Pain Agitation Delirium PAD RN Final 329.ppt

Pain Agitation Delirium

1. Pain, Agitation, Delirium
Karina Muzykovsky, Pharm.D., BCPS
Clinical Pharmacotherapy Specialist, Critical Care
The Brooklyn Hospital Center
Nursing Education Day

2. Objectives
Define pain, agitation and delirium (PAD)
Assess for PAD utilizing the most appropriate
bedside assessment tool
Demonstrate how to titrate/ taper medications
to patient specific goals
Understand TBHC’s PAD evidence based order
set

3. Suspended Life or Extending Death
“I am troubled when I make rounds in the critical care units today
because of the grotesque and inhuman scenarios that I so
frequently encounter . . .what I see these days are sedated patients,
lying without motion, appearing to be dead, except for the
monitors that tell me otherwise . . . when we first started our unit
in 1964, patients who required mechanical ventilation were awake
and alert . . . By being awake and alert, these individuals could
interact with their family, friends, and the environment. They
could feel human. By so doing, they could sustain the zest for
living, which is a requirement for survival. By contrast, patients
with induced coma cannot even maintain muscular tone or the
normal integrity of the GI tract unless food is introduced
artificially. Risks of thromboembolism rise, and muscle atrophy
begins”.
Petty P Chest1998;114:360

4. Chest2008;133:552-65
Factors Influencing Anxiety
in the Intensive Care Unit

5. Time to Wake Up
197019751980198519901995200020052010
Lorazepam
(1971)
Propofol
(1989)
Confusion
Assessment
Method
(1990)
Midazolam
(1975)
Dexmedetomidine
(1999)
Richmond
Agitation
Sedation
Scale
(2002)
1
st
SCCM
Sedation Guideline
(1995)
2
nd
SCCM
Sedation Guideline
(2002)
3
rd
SCCM
Sedation Guideline
(2012)
Critical Care
Pain
Observation
Tool
(2006)
www.sccm.org/criticalconnections

6. Last, First MRN/Visit ID Age (DOB) Sex
Location
Allergies
Allergies
Critical Care: Adult Pain, Agitation and Delirium Orders for Mechanically Ventilated Patients
Combined Measurements
Height (inches)Height (cm)Weight (lb) Weight (kg)BSA
Creatinine clearance (Actual)
Creatinine (mg/dl)Creat Clear (actual)))
Nursing
Order Target Start
Date
ScheduleFrequency Waking
hours
only
DurationInstructions
 Vitals - T RoutineQ1H
 Cardiac monitor- T Routinecontinuous
 Numeric Rating
Scale
0
1 to 3
T Routineq4h  If patient is able to self-report pain
Not at night, wait until repositioning or
some other intervention
 CPOT 0-1
2
T Routineq4h  If patient is NOT able to self-report
pain
Not at night, wait until repositioning or
some other intervention
 RASS 0
-1 to -2
-3 to -5
T Routineq4h  Not at night, wait until repositioning or
some other intervention
 CAM-ICU NegativeT RoutineDaily Perform before awakening trial
 Spontaneous
Awakening Trial
- T RoutineDaily at
7:00
6
Critical Care: Adult Pain, Agitation and Delirium Orders for Mechanically Ventilated Patients

7. Pain
International Association for the Study of Pain
defines pain as an “unpleasant sensory and
emotional experience associated with actual or
potential tissue damage, or described in terms
of such damage”
Medical, surgical and trauma critically ill
patients experience pain at rest
Pain assessment is the first step in pain relief
If not properly assessed, may be undertreated
Inadequate sleep, disorientation, evoke stress
response, delirium
Crit Care Med 2013; 41:263-306J Trauma Nurs 2011;18(1):52-60

8. Numeric Rating Scale

9. Indicator Score Description
Facial ExpressionsRelaxed, neutral 0No muscle tension observed
Tense 1Presence of frowning, brow lowering, orbit tightening, and levator
contraction
Grimacing 2All of the above facial movements plus eyelid tightly closed
Body MovementsAbsence of movement 0Does not move at all (does not necessarily mean absence of
pain)
Protection 1Slow, cautious movements, touching or rubbing the pain site,
seeking attention through movements
Restlessness 2Pulling tube, attempting to sit up, moving limbs/ thrashing, not
following commands, striking at staff, trying to climb out of bed
Compliance with
the Ventilator
Tolerating ventilator or 0
ventilator
Alarms not activated, easy ventilation
Coughing but tolerating 1Alarms stop spontaneously
Fighting ventilator 2 Asynchrony: blocking ventilation, alarms frequently activated
Muscle TensionRelaxed 0 No resistance to passive movements
Tense, rigid 1Resistance to passive movements
Very tense or rigid 2 Strong resistance to passive movements, inability to complete
them
Total __/8
Am J Crit Care 2006;15:420-427

