sedation in icu
TRANSCRIPT
Sedation in ICU Sedation in ICU
T Mphanza FRCA, FFICM
The correct management of sedation is one of the most
important aspects of Intensive Care management
AimsAimsComfortable and pain free
Minimise anxiety
Calm and co-operative
Ability to tolerate appropriate organ system support
Patients MUST NOT be paralysed and awake
Subjective Subjective ImpressionsImpressions
Bion JF. Sedation and analgesia in the intensive care unit. Hospital Update. 1988;
14:1271-1286.
ExperienceRecall of
Experience (%)Reported as
Unpleasant (%)
Anxiety 55 78
Pain 40 67
Thirst 67 60
ETT (N=50) 38 57
Face Mask 67 52
Physiotherapy 75 33
Urinary Catheter 75 17
Nausea 13 12
Paralysis 13 100
Critical Care 2007, 11:R124 doi:10.1186/cc6189
Changes in sedation management in German intensive care units between 2002
and 2006: a national follow up surveyJoerg Martin ([email protected]) Martin Franck ([email protected])
Stefan Sigel ([email protected]) Manfred Weiss (manf
[email protected]) Claudia D Spies
82% response rate
67% changes in sedation managent
Critical Care 2007, 11:R124 doi:10.1186/cc6189
Critical Care 2007, 11:R124 doi:10.1186/cc6189
How often do we get it How often do we get it right?right?
Kaplan et al., Critical Care 2000; 4(1):s110
Olson D et al., NTI Proceedings 2003;CS 82:196
Does it matter?Does it matter?
Over - sedated
Increased drug costs
Delayed weaning
Increased ICU LOS
Increased testing
Does it matter?Does it matter?Under-sedated
Anxiety and agitation
Awareness and recall
PTSD
Increased adverse events
Increased use of NMR
AnalgesiaAnalgesiaWhy in pain:
Pre-existing conditions
Invasive procedures
Therapeutic devices
Catheters
Drains
NIV
ETT
AnalgesiaAnalgesiaUnrelieved pain
Stress response:
Tachycardia
Increased O2 consumption
Hypercoaguability
Immunosuppression
Persistent catabolism
AnalgesiaAnalgesiaPain assessment
Unidimensional
VAS
VRS
Multidimensional
McGill Pain Questionnaire
Wisconsin Brief Pain Questionnaire
AnalgesiaAnalgesiaPain Assessment
Behavioural-physiological scales
Behavioural
Facial expression
Posture
Movement
Physiological
RR
HR
BP
Analgesia TherapyAnalgesia TherapyNon-pharmacologic
Proper positioning
Stabilisation of fractures
Pharmacologic
Opioids
NSAIDs
Paracetamol
Analgesia TherapyAnalgesia TherapyDesirable attributes of opioids
Rapid onset
Ease of titration
Lack of accumulation
Low cost
Lack of adverse effects
Analgesia TherapyAnalgesia TherapyOpioid Administration Techniques
Route
IV
Intermittent
PCA
Infusion
Strategy
Daily awakening
SedationSedation
Indications
Anxiety
Agitation
Sleep deprivation
SedationSedation
Deleterious effects of anxiety
Ventilator dysynchrony
Increased oxygen consumption
Inadvertent removal of devices
SedationSedationBefore sedation ensure:
Correct physiological anomalies
Hypoxemia
Hypoglycaemia
Hypotension
Pain
Withdrawal from drugs
Sedation AssessmentSedation Assessment
SUBJECTIVE
Sedation AssessmentSedation Assessment
SUBJECTIVE
Sedation AssessmentSedation AssessmentObjective
Vital signs
Heart rate variability
Lower-oesophageal contractility
EEG
BIS
Sedation TherapySedation Therapy
Benzodiazepines
Anterograde amnesia
No analgesic property
Opioid-sparing
Sedation TherapySedation Therapy
Propofol
Central alpha agonists
Clonidine
Dexmedetomidine
Sedative SelectionSedative SelectionOutcome measures
Speed of onset
Ability to maintain target level of sedation
Adverse effects
Time to awakening
Ability to wean from ventilation
Sedative SelectionSedative SelectionDuration of Therapy
Short-term
Propofol V Midazolam
Intermediate
Propofol V Midazolam
Propofol V Midazolam V Lorazepam
Long-term
Propofol V Midazolam
Sedative and Analgesic Sedative and Analgesic WithdrawalWithdrawal
Beware of withdrawal symptoms after more than one week of medication. Doses should be tapered systematically.
Sedation in ICUSedation in ICU
An important component
Most common therapy
$ 1.2 billion per year
Treatment should have specific and individualised goals