assessing and managing sedation in the intensive care and the perioperative settings
TRANSCRIPT
Assessing and Managing Sedation in the Intensive Care and the
Perioperative Settings
SEDATION Curriculum Learning Objectives
• Manage adult patients who need sedation and analgesia while receiving ventilator support according to current standards and guidelines
• Use validated scales for sedation, pain, agitation, and delirium in the management of these critically ill patients
• Assess recent clinical findings in sedation and analgesia management and incorporate them into the management of patients in the acute care, procedural, and surgical sedation settings
Procedural SedationMajor Applications
• Surgical– Neurosurgery
– Bariatric surgery
– Oral
– Plastic/reconstructive
– Biopsy
– CV surgery
• Endoscopic– Bronchoscopy
– Fiberoptic intubation
– Colonoscopy
Growth of Ambulatory Surgery Centers (ASC)
• ASCs increased outpatient operations from
< 10% in 1979 to 50% in 19901 • From 1993 to 20012
– ASCs in metropolitan areas increased by 150%– Hospital outpatient surgeries increased 28%– Inpatient surgeries decreased by 4.5%
• 70% of surgical interventions in the United States are outpatient procedures1
1. Pregler JL, et al. Anesthesiol Clin North America. 2003;21(2):207-228. 2. Bian J, et al. Inquiry. 2009-2010;46(4):433-447.
Common Agents for Conscious Sedation
Mustoe TA, et al. Plast Reconstr Surg. 2010;126(4):165e-176e.
Factors Jeopardizing Safety
• Risk of major blood loss• Extended duration of surgery (> 6 h)• Critically ill patients (evaluate and document prior to
procedure) • Need for specialized expertise or equipment (cardio-
pulmonary bypass, thoracic or intracranial surgery)• Supply and support functions or resources are limited• Inadequate postprocedural care• Physical plant is inappropriate or fails to meet
regulatory standards
Eichhorn V, et al. Curr Opin Anaesthesiol. 2010;23(4):494-499.
Standardized Monitoring• Hemodynamic
– ECG– Blood pressure
• Respiration– Oxygenation (SpO2 by pulse oximetry, supplemental oxygen)
– Ventilation (end tidal CO2, EtCO2)
• Temperature (risk of hypothermia)• Higher risk at remote locations
– Inadequate oxygenation/ventilation– Oversedation– Inadequate monitoring
Eichhorn V, et al. Curr Opin Anaesthesiol. 2010;23(4):494-499.
Endoscopic Procedures
Sedation for Endoscopy
• Desirable qualities– Permits complete
diagnostic exam– Safe – Diminishes memory of
the procedure– Permits rapid discharge
after procedure
• Risk factors– Depth of sedation– ASA status– Medical conditions– Pregnancy – Difficult airway mgt– Extreme age– Rapid discharge time
Runza M. Minerva Anestesiol. 2009;75:673-674.
Drugs for Fiberoptic Intubation
Agent Class
Example Advantages Considerations
GABA agonist
Benzodiazepine Midazolam
•Quick onset• Injection not painful•Short duration
• Not analgesic• Airway reflexes persist
GABA agonist
Benzodiazepine Propofol
•Quick onset • Respiratory depression• Unconsciousness• Decreased bp, cardiac
output• Increased HR
Opioid FentanylRemifentanil
•Analgesic•Cough suppressive
• Respiratory depression
a2 Agonist Dexmedetomidine •Pt easily arousable•Anxiolytic •Analgesic•No respir. depression
• Transient hypertension• Hypotension • Bradycardia
Summary courtesy of Pratik Pandharipande, MD.
Propofol vs Combined Sedationin Flexible Bronchoscopy
• Randomized non-inferiority trial• 200 diverse patients received propofol or
midazolam/hydrocodone• 1o endpoints
– Mean lowest SaO2
– Readiness for discharge at 1h
• Result– No difference in mean lowest SaO2
– Propofol group had Higher readiness for discharge score (P = 0.035)
Less tachycardia
Higher cough scores
• Conclusion: Propofol is a viable alternative to midazolam/hydrocodone for FB
Stolz D, et al. Eur Respir J. 2009;34:1024-1030.
Dexmedetomidine vs Midazolam for Upper Endoscopy
50 adults undergoing upper endoscopy
Dexmedetomidine• Bolus 1 µg/kg • Infusion 0.2 µg/kg/hr
( n = 25)
Midazolam 0.07 mg/kg • Total dose 5 mg
(n = 25)
Demiraran Y, et al. Can J Gastroenterol. 2007;21(1):25-29.
