Sedation Use in the Critical Care Environment

Lisa NotleyLP in Critical Care

Royal Bournemouth Hospital & Christchurch NHS Foundation Trust

Bournemouth University

Aims

• To review sedation use in critically ill

• Draw upon clinical experience of changing a sedation scoring tool

• Discuss sedations holds in relation to care bundles and patient outcomes.

Why use sedation?

‘Sedation is an essential component of the management of intensive care patients. It is required to relieve the discomfort and anxiety caused by procedures such as tracheal intubation, ventilation, suction and physiotherapy. It can also minimise agitation yet maximise rest and appropriate sleep’

(Werrett, 2003)

Agitation….Agitation….

• … complicates management in the ITU• … leads to further complications • … is characterised by abnormal vital signs

Characteristics…• continual movement, fidgeting, pulling at

dressings & sheets, attempting to remove catheters or tubes, shouting, calling out, moaning, unable to follow requests

General aims of sedationAllows sleepminimises discomfortabolishes painalleviates anxietyfacilitates organ supportfacilitates nursing careallows communicationexpediates weaning

Two Extremes

Over-sedated• Hypotension• Prolonged recovery• Delayed weaning • Gut ileus• DVT• Nausea & vomiting • Immunosuppression

Under sedation• Hypertension• Tachycardia• Increased O2

consumption• Myocardial ischaemia• Atelectasis• Tracheal tube

intolerance• Infection

COMPONENTS OF SEDATION REGIME

• ANXIOLYSIS• SLEEP• ANALGESIA• MUSCLE

RELAXATION

Ideal sedative…...

AnalgesiaHypnoticAmnesicshort onset and offset of actionno effect on cardiovascular or respiratory functionAllow ‘natural’ sleepMetabolic pathways independent of hepatic and renal functionNon-cumulativeInactive metabolitesModest cost

Back to reality…...Cardiovascular compromiseRespiratory depressionDependenceIncreased tolerance (down regulation of receptors)

Prolonged ventilator timeIncreased risk of nosocomial pneumoniaMuscle wastingIncreased risk of DVTPrevention of REM sleepAmnesia / DeliriumIncreased need for tracheotomy

Drugs used typically drug combinations

• Benzodiazepines • Propofol• Barbituates• Phenothiazines • Clonidine• chlormethiazole • ?Ketamine• Chloral hydrate• Volatile agents

• Morphine• Fentanyl• Alfentanil• Remifentanil

??muscle relaxation

•Early resuscitation

•Refractory hypoxaemia

•Raised ICP

•Status epilepticus and tetanus

•Pateint transfer and inverse ratio’s

•Prone ventilation

Ventilation Care Bundle & Sedation

• Started in the USA and introduced in UK in 2002

• Group of evidenced based elements which have been shown to improve patient outcomes & collectively audited review standards of treatment (Berenholtz 2002)

• DOH, NICE & Modernisation Agency – protocol based care

‘Clinical audit is a quality improvement process that seeks to improve patient care and outcomes through systematic review of care against explicit criteria. Where indicated changes are implemented at an individual, team or service level and further monitoring is used to confirm improvement in healthcare delivery’

(NICE )

Ventilation Care Bundle

• DVT prophylaxis• Gastric ulcer prophylaxis• Sedation holdsSedation holds• Head of bed elevation (30 degrees)Also• BM control• Use of steroids in catecholamine dependent

septic shockAudit & monitoring compliance is a key aspect i.e.

sedation costs, time on ventilator, ICU LOS

What’s the score?

• HUMANE? OVER OR UNDER SEDATED

• PATIENT PHYSIOLOGICAL SAFETY

• PATIENT PHYSICAL SAFETY• PARALYZING AGENTS – STOP!!

• WHICH TOOL???

TOOLS/SCALES

• RAMSEY SCALE• COHEN AND KELLY SCALE• THE NEWCASTLE SCALE• ADDENBROOKES/CAMBRIDGE SCALE• NEW SHEFFIELD SCALE• BLOOMSBURY SCALE• Intensive Care Society• EEG (Bispectral Index)

The benefits of a sedation protocol

• Removes the effects of external influences• All nurses aware of common goal• Sedation level will be much ‘lighter’ (+/- sedation

vacation)• Aim to reduce ventilator time• Reduced need for tracheotomy• Reduced rate of complications• Increase patient throughput• Cost savings

A little about my unit

• The Critical Care Unit consists of the Intensive Care Unit (ICU) and High Dependency Unit (HDU), together comprising a total of 10 critical care beds.

