sedation-in-the-icujhsdgasdjasdasgdjhasgdj.ppt

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1. Sedation in the ICU
Mairi Mascarenhas
Clinical Educator ICU

2. Sedation is an induced state of reduced consciousness to
which verbal contact with the patient may be maintained.
It is used to reduce anxiety and distress, and to facilitate
compliance with invasive procedures such as mechanical
ventilation.
Before sedation is initiated, the cause of distress should be
identified – common causes in critically ill patients include
anxiety, pain, delirium, dyspnoea and neuromuscular
paralysis. These aetiologies may occur separately or in
combination.
Introduction

3. Pain, Agitation and Delirium (PAD) Guidelines

4. The PAD triad

5. Deep sedation should only be used when the benefits are
likely
to outweigh the risks
•Patients receiving NMBA’s.
•Acute cerebral injury: for control of intracranial pressure.
•Patients that are difficult to ventilate
•Refractory status epilepticus.
Avoid deep sedation or over sedation

6. •Mechanical ventilation asynchrony
•Stress response with increased myocardial
oxygen consumption
•Cardiovascular instability
•Failure to comply with treatment
•Unplanned extubation or removal of lines
and monitoring devices by the patient
Under-sedation

8. Monitoring level of sedation
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9. Sedation – goals of care
Stop sedation → lighten patient → change to PS → extubate
Sedation interruption doesn’t always mean that the patient will be
extubated – the important point is that sedation interruption has been
attempted

10. Avoid excess sedation
•Allows neurological function to be assessed
•Assists to reduce the need for diagnostic testing CT/MRI
•Allows sedation dose to be optimised to an ideal level
•Prevents drug accumulation
•Reduces inotrope/vasopressor requirements
•Cardiovascular instability is reduced – bradyarrhythmias
•Reduces risk of complications e.g. muscle wastage,
debility, critical illness myopathy.
•Reduces time on ventilator, risk of VAP and LOS in ICU
Benefits of sedation interruption

11. •Hold sedation until patient awake and then
restart at 50% of the prior dose.
•“Awake” defined as any of the following
-Opens eyes in response to voice
-Uses eyes to follow investigator on request
-Squeeze hand on request
-Stick out tongue on request
Daily sedation interruption

12. If there are no contra-indications
1.Stop sedation at 0800hrs or as otherwise directed by medical staff.
2.Pain control may be an issue. If patient scoring positive for pain
→
maintain opioid infusion
3.Continue to hold sedation until patient obeys commands and RASS
improves e.g. -1
4.If after 1 hour the RASS doesn’t improve or remains 3 and the
≥
patient is still receiving an opioid infusion discuss with medical staff
→
regarding appropriateness for stopping opioid infusion
5.Wait a minimum of 15 minutes before changing ventilator settings
e.g. Observe for spontaneous breathing change to PS mode
→
6.If patient becomes difficult to manage i.e. RASS + 2, +3 or +4 re-sedate
patient with rescue bolus of propofol (increments of 20 to 30mg) and
inform medical staff.
Procedure for stopping sedation

13. Whenever sedation needs to be restarted → restart at ½ the
previous infusion rate as per protocol
Adhere to the sedation interruption protocol

14. •Sustained anxiety, agitation or pain.
•Respiratory rate > 35 per minute for 5 minutes.
≥
•Oxygen saturation 88% for 5 minutes.
≤ ≥
•Acute cardiac dysrhythmia.
•
≥
2 signs of respiratory distress, including
tachycardia, bradycardia, accessory muscle use,
abdominal paradox, diaphoresis or marked
pyrexia.
Failure criteria for sedation
interruption

15. •Propofol
•Alpha2 agonists: dexmedetomidine
•Benzodiazepines: midazolam (infrequently used)
•Analagesics i.e. opioid infusions are often
combined
Treat
Sedatives used in ICU

16. •IV anaesthetic
•Frequently used on ICU and given as an infusion
•Insoluble in water and prepared in a lipid
emulsion, calorie content 1 calorie per ml
•Available in 1% and 2% preparations
•Rapid onset of action i.e. 30 seconds
•Single dose will last 5 to 10 minutes
•No change in pharmacokinetics with hepatic or
renal dysfunction
Propofol
Treat

17. •Respiratory depression
•Suppression of laryngeal reflexes – caution is
required in patients with unprotected airways.
•Cardiovascular depression
•Inotropic/vasopressor support often necessary
•Hypertriglyceridaemia
•No analgesic properties
•Pain if given peripherally
Adverse effects of propofol
Treat

18. •Benzodiazepine
•Produces sedation, amnesia, muscle relaxation and
has anti-epileptic effects
•Rapid onset of action i.e. 30 secs to 2 minutes
•Minimal accumulation occurs with infusions <24hrs
but can occur thereafter
•Metabolism can be affected by hepatic function/blood
flow and other drugs – wide variability in half-life
•Not frequently used but may have a role in alcohol
and drug withdrawal.
Treat
Midazolam

19. •Hypotension
•Delirium
•Accumulation when given by IV infusion
especially > 24hrs
•Slow to wear off
•Liver and renal impairment can prolong
sedative effect
•No analgesic properties
Adverse effects of midazolam
Treat

20. •Alpha-2 agonists
•CNS actions include sedation, anxiolysis and analgesia but
without reduced respiratory depression “awake sedation”
•Dexmedetmodine has a higher affinity to alpha-2 receptor than
clonidine making its sedative effects more prominent
•Dexmedetomidine only licensed for patients requiring RASS no
deeper than -3
•Sedation is unique – patients can be roused more readily. Can
extubate patient without stopping sedation. Doesn’t produce
delirium.
•Dexmedetomidine decreases ventilation compared to midazolam
(but not to propofol)
Dexmedetomidine and Clonidine
Treat

21. •Bradycardia most common
•Hypotension
•Rebound hypertension on abrupt withdrawal
•Dose reduction may be needed in elderly/frail and
hepatic impairment
•Expensive – Consultant only
•Contraindications - advanced heart block unless paced,
uncontrolled hypotension, acute cerebrovascular
conditions
Adverse effects of Dexmedetomidine
Treat

22. Dexmedetomidine infusion table
Titrate infusion up or down every 10 minutes as per BP/HR
response
Infusion table: dexmedetomidine 8 micrograms/ml

23. Dexmedetomidine
Treat
•Patient aged 50 years
•Weighs 80kg
•Starting dose is 7mls/hr
•Titrate dose up every 10 minutes where possible to
maximum dose i.e. 14mls/hr provided BP and HR are
stable
•The propofol infusion needs to be titrated
↓
and suggest
doing this every 10 minutes