Upper Endoscopy Results
• Dexmedetomidine was similar to midazolam – Gagging– Patient satisfaction– Patient discomfort– Anxiety scores– Recovery time
• Dex was superior to midazolam– Endoscopist satisfaction– Retching – Total number of patients having
any type of side effects
VariableMidazolam
(n = 25)Dex
(n = 25)P-value
Time to full recovery, min
37.6±11 42±12.5 0.30
Patients fully recovered, n (%)
15 min 12 (48) 10 (40) 0.56
30 min 20 (80) 18 (72) 0.74
45 min 25 (100) 25 (100) 0.99
Demiraran Y, et al. Can J Gastroenterol. 2007;21(1):25-29.
Recovery
Dexmedetomidine Increases Comfort in AFOI • Double-blinded randomized trial• Midazolam +/- dexmedetomidine• Awake fiberoptic intubation (AFOI)• Patient comfort rated by 2 observers
Bergese SD, et al. J Clin Anesth. 2010;22(1):35-40.
Tota
l C
om
fort
Sco
re (
max
= 3
5)
Pre-oxygenation
Introduction of scope
Introduction of ET tube
n = 24n = 31
Use of Sedation for Colonoscopy
Austra
lia
Hong
Kong
Unite
d Sta
tes
Germ
any
Switzer
land
Greec
e Ita
ly
China
0
10
20
30
40
50
60
70
80
90
100
Cohen LB. Gastrointest Endosc Clin N Am. 2010;20(4):615-627.
Co
lon
osc
op
ies
Wit
h S
edat
ion
(%
)
Sedative Use for Colonoscopy: USA
74%
18%
8%
Cohen LB, et al. Am J Gastroenterol. 2006;101(5):967-974.
BZD + Opioid
BZD + Opioidand/or
Propofol
Propofol
BZD + Opioid
37%
1%
Endoscopist Choices for Their Own Colonoscopy
41%
14%
8%
Cohen LB, et al. Am J Gastroenterol. 2006;101(5):967-974.
* More than one answer was permitted
Propofol
No Sedation
BZD AloneOpiod Alone
Outpatient Colonoscopy: Study Design
90 colonoscopy patients
Dex 1 µg/kg over 15
mins, then 0.2 µg/kg/hr (n = 19)
Meperidine 1 mg/kg with
midazolam 0.05 mg/kg (n = 21)
Fentanyl 0.1-0.2 mg on
demand (n = 24)
Jalowiecki P, et al. Anesthesiology. 2005;103(2):269-273.
• Study halted after 64 subjects because of AE in the Dex group• Hb saturation and respiration rate variations not observed
Outpatient Colonoscopy: Results
Jalowiecki P, et al. Anesthesiology. 2005;103(2):269-273.
Dex (n = 19)
Meperidine (n = 21)
Fentanyl(n = 24)
Average MAP reduction 26% 14% 3%
Maximum BP reduction50%
(4 cases)35% 30%
Mean HR reduction 17% 9% 7%
Lowest HR 40 bpm (2 cases) 50 bpm 50 bpm
Vertigo & nausea (n) 5 0 0
Time to discharge readiness (min) 85 39 32
Jaw thrust maneuver 0 6 (29%) 0
Jalowiecki P, et al. Anesthesiology. 2005;103(2):269-273.
Outpatient Colonoscopy: Hemodynamics
* P < 0.05 after Bonferroni correction
Elective Colonoscopy: Can the Patient Control Sedation?
• Patient-controlled sedation (PCS) with propofol-remifentanil (PR) – Rapid sedation
– Rapid recovery
– More airway rescue needed with PR than with MDZ-fentanyl
• Prospective, randomized, open-label trial– n = 25 Patient-controlled sedation (PCS)
– n = 25 Anesthesiologist-administered sedation (AAS)
• Procedure – Outpatient colonoscopy
– All patients received propofol-remifentanil
– 100% oxygen via an anesthesia mask
– Continuous spirometry and bispectral index (BIS) monitoring
• Primary endpoint: oversedation– Respiratory rate
– BIS
Mandel JE, et al. Gastrointest Endosc. 2010;72(1):112-117.
Outpatient Colonoscopy: Respiratory Depression
Mandel JE, et al. Gastrointest Endosc. 2010;72(1):112-117.
Respiratory Rate (breaths/min)
Rel
ativ
e F
req
uen
cy
• AAS group used more mean total drug
• Safety interventions
– Criterion: 30s of SaO2 < 90%
– PCS: 0/25
– AAS: 5/25
• Median BIS values– PCS: 88.1
– AAS: 71.7 P < 0.001
Bariatric Surgery
Propofol or BZD/Narcotics forPre-Surgical Endoscopy?
• Endoscopy prior to bariatric surgery• Anesthesiologist-monitored sedation
(AMS)– IV propofol (n = 51)
• Surgeon-monitored sedation (SMS)– IV narcotics and benzodiazepines
• Study design – Observational study
– Data from patient survey
– Doses/regimens not reported
• Results– Generally no difference between methods
– Trend toward amnesia in AMS group
Patient YES responses (%)
Throat pain during procedure
Throat pain after procedure
Remembered scope placement
Remembered gagging
Reported recovery < 1 hour
Nausea after endoscopy
0 10 20 30 40 50 60
AMS
SMS
P < 0.02
Madan AK, et al. Obes Surg. 2008;18(5):545-548.
