are
currently the #est availa#le
7/25/2019 JURDING Sedation and Delirium in the Intensive Care Unit
7/35
' minority of ICU patients havean indication for continuousdeep sedation for reasonssuch as the treatment ofintracranial hypertensionsevere respiratory failurerefractory status epilepticus
and prevention of awarenessin patients treated withneuromuscular #loc!ing
agents
7/25/2019 JURDING Sedation and Delirium in the Intensive Care Unit
8/35
This review will focus onthe remainingoverwhelming majority of
patients undergoingmechanical ventilation forwhom the use of sedatives
and analgesics should #eminimi(ed with the goalthat they #e calm lucid
pain-free interactive and
7/25/2019 JURDING Sedation and Delirium in the Intensive Care Unit
9/35
)vidence from randomi(edcontrolled trials consistentlysupports the use of the minimumpossi#le level of sedation
"atients whose sedation wasroutinely interrupted received lesssedation overall and spent fewerdays undergoing mechanicalventilation and fewer days in theICU
7/25/2019 JURDING Sedation and Delirium in the Intensive Care Unit
10/35
*aily interruption of sedation wasassociated with reducedadministration of a#en(odia(epine sedative reduced
duration of mechanicalventilation reduced length ofstay in the ICU and signi+cantlyincreased survival
7/25/2019 JURDING Sedation and Delirium in the Intensive Care Unit
11/35
"atients undergoingmechanical ventilationreceived morphine for thetreatment of pain in an,analgesia +rst approachcompared a protocol of nosedation with the routine use
of sedation with dailyinterruption. "atients whowere assigned to the protocol
of no sedation had shorter
7/25/2019 JURDING Sedation and Delirium in the Intensive Care Unit
12/35
CHOICE OF SEDATIVE AGENT
%edatives that are commonlyused in the ICU are the#en(odia(epines mida(olamand lora(epam and to alesser extent dia(epam/ theshort-acting intravenousanesthetic agent propofol
and dexmedetomidine.0emifentanil an opioid isalso used as a sole agent
#ecause of its sedative
7/25/2019 JURDING Sedation and Delirium in the Intensive Care Unit
13/35
If minimi(ing the depth and durationof sedation is accepted as a desira#legoal then the use of a short-actingagent with an e1ect that can #erapidly adjusted such as propofol orremifentanil should o1er advantagesover longeracting agents or agentswith active meta#olites
7/25/2019 JURDING Sedation and Delirium in the Intensive Care Unit
14/35
's compared with #en(odia(epinespropofol has not #een shown toreduce mortality #ut may result ina reduction in the length of stay in
the ICU*exmedetomidine may also have
advantages over #en(odia(epinessince it produces analgesiacauses less respiratorydepression and seeminglyprovides a qualitatively di1erenttype of sedation in which patientsare more interactive and so
7/25/2019 JURDING Sedation and Delirium in the Intensive Care Unit
15/35
's compared with lora(epam andmida(olam dexmedetomidineresulted in less delirium and ashorter duration of mechanical
ventilation #ut not reduced staysin the ICU or hospital
7/25/2019 JURDING Sedation and Delirium in the Intensive Care Unit
16/35
7/25/2019 JURDING Sedation and Delirium in the Intensive Care Unit
17/35
PREVENTION AND TREATMENT OF DELIRIUM
2our domains of delirium3distur#ance of consciousnesschange in cognition developmentover a short period and
4uctuation*elirium is a nonspeci+c #ut
generally reversi#le manifestationof acute illness that appears tohave many causes includingrecovery from a sedated oroversedated state
7/25/2019 JURDING Sedation and Delirium in the Intensive Care Unit
18/35
The pathophysiology ofdelirium that is associatedwith critical illness remainslargely uncharacteri(ed andmay vary depending on thecause. The increased ris!associated with the use of
5'$'a agonists andanticholinergic drugs led tothe suggestion that the
5'$'ergic and cholinergic
7/25/2019 JURDING Sedation and Delirium in the Intensive Care Unit
19/35
%tudies using magneticresonance imaging haveshown a positive association#etween the duration ofdelirium in the ICU and #othcere#ral atrophy and cere#ralwhite-matter disruption
7/25/2019 JURDING Sedation and Delirium in the Intensive Care Unit
20/35
There are two distinct forms ofdelirium hypoactive and agitated
or hyperactive/The hypoactive form is
