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New Insights in ICU Sedation
1. New insights in ICU sedation
Jean Mantz, MD, PhD
Professor and Chair, Department of
Anesthesia and Critical Care
F- Paris Val de Seine University Hospitals
Univ Paris Diderot, Paris Sorbonne Cité
INSERM U 676, Pharmacological
Neuroprotection
3. Goals of the lecture
To review the recent changes in goals and
practices of ICU sedation.
To focus on the detrimental role of the ICU
environment(including sedation) on brain function
(delirium, sleep disorders, cognitive impairment)
To discuss the role of dexmedetomidine in the
modern era of sedation and analgesia
4. Goals of the lecture
To review the recent changes in goals and
practices of ICU sedation.
To focus on the detrimental role of the ICU
environment(including sedation) on brain function
(delirium, sleep disorders, cognitive impairment)
To discuss the role of dexmedetomidine in the
modern era of sedation and analgesia
5. The moving landscape of ICU sedation
1980-2000: to provide sedation is beneficial to
the ICU mechanically ventilated patient
2000: to alleviate sedation improves patient
outcome (except specific situations)
2000-2010: to protocolize, monitor and titrate
sedation by nurses-driven algorithms allows to
improve pain control and avoid oversedation
2010-….: to develop cooperative sedation and
physiotherapy still improves outcome, during and
after the ICU stay.
16. Pitfalls with sedatives and analgesics
Sedatives and analgesics may contribute to
increased duration of mechanical ventilation and
length of stay (perhaps mortality ?)
They may impede neurological examination and
favor delirium.
They may have detrimental consequences on
cognitive function after ICU.
17. Goals of the lecture
To review the recent changes in goals and
practices of ICU sedation.
To focus on the detrimental role of the ICU
environment(including sedation) on brain function
(delirium, sleep disorders, cognitive impairment)
To discuss the role of dexmedetomidine in the
moderns era of sedation and analgesia
18. Brain dysfunction in the critically ill
Patients’status Anesthesia ICU
Addiction sedation
Surgical trauma
Sleep disorders Postop care
Pain Inflammation
Medications
Delirium
Recall
Sleep disorders
PTSD, Cognitive dysfunction
Altered recovery and QOL
28. Issues with diagnosis of post-operative delirium
in the elderly
• Hypoactive vs hyperactive forms
• Pre-existing delirium
• Pre-existing cognitive function
29. Ely EW et al. JAMA 2001;286:2703-10
CAM-ICU
1 + 2 + [3 or 4]
1. Acute, fluctuating
2. Inattention
3. Disorganized
ABRACADABRA
thinking
4. Altered
consciousness
37. Hypnogram in a young and healthy subject
Anaesthesia, 2004; 59: 374–84
38.
39.
40.
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42.
43. Perspectives to attenuate brain dysfunction in
ICU patients
Alleviate sedation (benzodiazepines)
Monitor delirium
Develop rehabilitation programs
Preserve sleep
Target an organic cause of delirium ++++
Use restricted and reasonable pharmacologic
therapy.
44. Goals of the lecture
To review the recent changes in goals and
practices of ICU sedation.
To focus on the detrimental role of the ICU
environment(including sedation) on brain function
(delirium, sleep disorders, cognitive impairment)
To discuss the role of dexmedetomidine in the
modern era of sedation and analgesia
52. Dexmedetomidine decreases length of stay in
comparison with a benzodiazepine comparator
Trend toward more hypotension and
bradycardia requiring interventions
53. Is there a role for dexmedetomidine in the
ICU?
• Primary agent for cooperative sedation and
analgesia
• Weaning from the ventilator
• Sedation weaning syndromes
54. Conclusion
The landscape of ICU sedation has moved from
the concept of « comatose » to « cooperative »
patient.
Attenuation of brain dysfunction at the early
stage of ICU stay may improve long term
recovery, cognitive function and quality of life
post ICU.
Dexmedetomidine may play a major role in
ensuring cooperative ICU sedation.
55. Thank you for your kind attention !
Thank you
for your kind
attention
Notas del editor
Role of the severity of illness
Role of the patients’ status and comorbidities with aprtciular atention to elderly persons (frequently admitted into ICU)
Role of the environment (noise, light, emergency situaions)
Role of pain and pain treatment in sleep disturbances
Speaker’s Notes: Alpha 2 -adrenoceptor agonists are not a new class of drug. But a highly selective alpha 2 agonist like dexmedetomidine is an entirely different mechanism for providing sedation (and many other clinical effects). Because the alpha 2 adrenoceptors are located primarily in the CNS, dexmedetomidine delivers its clinical effects in a more targeted manner throughout the body.