 • The ICU & HDU admit over 800 patients a year, with a

wide variety of conditions. • 20% are routine admissions for post-operative care

following major surgery, the remaining 80% are emergency admissions.

• The critical care unit receives patients from all specialities and has particular expertise in the care of patients following oesophageal and vascular surgery.

RBH Critical Care Adopted System for Sedation Scoring

Old sedation scoring method:Adaptation of Addenbrookes Sedation Score0 Agitated1 Awake2 Roused by voice3 Roused by pain/coughs on suction4 No response/unrousableP paralysed

Sedation scoring flow chart 2004 ADS/PB/RR

A suggested time for this is 08:00, however please always confirm with nurse in charge before making any alterations

Is patient receiving intravenous sedation? Continue reviewing sedation score PRN

YES

Is patient receiving sedation as per protocol? NO Unless directed otherwise by anaesthetist, transfer over to correct infusions after confirming with Nurse In Charge (NIC)

YES

Has patient received continuous intravenous sedation for 6 hours or more?

NO

Review when 6 hours of continuous sedation has been reached or at a time agreed with NIC / anaesthetist.

YES

If appropriate consider stopping infusions until patient rouses to satisfactory level or sedation score 14 plus

On recommencement use boluses as stated below and run infusions at a reduced rate until sedation score of 11-14 is reached or patient comfortable and compliant. Review sedation score prn (hourly if necessary) and repeat daily to ensure consistant sedation levels.

N.B. Please note that the sedation protocol guidelines state the following: Morphine infusion 1-8mgs/hr (bolus of 2-5mg IV). Propofol 1% 1-50mls/hr. Midazolam infusion 1-10mgs/hr (bolus of 1-2.5mg IV).

SEDATION SCORING TOOL ADAPTED FROM NEWCASTLE SCALE COOK AND PALMA 1989 RESPONSE TO NURSING PROCEDURES EYES OPEN SPONTANEOUSLY 4 TO SPEECH 3 OBEYS COMMANDS 4 TO PAIN 2 PURPOSEFUL MOVEMENT 3 NONE 1 NON-PURPOSEFUL MOVEMENT 2 NONE 1 RESPIRATION COUGH EXTUBATED 5 SPONTANEOUS STRONG 4 SPONT. BREATHS INTUBATED/TRACHE 4 SPONTANEOUS WEAK 3 BiPAP AND BREATHS 3 ON SUCTION ONLY 2 RESPS AGAINST VENTILATOR 2 NONE 1 FULLY VENTILATED 1 GRADES OF SEDATION FORM THE ASSESSMENT FOR SPONTANEOUS COMMUNICATION ADD 2 AWAKE 17-19 IF YOUR PATIENT IS REQUIRING BOLUSES OF ASLEEP 15-17 SEDATION ON TOP OF AN INFUSION PLEASE LIGHT SEDATION 12-14 ADD A “B” ON YOUR CHART AT THE TIME MODERATE SEDATION 8-11 GIVEN FOLLOWED BY THE AMOUNT DEEP SEDATION 5-7 ANAESTHETISED 4

New Sedation Score with Holiday3 Agitated and restless

4 Awake and uncomfortable

5 Aware but calm

0 roused by voice

-1 roused by touch

-2 roused by painful stimuli

-3 unrousable

A natural asleep

P paralysed

Hourly sedation score

3 2 1 0 -1 -2 -3

Give bolus or start infusion

No change

Reduce infusion rate

Stop infusions

Recommence at lower rate when sedation score reaches desired level

•If your patient meets with the protocol for stopping sedation, please stop at 11.00 and access using the above tool. If the patient scores 2 on assessment consider analgesia or re-sedation

•If patient score 3 and is unable to settle sedation may be recommended

•If your patient does not meet the protocol and therefore sedation is not stopped, please document that it was considered.

BED NO: KEY: Y-Yes N – No C N/A –

Considered but not appropriate

Date Sedation

Hold Bed elevation >30 degrees

DVT Prophylaxis

Peptic Ulcer Prophylaxis

Comments and Queries

Signature

Sedation Holds/Holiday/Interruption!!

Guideline: Sedation scoring with holiday Objective: Break of all sedation

1 Sedation must be identified by multi disciplinary team on admission then subsequently on daily ward round or with any significant change in patient’s condition.

2 All patients receiving sedation / analgesic drugs will have a sedation

score assessment hourly.

3 All patients to have their sedation stopped following physiotherapy in order to assess depth of sedation and neurological status. Timing between 11.00am and 12.00 midday. Sedation will not be withheld in patients receiving muscle relaxants. If sedation is assessed as being required recommence at 50% of previous dose and titrate to achieve a level acceptable for the patient.