Fentanyl vs Dexmedetomidine Use in Bariatric Surgery
• 20 morbidly obese patients• Roux-en-Y gastric bypass surgery• All received midazolam, desflurane to maintain BIS at
45–50, and intraoperative analgesics– Fentanyl (n = 10) 0.5 µg/kg bolus, 0.5 µg/kg/h– Dexmedetomidine (n = 10) 0.5 µg/kg bolus, 0.4 µg/kg/h
• Dexmedetomidine associated with – Lower desflurane requirement for BIS maintenance– Decreased surgical BP and HR – Lower postoperative pain and morphine use (up to 2 h)
Feld JM, et al. J Clin Anesthesia. 2006;18:24-28.
• 80 morbidly obese patients• Gastric banding or bypass surgery• Prospective dose ranging study• Medication
– Celecoxib 400 mg po
– Midazolam 20 µg/kg IV– Propofol 1.25 mg/kg IV– Desflurane 4% inspired– Dexmedetomidine 0, 0.2, 0.4, 0.8 µg/kg/h IV
Dexmedetomidine as Desflurane Adjuvant in Bariatric Surgery
Tufanogullari B, et al. Anesth Analg. 2008;106:1741-1748.
• More dex 0.8 patients required rescue phenylephrine for hypotension than control pts (50% vs 20%, P < 0.05)
• All dex groups – Required less desflurane (19%–22%)– Had lower MAP for 45’ post-op– Required less fentanyl after awakening (36%–42%)– Had less emetic symptoms post-op
• No clinical difference – Emergence from anesthesia– Post-op self-administered morphine and pain scores – Length of stay in post-anesthesia care unit– Length of stay in hospital
Dexmedetomidine as Desflurane Adjuvant in Bariatric Surgery: Results
Tufanogullari B, et al. Anesth Analg. 2008;106:1741-1748.
Oral Surgery
EndodontistsN = 31
Sublingual Triazolam/Halcion (45.2%)Oral Triazolam/Halcion( 19.5%)No Premedication Agents Used (19.4%)
MD AnesthesiologistsN = 19
All Agents Identified Are Used (52.6%)Intramuscular Ketamine (26.3%)Oral Midazolam (10.5%)
Dental AnesthesiologistsN = 75
All Agents Identified Are Used (32.0%)Intramuscular Ketamine (22.4%)Intramuscular Ketamine & Midazolam (14.7%)
General DentistsN = 144
Oral Triazolam/Halcion (45.1%)No Premedication Agents Used (25.7%)Sublingual Triazolam/Halcion (13.9%)
PeriodontistsN = 55
Oral Triazolam/Halcion (38.2%)No Premedication Agents Used (32.7%)Sublingual Triazolam (14.5%)
Pediatric DentistsN = 33
Demerol and Hydroxyzine Elixir (36.4%)Oral Midazolam (27.2%)No Premedication Agents Used (21.2%)
Oral/Maxillofacial SurgeonsN = 356
No Premedication Agents Used (54.2%)Oral Midazolam (9.6%)Oral Triazolam/Halcion (8.1%)
Public Health PractitionerN = 2
Oral Triazolam/Halcion (50.0%)No Premedication Agents Used (50.0%)
ProsthodontistsN = 2
Oral Triazolam/Halcion (100%)
Dental Anesthesia Survey:Premedication by Specialty
Boynes SG, et al. Anesth Prog. 2010;57(2):52-58.
Dental Anesthesia Survey:Sedation/Anesthesia Method by Specialty
Boynes SG, et al. Anesth Prog. 2010;57(2):52-58.
OMFSN = 356
Per
cen
t
DENT ANESN = 75
PED DENT N = 33
PERIO N= 55
OMD ANESN N = 19
GEN DENT N = 144
ENO N = 31
Oral SedationIV Conscious SedationIV Deep SedationGETA
Plastic/Reconstructive Surgery
Cosmetic Procedures
• In 2007, 11.7 million procedures in US– Liposuction– Breast augmentation– Eyelid surgery– Abdominoplasty– Breast reduction
• Site– Surgeons’ offices 54%– Ambulatory centers 29%– Hospitals 17%
Shapiro FE. Curr Opin Anaesthesiol. 2008;21(6):704-710.
Face Lift Surgery
• Retrospective study– Single surgeon– Multiple anesthetists
• Groups– N = 77 Standard of care (mainly propofol,
ketamine, fentanyl, and midazolam)– N = 78 SOC plus dexmedetomidine– Not randomized, treated per anesthetist choice– All patients in deep sedation
Taghinia AH, et al. Plast Reconstr Surg. 2008;121(1):269-276.