10. Critical Care Pain Observation Tool
CPOT cutoff score of 2 (sensitivity 86%, specificity 78%)
for predicting significant pain in postop ICU adults
exposed to nociceptive procedure
Criterion established using patient self-report and statistical
analysis
Score increases by 2 points intervention to alleviate pain
Score decreases by 2 points intervention effective in relieving
pain
Tested in 5 studies, n= 255 medical, surgical and trauma
ICU patients
Behavioral pain scales are not only useful for
assessment/ reassessment of pain, but to discriminate
between other disease states and guide therapy
accordingly
Crit Care Med 2013;41:263-306
Crit Care Nurse 2011;31:66-68

11. Case 1
PA is a 75 y/o male s/p cardiac surgery
who is admitted to the ICU. He is
intubated and too drowsy to communicate
effectively with the you. The patient is
uncomfortable, grimaces, sits up in bed
and gets agitated every time he is touched.
Both sedatives and analgesics are ordered
in the PAD protocol; what should you
administer?
Crit Care Nurse 2011;31:66-68

12. Pharmacology 101 of Opiate Analgesics
Drug
Equi-Analgesic
Dose (mg) IV
Onset (IV) (min)Duration (hr)
Active
Metabolites
Comments
Morphine 10 5 -10 3 -4 Yes
Renal adjustment
necessary,
histamine release
Hydromorphone 1.5 5-15 2 -3 No
Fentanyl 0.1 1-2 2 -4
No, parent
compound
accumulates
Preferred for
morphine allergy,
hemodynamic
instability, and
renal
insufficiency
Crit Care Med 2013; 41:263-306

13. * Patient must also have an active prn order for breakthrough pain

14. Crit Care Med 2007;35(2):393-401

15. Effect of a Nursing-implemented Sedation Protocol
on the Duration of Mechanical Ventilation
Single-center RCT
N = 321 ventilated MICU patients
Assigned to receive either protocol-directed sedation
(n = 162) or non-protocol-directed sedation (n = 159)
Study objectives:
To test hypothesis that use of nursing-implemented
sedation protocol would decrease the duration of
mechanical ventilation
To show association between duration of continuous
intravenous sedation and duration of mechanical
ventilation
Crit Care Med 1999 27(12): 2609-2615

16. Results
r
2
=0.437

17. Richmond Agitation Sedation Scale (RASS)
“Are the lights on?”
ScoreTerm Description
+ 4 CombativeOvertly combative or violent, immediate danger to staff
+ 3 Very agitatedPulls on or removes tube(s) or catheter(s) or has aggressive behavior
toward staff
+ 2 Agitated Frequent nonpurposeful movement or patient–ventilator dyssynchrony
+ 1 Restless Anxious or apprehensive but movements not aggressive or vigorous
0 Calm & Alert
-1 Drowsy Not fully alert, but has sustained (> 10 seconds) awakening, with eye
contact, to voice
-2 Light sedationBriefly (< 10 seconds) awakens with eye contact to voice
-3 Moderate
Sedation
Any movement (but no eye contact) to voice
-4 Deep
Sedation
No response to voice, but any movement to physical stimulation
-5 UnarousableNo response to voice or physical stimulation
Am J Respir Crit Care Med 2002;166:1338–1344
V
O
I
C
E
T
O
U
C
H