4 Boluses of sedation required prior to procedures or therapeutic

interventions must be documented on the ITU observation chart.

5 Sedation scoring is inappropriate when patient receives paralysing agents. However it is essential to assess patient’s sedation level prior to commencing muscle relaxants. The patient must be constantly observed for autonomic signs of under-sedation, i.e. unexplained tachycardia, hypertension or sweating.

6 Where there are no complications and on consultation with the

anaesthetist, paralysing agents should be discontinued daily for assessment or neuromuscular blockade.

7 Airway pressure will be observed for signs of increase and the

patient observed for signs of “fighting the ventilator”. The patient’s sedation score will be recorded and sedation adjusted accordingly once paralysis is reversed.

8 Patients not being sedated should have a documented Glasgow

Coma Scale score at least once per shift.

9 This Unit uses propofol in short term ventilation. Longer periods of ventilation may require midazolam and morphine, although this should be discussed with the anaesthetic team and reviewed on daily ward round.

PROTOCOL FOR SEDATION HOLIDAY

N.B. Neurologically intact = no history of head injury / #C spine injury

SEDATION HOLIDAY 11am – 12pm

Patient sedated only

Patient sedated and paralysed

Yes No No Yes

Fi02 < 60% PEEP < 10CM

ASSESS GCS

Follow sedation Only flow chart

Fi02 < 60% PEEP <10CM

RE-ASSESS No Yes No Yes

Maintain sedation for further 6 hours

Stop sedation Stop paralysing agent Maintain sedation & paralysing agent

RE-ASSESS ASSESS Assess if stable 1 hour stop sedation

REASSESS IN 6 HOURS

RE-ASSESS

No Yes No Yes

Maintain sedtion for further 6 hours

Patient neurologically intact

Patient Neurologically intact

Monthly Audit Results .v. recently published report

0102030405060708090

100

May-05 Jun-05 Jul-05 Aug-05

Sed hold

bed elev

DVT

GI

East Surrey HospitalCruden, E. 2005 an evaluation of the impact of the

ventilator care bundle. Nursing in Critical Care. 10 (3) 242-246.

0102030405060708090

100

2002 2003

sed stop

head elev

DVT

GI

Sedation and Analgesia in Sepsis

Sedation protocol for mechanically ventilated patients with standardized subjective sedation scale target.• Intermittent bolus• Continuous infusion with daily

awakening/retitrationGrade B

Kollef, et al. Chest 1998; 114:541-548Brook, et al. CCM 1999; 27:2609-2615

Kress, et al. NEJM 2000; 342:1471-1477

Conclusion

Sedation in intensive care means caring for the physical and psychological comfort of critically ill patients receiving organ support

Competence, compassion and communication are basic elements; drugs only provide part of the care

(oh 2003)

Other approaches are just as important

• Good communication with regular reassurance

• Environmental control such as humidity, lighting, temperature, noise

• Explanation prior to procedure

• Management of thirst, hunger, constipation, full bladder

• Variety for the patient – radio, visits from relatives, washing

• Appropriate diurnal variation

References

1 Hansen-Flaschen J, Cowen J, Polomano RC: Beyond the Ramsey Scale: Need for Validated Measure of Sedating Drug Efficiency in the Intensive Care Unit. Critical Care Med 1974; 22:732-733.

2 Jacobi J, Fraser GL, Coursin DB, et al: 2002. Clinical Practice Guidelines for the use of Sedatives

and Analgesics in the Critically ill. Critical Care Med.; 30:119-141.

3 Kollef MH, Levy NT, Ahrens TS, et al: 1998. The use of continuous i.v. sedation is associated with prolongation of mechanical ventilation. Chest, 114:541 – 548.

4 Kress JP, Pohlman AS, O’Connor MF, Hall JB: 2000. Daily interruption of sedative infusions in

critically ill patients undergoing mechanical ventilation. N Engl.J Med; 342:1471-7.

5 Ramsey MAE, Savage TM, Simpson BRJ, et al: 1974 Controlled Sedation with Alphalaxone-alphadolone. BMJ; 2:256-259.

6 Riker RR, Picard JT, Fraser GL; 1999. Prospective Evaluation of the Sedation-agitation Scale for

Adult Critically Ill Patients. Crit. Care Med; 27: 325-1329.

7 Werrett, G. 2003. Sedation in Intensive Care Patients. Update in Anaesthesia, issue 16 article 5. On-line, available at http://www.nda.ox.ac.uk/wfsa/html/u16/u1605_01.htm Accessed on 30/10/05.

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