characteri(ed #y inattentiondisordered thin!ing and adecreased level of consciousnesswithout agitation
7/25/2019 JURDING Sedation and Delirium in the Intensive Care Unit
21/35
"atients with hypoactivedelirium are the least li!ely tosurvive #ut those who dosurvive may have #etter long-term function than those withagitated or mixed delirium
7/25/2019 JURDING Sedation and Delirium in the Intensive Care Unit
22/35
ASSESSMENT AND MONITORINGOF SEDATION AND DELIRIUM
Sedation scale
2or the majority of patients undergoing mechanicalventilation in an ICU an appropriate target is ascore of 6 to 7 on the 0i!er %edation8'gitation
%cale which ranges from 9 to : with scores of ;7indicating deeper sedation a score of 7 indicatingan appearance of calm and cooperativeness andscores of ? to @ on the 0ichmond 'gitation8
%edation %cale which ranges from >= to A7 withmore negative scores indicating deeper sedationand more positive scores indicating increasingagitation and with @ representing the appearanceof calm and normal alertness/
7/25/2019 JURDING Sedation and Delirium in the Intensive Care Unit
23/35
7/25/2019 JURDING Sedation and Delirium in the Intensive Care Unit
24/35
IDENTIFYING DELIRIUM
7/25/2019 JURDING Sedation and Delirium in the Intensive Care Unit
25/35
7/25/2019 JURDING Sedation and Delirium in the Intensive Care Unit
26/35
PREVENTION AND TREATMENTOF DELIRIUM
P e!ention
&utside the ICU repeatedreorientation noisereduction cognitivestimulation vision an hearingaids adequate hydration andearly mo#ili(ation can reducethe incidence of delirium inhospitali(ed patients
7/25/2019 JURDING Sedation and Delirium in the Intensive Care Unit
27/35
low-dose haloperidol and low-dose risperidone #othreduced the incidence ofdelirium as did a single lowdose of !etamine during theinduction of anesthesia
These trials were conductedamong patients undergoingelective surgical proceduresand it is not clear whether
their results can #e
7/25/2019 JURDING Sedation and Delirium in the Intensive Care Unit
28/35
Cholinesterase inhi#itorrivastigmine wasine1ective inpreventing delirium
%edation with dexmedetomidinerather than #en(odia(epinesappears to reduce theincidence of delirium in the ICU
7/25/2019 JURDING Sedation and Delirium in the Intensive Care Unit
29/35
'dministration of dexmedetomidine ormida(olam resulted in similarproportions of time within the targetrange of >? to A9 on the 0ichmond'gitation8%edation %cale among
patients #ut those assigned to receivedexmedetomidine had a reduced ris!of delirium and spent less timeundergoing mechanical ventilation
7/25/2019 JURDING Sedation and Delirium in the Intensive Care Unit
30/35
T eat"ent
In a study of 6B patients who wererandomly assigned to treatmentwith quetiapine or place#o
delirium resolved faster inpatients who received quetiapine.The use of quetiapine alsoincreased the num#er of patientswho were discharged to their ownhome or to reha#ilitation
7/25/2019 JURDING Sedation and Delirium in the Intensive Care Unit
31/35
' study of 9@6 patients who wererandomly assigned to receiveregular haloperidol (iprasidoneor place#o showed no signi+cant
di1erences in the num#er of daysthat patients survived withoutdelirium or coma
7/25/2019 JURDING Sedation and Delirium in the Intensive Care Unit
32/35
The single study comparinghaloperidol with an atypicalantipsychotic olan(apine/ showedequivalent e cacy
Comparing dexmedetomidine withhaloperidol in patients withhyperactive deliriumdexmedetomidine was associatedwith a shorter time to extu#ationand shorter length of stay in theICU
7/25/2019 JURDING Sedation and Delirium in the Intensive Care Unit
33/35
CONCLUSIONS
Danagementof sedation anddelirium can have animportante1ect on the outcomes of patientswho are treated in ICUs
7/25/2019 JURDING Sedation and Delirium in the Intensive Care Unit
34/35
The #est outcomes are achieved with the
use of a protocol in which the depth ofsedation and the presence of pain anddelirium are routinely monitored pain istreated promptly and e1ectively theadministration of sedatives is !ept to theminimum necessary for the comfort andsafety of the patient and earlymo#ili(ation is achieved wheneverpossi#le
7/25/2019 JURDING Sedation and Delirium in the Intensive Care Unit
35/35
T)0ID'
E'%IF