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- 1. Sedation in the ICU: Liberation strategies for improved outcomes Leanne Boehm, MSN, RN, ACNS-BC Delirium and Cognitive Impairment Study Group Vanderbilt University Medical Center Nashville, TN USA
- 5. Identifying and Treating Pain
- 6. Behavioral Pain Scale (BPS) 3-12 Payen JF, et al. Crit Care Med. 2001;29(12):2258-2263. Item Description Score Facial expression Relaxed 1 Partially tightened (eg, brow lowering) 2 Fully tightened (eg, eyelid closing) 3 Grimacing 4 Upper limbs No movement 1 Partially bent 2 Fully bent with finger flexion 3 Permanently retracted 4 Compliance with ventilation Tolerating movement 1 Coughing but tolerating ventilation for most of the time 2 Fighting ventilator 3 Unable to control ventilation 4
- 9. Sedation assessment and maintaining a sedation goal
- 10. Sedation Scales Pun & Dunn, AJN 2007; 107(7):40-48
- 11. Richmond Agitation Sedation Scale (RASS) Ely EW, et al. JAMA . 2003;289(22):2983-2991. Sessler CN, et al. Am J Respir Crit Care Med. 2002;166(10):1338-1344. Verbal Stimulus Physical Stimulus
- 14. The importance of preventing and identifying delirium
- 16. Delirium Morandi, A et al., ICM 2009;34:1907-15
- 19. Sequelae of Delirium After Hospital Discharge During the ICU/Hospital Stay - Increased mortality - 3x greater re-intubation rate - Average 10 additional days in hospital - Higher costs of care - Increased mortality - Long-term cognitive impairment - D/c requirement for chronic care facility - Decreased functional status at 6 months Milbrandt EB, et al. Crit Care Med. 2004;32:955-962. Nelson JE, et al. Arch Intern Med. 2006;166:1993-1999. Ely EW, et al. JAMA. 2004;291:1753-1762. Jackson JC, et al. Neuropsychol Rev. 2004;14(2):87-98.
- 21. Confusion Assessment Method (CAM-ICU) or 3. Altered level of consciousness 4. Disorganized thinking = Delirium Ely EW, et al. Crit Care Med . 2001;29:1370-1379. Ely EW, et al. JAMA . 2001;286:2703-2710. 1. Acute onset of mental status changes or a fluctuating course 2. Inattention and and
- 26. If sedation is required, what is the optimal sedative choice?
- 30. Risk of delirium with benzodiazepines Pandharipande P, et al. J Trauma. 2008; 65:34-41. Pandharipande P, et al. Anesthesiol. 2006:104:21-26.
- 31. Propofol vs benzodiazepines Outcomes improved by propofol : sedation quality, ventilator synchrony, time to awakening, variability of awakening, time to extubation from discontinuation of sedation, overall time to extubation, ventilator days, ICU LOS among survivors, costs of sedation
- 36. Strategies to Reduce the Duration of Mechanical Ventilation in Patients Receiving Continuous Sedation
- 38. The ABC Trial (both groups get patient targeted sedation) Control Intervention Girard TD, et al. Lancet. 2008;371:126-134.