Face Lift Surgery:Hemodynamic Results
Taghinia AH, et al. Plast Reconstr Surg. 2008;121(1):269-276.
SOC+ Dex SOC
Laparoscopy
Ambulatory Gynecologic Laparoscopy
ASA I-II patients • N = 60• Prospective• Randomized • Double blind
Remifentanil• 1 µg/kg over 10 mins then• 0.2 µg/kg/min
Dex • 1 µg/kg over 10 mins then• 0.4 µg/kg/hr
Salman N, et al. Saudi Med J. 2009;30(1):77-81.
Dexmedetomidine associated with• Slower recovery
• Less nausea and vomiting
• Lower analgesia requirement
Recovery Data Group Remifentanil Group DEX
Time to eye opening (mins)
3.5 ±1.1 4.1 ±1.4
Extubation time (mins)
6.1 ±1.6 * 7.3 ±1.3
Orientation to person (mins)
9.1 ±2.3 * 10.5 ±1.8
Orientation to place and time
(mins)
16.1 ±6.3 * 21.2 ±11.7
Discharge time (mins)
200.3 ±29.5 224.5 ±49.2
*P < 0.05
Salman N, et al. Saudi Med J. 2009;30(1):77-81.
Ambulatory Gynecologic Laparoscopy
CV Surgery
What Do Neurointerventionalists Prefer for AIS Interventions?
*Treated as ordinal
4 = Most frequent
3 = Frequent
2 = Least frequent
1 = Never
McDonagh DL, et al. Front Neurol. 2010;1:118.
General Anesthesia During AIS Intervention?
McDonagh DL, et al. Front Neurol. 2010;1:118.
Trial of Dexmedetomidine for CV Procedure: Design
• Prospective, randomized, double-blinded, placebo-controlled multicenter trial
• Procedure – AV fistula creation and peripheral vascular stent placement– Local anesthesia or peripheral nerve block
• Patients randomized 2:2:1 – Dex 1.0 mg/kg load, then infusion of 0.6 mg/kg/h– Dex 0.5 mg/kg load, then infusion of 0.6 mg/kg/h– Normal saline 0.9% infusion
• Drug titrated to achieve a target OAA/S of ≤ 4• Fentanyl in 25 μg increments IV for pain• 1o EP: % patients not requiring MDZ during infusions
Huncke TK, et al. Vasc Endovascular Surg. 2010;44(4):257-261.
Trial of Dexmedetomidine for CV Procedure: Results
Number (%) of Patients Not Requiring Rescue Midazolam (MDZ)
The Perioperative Use of MDZ and Fentanyl
Huncke TK, et al. Vasc Endovascular Surg. 2010;44(4):257-261.
Sedation/Analgesia for Traumatic Brain Injury
Goal: reduce ICP by decreasing pain, agitation
Saiki RL. Crit Care Nurs Clin North Am. 2009;21:549-559.
Agent Advantages Considerations
Propofol
• Short acting• Reduces cerebral
metabolism, O2 consumption
• Improves ICP after 3d
• Propofol infusion syndrome
Barbiturates• Reduce ICP• Neuroprotection
• Interfere with neuro exam• Hypotension, reduced CBF• OCs not improved with severe TBI
44
• Randomized, double-blind, placebo-controlled, multicenter
• 326 pts undergoing MAC for surgery (orthopedic, ophthalmic, vascular, excision of lesions, others < 10%)
• All patients sedated – Observer’s Assessment of Alertness/Sedation Scale (OAA/S ) to < 4
• Sedation with – Dex ± rescue midazolam, or
– Placebo + rescue midazolam
• Fentanyl PRN for pain
MAC with Dexmedetomidine
Candiotti KA, et al; MAC Study Group. Anesth Analg. 2010;110(1):47-56.
MAC = Monitored anesthesia care
Placebo Dex 0.5 Dex 1.00
25
50
75
100 96.8
59.7
45.7
Mid
azo
lam
Tre
atm
ent,
%
Placebo Dex 0.5 Dex 1.00
1
2
3
4
5
4.1
1.40.9
Mid
azo
lam
, m
g
**
144.4
84.8 83.6
0
50
100
150
200
Placebo Dex 0.5 Dex 1.0
Fe
nta
ny
l, µ
g Midazolam UseFentanyl Use
Dexmedetomidine Reduces Fentanyl and Midazolam Use During MAC
*P < 0.001 compared with placebo, MAC = monitored anesthesia care
**
Placebo Dex 0.5 Dex 1.00
25
50
75
10088.9
59.0
42.6
Fen
tan
yl T
reat
men
t, %
*
*
*
*
Candiotti KA, et al; MAC Study Group. Anesth Analg. 2010;110(1):47-56.