Drugs and weaning: a brief

overview of pain, sedation,

and agitation management

Lisa Burry, PharmD

Mount Sinai Hospital

University of Toronto

Disclaimer

No financial disclosures

This is my interpretation of the literature

Personal mission: to stop polypharmacy

Weaning

Definition: liberation from mechanical

ventilatory support

Process should start with intubation

◦ Readiness for weaning should be monitored daily,

with consideration of both clinical trends and

stability

Boles JM Eur Respir J 2007 29:1033-1056

Estaban A NEJM 1995;332:345-350

Weaning criteria

Resolution of underlying cause of acute

respiratory failure

Haemodynamic stability, defined as no need for

vasoactive/inotropic drugs

Absence of fever (preferable)

Adequate gas exchange

◦ (Pa02:Fi02 > 200 with a PEEP=5)

Adequate neurological status or cooperative

sedationDrive,

Endurance,

Energy consumption,

Psychological wellbeing

G – Get some sleep

H – Home meds & withdrawalwww.iculiberation.org

SAT

SAT

Dale CR Ann Am Thor Soc 2014;11:367-74

PAD Protocol + SATs + SBTs

How can we minimize sedation?

Sedation protocols

Daily sedation interruption

No sedation

Choice of drug or the method of administration (infusion vs. bolus)

Combination(s) of the above

Strategies endorsed by SCCM PAD

Any route: OR 1.04 (per 5 mg midazolam, 1.02-1.05)

Infusions: OR 1.04 (1.03-1.06) vs. bolus 0.97 (0.88-1.05)

In all 4 trials patients who received dexmedetomidine were

significantly more arousable, more co-operative and better able to

communicate their pain than those who received propofol or

midazolam (p ≤ 0.001 in all cases)

Ventilator Free Days – mean diff 3.28 days

Time to extubation - Mean diff 1.85 days favouring dexmedetomidine

Eligibility

Adults who continue to require MV only because their degree of agitation is so severe sedation could not be lessened

Required to meet all 3 criteria during the 4 h prior to randomization:

(1) need for mechanical restraint, antipsychotic or sedative medication, or both

(2) CAM-ICU + for delirium

(3) MAAS score ≥ 5, confirming psychomotor agitation

Primary OutcomeMedian difference 19.5 hours (95% CI 5.3 to 31.1 h, P<0.001)

LimitationsN = 72Stopped earlyBaseline imbalancesNo weaning/extubation protocol

What about Sleep? Now patients

are awake...

Higher night time doses

independently associated with

failure to…

1. Meet SBT screen

2. Pass SBT

3. Be extubated

What about sleep? Now patients

are awake...

Promote sleep: control light, noise, cluster patient-care

activities, reduce nocturnal stimuli

H: Home medication and withdrawal

Consider withdrawal

from home

medications (e.g.

SSRI), nicotine &

alcohol.

Consider withdrawal

of sedatives &

opioids used during

the ICU stay

Summary

• It is very important to consider pain, sedation,

& agitation in the weaning process.

• Use ABCDEFGH to support the weaning

process

• Consider the pharmcokinetics-dynamics of

the drugs you select

– Consider this at minimum daily as requirements

will vary