18. Pharmacology 101 of Sedative Medications
Drug
Onset after
IV Loading
Dose (min)
Elimination
Half-Life (hrs)
Active Metabolites Comments
Midazolam
(Versed®)
2 -5 3 -11 Yes
Dose adjust in elderly, obese, heptically (low
albumin) and renally impaired
Lorazepam
(Ativan®)
15-20 8 -15 No Preferred for alcohol withdrawal
Propofol
(Diprivan®)
1 -2
Short-term
use 3 –12;
long-term use
50 ±18.6
No
Preferred for frequent awakenings
Hypotension and bradycardia = dose related
10% lipid emulsion (1.1 kcal/mL)
Hypertriglyceridemia, pancreatitis
Caution soy and egg allergy
Infection
Separate line (IV incompatibilities), change tube
q12h
Pain at injection site when administered periperally
Propofol Infusion Syndrome
Discolors urine green due to phenolic metabolite
Dexmedeto -
midine
(Precedex®)
5 -10 1.8 –3.1 No
Limited data for first line use
Hypotension, bradycardia
Sympathetic rebound after >24 hours
Crit Care Med 2013; 41:263-306

19. Dexmedetomidine (Precedex
®
)
Selective central a-2 receptor
agonist
Sedative, analgesic/ opioid
sparing, sympatholytic
properties
Patients are more easily arousable,
interactive, with minimal respiratory
depression
FDA approved indications
Short-term sedation < 24 hrs
Sedation in non-intubated ICU
patients
Crit Care Med 2013; 41:263-306
Dimens Crit Care Nurs 2009;28(3):102-109

20. * Patient must also have an active prn order for breakthrough agitation

21. Choice of Sedative: Benzodiazepine Vs.
Nonbenzodiazepine Sedatives
We suggest that sedation strategies using nonbenzodiazepine
sedatives (either propofol or dexmedetomidine) may be
preferred over sedation with benzodiazepines (either
midazolam or lorazepam) to improve clinical outcomes in
mechanically ventilated adult ICU patients (+2B)
Sedation with benzo may increase ICU LOS by approximately 0.5 days
compared w/ nonbenzo (p=0.04)
SEDCOM trial:
Time to extubation, [median days (IQR) 3.7 (3.1 -4) dexmed vs 5.6 (4.6 –5.9)
midazolam p = 0.01
Prevalence of delirium, 54% dexmed vs 76.6% midazolam p < 0.001
Mean delirium free days, 2.5 dexmed vs 1.7 midazolam p = 0.002
Benzodiazepine role in therapy: treating anxiety, seizures, alcohol and
benzodiazepine withdrawal, deep sedation, amnesia
Crit Care Med 2013; 41:263-306
JAMA2009;301(5):489-499

22. Delirium
Definition: acute brain dysfunction
Prevalence 60-80% of mechanically ventilated ICU
patients
20 -60% of lower severity patients
Duration of delirium is one of strongest independent
predictors of negative clinical outcomes
Longer ICU and hospital LOS, increased cost of care, long-
term cognitive dysfunction and higher mortality
ICU team practices affect incidence of delirium and
its consequences
Delirium is often invisible unless you look for it
Crit Care Med 2013; 41:263-306 JAMA 2001;286:2703-2710Intensive Care Med 2009 35:1276–1280

23. Delirium: A Multifactorial Syndrome
Delirium
Disease-induced
-Preexisting dementia
-h/oHTN
-High APACHE II
-Coma
d/tDrug ±Alcohol
Withdrawal
Acute Opiate Withdrawal
Sweating, piloerection, mydriasis, lacrimation, rhinorrhea, V/D, abdominal cramping,
tachycardia, HTN, fever, tachypnea, yawning, restlessness, irritability, myalgias,
increased sensitivity to pain and anxiety
Benzodiazepine Withdrawal
Anxiety, agitation, tremors, H/A, sweating, insomnia, N/V, myoclonus(seizures), muscles
cramps, hyperactive delirium
Iatrogenic
-Exposure to
opioid& sedative
medications
Environmental
-Prolonged physical
restraints, immobilization
Risk increase with increasing number of risk factors
Crit Care Med 2013; 41:263-306

24. Observational, single center study
n = 46
Mixed medical –surgical patients with LOS > 48 hrs were
screened for delirium
“Clinical impression” by ICU attending physician and bed-side nurse
CAM-ICU by delirium working group research nurse
Results:
50% of patients CAM-ICU (+) with a median ICU LOS of 3 days
Delirious days were picked up 28% by attending intensivist and
34.8% by bed-side nurse
Conclusion: delirium is severely under recognized in the ICU
by intensivists and ICU nurses in daily care. More attention
should be paid to the implementation of a validated
delirium screening instrument during daily ICU care.
Occurrence of Delirium is Severely
Underestimated in the ICU During Daily Care
Intensive Care Med 2009 35:1276–1280

