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Sedation in icu
- 1. Sedation in ICUSedation in ICU T Mphanza FRCA, FFICM
- 2. The correct management of sedation is one of the most important aspects of Intensive Care management
- 4. AimsAims Comfortable and pain free Minimise anxiety Calm and co-operative Ability to tolerate appropriate organ system support Patients MUST NOT be paralysed and awake
- 5. Subjective ImpressionsSubjective Impressions Bion JF. Sedation and analgesia in the intensive care unit. Hospital Update. 1988; 14:1271-1286.
- 6. Experience Recall 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
- 7. 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 (Joerg.Martin@email.de) Martin Franck (mfranck@pipeline.com) Stefan Sigel (Stefan.Sigel@kae.de) Manfred Weiss (manfred.weiss.ulm@onlin e.de) Claudia D Spies (claudia.spies@charite.de)
- 8. 82% response rate 67% changes in sedation managent Critical Care 2007, 11:R124 doi:10.1186/cc6189
- 9. Critical Care 2007, 11:R124 doi:10.1186/cc6189
- 10. How often do we get it right?How often do we get it right? Kaplan et al., Critical Care 2000; 4(1):s110 Olson D et al., NTI Proceedings 2003;CS 82:196
- 12. Does it matter?Does it matter? Over - sedated Increased drug costs Delayed weaning Increased ICU LOS Increased testing
- 13. Does it matter?Does it matter? Under-sedated Anxiety and agitation Awareness and recall PTSD Increased adverse events Increased use of NMR
- 14. AnalgesiaAnalgesia Why in pain: Pre-existing conditions Invasive procedures Therapeutic devices Catheters Drains NIV ETT
- 15. AnalgesiaAnalgesia Unrelieved pain Stress response: Tachycardia Increased O2 consumption Hypercoaguability Immunosuppression Persistent catabolism
- 16. AnalgesiaAnalgesia Pain assessment Unidimensional VAS VRS Multidimensional McGill Pain Questionnaire Wisconsin Brief Pain Questionnaire
- 17. AnalgesiaAnalgesia Pain Assessment Behavioural-physiological scales Behavioural Facial expression Posture Movement Physiological RR HR BP
- 18. Analgesia TherapyAnalgesia Therapy Non-pharmacologic Proper positioning Stabilisation of fractures Pharmacologic Opioids NSAIDs Paracetamol
- 19. Analgesia TherapyAnalgesia Therapy Desirable attributes of opioids Rapid onset Ease of titration Lack of accumulation Low cost Lack of adverse effects
- 20. Analgesia TherapyAnalgesia Therapy Opioid Administration Techniques Route IV Intermittent PCA Infusion Strategy Daily awakening
- 22. SedationSedation Deleterious effects of anxiety Ventilator dysynchrony Increased oxygen consumption Inadvertent removal of devices
- 23. SedationSedation Before sedation ensure: Correct physiological anomalies Hypoxemia Hypoglycaemia Hypotension Pain Withdrawal from drugs
- 29. Sedation AssessmentSedation Assessment Objective Vital signs Heart rate variability Lower-oesophageal contractility EEG BIS
- 30. Sedation TherapySedation Therapy Benzodiazepines Anterograde amnesia No analgesic property Opioid-sparing
- 31. Sedation TherapySedation Therapy Propofol Central alpha agonists Clonidine Dexmedetomidine
- 32. Sedative SelectionSedative Selection Outcome measures Speed of onset Ability to maintain target level of sedation Adverse effects Time to awakening Ability to wean from ventilation
- 33. Sedative SelectionSedative Selection Duration of Therapy Short-term Propofol V Midazolam Intermediate Propofol V Midazolam Propofol V Midazolam V Lorazepam Long-term Propofol V Midazolam
- 34. Sedative and AnalgesicSedative and Analgesic WithdrawalWithdrawal Beware of withdrawal symptoms after more than one week of medication. Doses should be tapered systematically.
- 35. Sedation in ICUSedation in ICU An important component Most common therapy $ 1.2 billion per year Treatment should have specific and individualised goals