- 40. Early Mobilization Schweickert et al, Lancet 2009;373:1874-82
- 43. Daily Wake-Up + Early Mobility Schweickert WD, et al. Lancet . 2009;373:1874-1882. Outcome Intervention (n=49) Control (n=50) P Functionally independent at discharge 29 (59%) 19 (35%) .02 ICU delirium (days) 2.0 (0.0-6.0) 4.0 (2.0-7.0) .03 Time in ICU with delirium (%) 33% (0-58) 57% (33-69) .02 Hospital delirium (days) 2.0 (0.0-6.0) 4.0 (2.0-8.0) .02 Hospital days with delirium (%) 28% (26) 41% (27) .01 Barthel Index score at discharge 75 (7.5-95) 55 (0-85) .05 ICU-acquired paresis at discharge 15 (31%) 27 (49%) .09 Ventilator-free days 23.5 (7.4-25.6) 21.1 (0.0-23.8) .05 Length of stay in ICU (days) 5.9 (4.5-13.2) 7.9 (6.1-12.9) .08 Length of stay in hospital (days) 13.5 (8.0-23.1) 12.9 (8.9-19.8) .93 Hospital mortality 9 (18%) 14 (25%) .53
- 45. Putting it all together
- 47. Clinical case Male patient, age 74 Hx : Dementia, coronary artery disease, diabetes, hypertension CC : altered mental status, shortness of breath Currently hypoxic and required MV Dx : Septic shock, ARDS, acute renal failure
- 49. Clinical case Current vent settings : A/C 16, TV 400, PEEP 5, FiO2 40% Current infusions : propofol 40 mcg/kg/hr, norepinephrine 4 mcg/min, vasopressin 0.4 units/min, insulin gtt, IVF Intermittent fentanyl for analgesia Assessment : Target RASS -1, actual RASS -3, CAM-ICU positive, not breathing over vent set rate, bilat rhonchi, pulses present, moving extremities spontaneously Nursing interventions : for sedation? for delirium? (pharm/nonpharm)
- 50. Clinical case Current vent settings : PS 5, PEEP 5, FiO2 40%, RR 22 Current infusions : Norepinephrine/vasopressin off, insulin gtt, IVF, propofol off Septic shock resolved, passed SAT/SBT Assessment : Target RASS 0, actual RASS 0, CAM-ICU positive, lungs clear, moves all extremities Nursing interventions : for sedation? for delirium? (pharm/nonpharm)
Notas del editor
- CONSCIOUS SEDATION (Ability to make cognitive evaluation) A sedation goal or endpoint should be established and regularly redefined for each patient. Regular assessment and response to therapy should be systematically documented. Give examples of Insulin, Pressors and how we titrate to endpoint Grade of recommendation = C The use of a validated sedation assessment scale is recommended. Grade of recommendation = B A sedation goal or endpoint should be established and regularly redefined for each patient. Regular assessment and response to therapy should be systematically documented. Grade of recommendation = C
- An acute brain dysfunction
- Delirium is a syndrome of acute organ dysfunction. While “respiratory failure” is the most common reason for ICU admission, delirium (i.e., brain “failure”) is the number one organ dysfunction Three take home messages with this slide: 1. The DSM IV-TR14 and the CAM-ICU define delirium as noted in Figure 1 ,15 which distinguishes delirium from coma 2.Criteria for delirium diagnosis, highlights the cardinal symptoms of delirium 3. A dashed line encircles optional symptoms of delirium (i.e. those sometimes present but not mandatory for a diagnosis of delirium). Hallucinations equal not normal Missing a lot if we wait to see hallucinations
- Up to 75% of delirium missed if a tool is not used…Most delirium is invisible unless you look for it
- Not a lot of great data to describe which are highly associated with delirium Benzos are a strong association
- Investigator initiated- D-RCT, with the investigators holding the FDA IND
- Sedation with dexmedetomidine in SEDCOM was safe (for up to 28 days, which is different than the currently approved 24-hour period) Max Dose: 1.4mcgs/kg/hr
- There was no difference between dexmedetomidine and midazolam in time at targeted sedation level in mechanically ventilated ICU patients. At comparable sedation levels, dexmedetomidine-treated patients spent less time on the ventilator, experienced less delirium, and developed less tachycardia and hypertension.
- Under-sedated in florid ARDS, increase drug delivery (gtt likely best approach), mobilize
- Over-sedated and delirious, stop sedation, daily wake-up, mobilize, cognitive stimulation, sleep preservation, sensory stimulation, tight titration Reorientation and cognitive stimulation Talk about family, friends, current events Convey day, date, place Reason for hospitalization Hearing aids and/or eye glasses Pain management Sleep preservation Maintain sleep hygiene Minimize interruptions Maintain vent synchrony Promote comfort and relaxation
- Need to think about cause of delirium, consider antipsychotics, mobilize, Reorientation and cognitive stimulation Talk about family, friends, current events Convey day, date, place Reason for hospitalization Hearing aids and/or eye glasses Pain management Sleep preservation: Maintain sleep hygiene, Minimize interruptions, Maintain vent synchrony, Promote comfort and relaxation THINK T oxic Situations CHF, shock, dehydration Deliriogenic meds (Tight Titration) New organ failure, e.g, liver, kidney H ypoxemia; also, consider giving H aloperidol or other antipsychotics I nfection/sepsis (nosocomial), I mmobilization N onpharmacological interventions Hearing aids, glasses, reorient, sleep protocols, music, noise control, ambulation K + or Electrolyte problems