25. Confusion Assessment Method (CAM-ICU)
“Is anyone home?”

26. Feature 2
Alternate: Pictures

28. Lorazepam and the Probability of
Transitioning to Delirium
Anesthesiology 2006; 104:21–6

29. A Multicomponent Intervention to Prevent
Delirium in Hospitalized Older Patients
RCT, prospective matching strategy
Population: 852 patients aged > 70 years
Usual care vs intervention
Standardized protocols for management of delirium risk factors:
cognitive impairment, sleep deprivation, immobility, visual impairment,
hearing impairment, dehydration
Results
Risk factor intervention strategy resulted in significant reduction in
number (9.9% vs 15%, matched OR 0.60, CI 0.39 to 0.92) and duration
(105 vs 161 days, p=0.02) of delirium episodes in older patients
Conclusion
Intervention had no significant effect on severity of delirium or on
recurrence rates; which is suggestive thatprimary prevention is
probably most effective treatment strategy
N Engl J Med 1999;340:669-676

30. Non-pharmacological Treatments for Delirium
Orientation
Provide visual and hearing aids
Encourage communication and reorient patient repetitively
Have familiar objects from patient’s home in the room
Attempt consistency in nursing staff
Allow television during day with daily news
Non-verbal music
Environment
Promote natural sleep cycle: Lights off at night, on during day
Control excess noise (staff, equipment, visitors) at night
Timely removal of catheters and physical restraints
Ambulate or mobilize patient early and often, range of motion exercises
Clinical parameters
Early correction of dehydration
Maintain systolic blood pressure > 90 mm Hg
Maintain oxygen saturations >90%
Treat underlying metabolic derangements and infections
http://www.mc.vanderbilt.edu/icudelirium

31. Pharmacological Treatment of Delirium
There is no published evidence that treatment with haloperidol reduces the
duration of delirium in adult ICU patients (No Evidence)
Atypical antipsychotics may reduce the duration of delirium in adult ICU
patients (C)
We do not suggest using antipsychotics in patients at significant risk for
torsades de pointes (-1B)
Black Box Warning: increased mortality seen when used in elderly patients w/
dementia-related psychosis d/t CV or infectious complications
Discontinue or reduce dose when patient has been CAM-ICU negative for 24
hours
Discontinue if high fever, QTc prolongation, or drug-induced rigidity
Adverse Effects
Antipsychotic
Agent
Dosage FormHalf-life
(hrs)
QT prolong-
ation
SedationDopaminergic
Receptor
Activity/ EPS
Anticholin-
ergic
Haloperidol IV 14 Low Low High Low
Quetiapine PO 26 Moderate Moderate Low Moderate
Crit Care Med 2013; 41:263-306

32. Case 2

33. Case 3

34. Case 4

35. aka ABCDE
Crit Care Med 2010; 38[Suppl.]:S683–S691
Awakening & Breathing trial
Coordination
Choice of sedatives &
analgesics
Daily Delirium monitoringEarly Mobility & Exercise
Liberation from ventilator
Early ICU and hospital discharge
Return to normal brain function
Independent functional status
Survival

36. Summary
Agitation of unclear etiology in critically ill patients is
challenging to manage and poses a high risk of patient
harm
Evidence supports a multidisciplinary approach to
provide safe, effective and reliable PAD management
Nurses are crucial in ensuring patient-focused therapy
through the use of valid and reliable bedside tools to
better assess for PAD
Nursing support and commitment is necessary for
successful implementation of this new ICU process of
care

37. Useful Resources
Barr Juliana, Fraser GL, Puntillo K, et al.
Clinical practice guidelines for the
management of pain, agitation, and
delirium in adult patients in the intensive
care unit Crit Care Med 2013;41:263-306
www.icudelirium.org
Karina, MICU Pharmacist, Pager # 2486
Pharmacotherapist On-Call, Pager # 3509

38. Pain, Agitation, Delirium
Karina Muzykovsky, Pharm.D., BCPS
Clinical Pharmacotherapy Specialist, Critical Care
The Brooklyn Hospital Center
Nursing Education Day