Réunion anniversaire SSAR SSMI Bâle 15-17 novembre 2012

Coping with the awakening patient Direction générale Centre des formations Brunner Dominique Infirmière Certifiée SI Chargée de formation

ICU sedation combines all means, pharmacological or not, used to ensure the comfort and safety of patient care in a physically and/or psychologically hostile environment.

Sauder, P.& al. (2008). Conférence de consensus commune (SFAR-SRLF) en réanimation. Sédation-Analgésie en réanimation (nouveau-né exclu). Réanimation Traduction K Grant, CHUV Lausanne.

Agenda • • • • • •

new models of sedation actual practices recommended care models nurses’ representation of sedated patients patients’ comments tools to help nurses manage moderate sedation • take home message

New models of sedation • • • •

protocols, guidelines moderate or «conscious » sedation daily interruption of sedation intermittent sedation administration (bolus doses) • patient controlled-sedation Jacobi & al 2002 + 2007, Brattebo & al 2002 + 2004, De Jonghe & al, 2005 + 2007, Chanques & al, 2006, Arias-Rivera & al, 2006 + 2008, Eliott 2006 /Mehta & al, 2007, Girard & al, 2008, Weir & O’Neill, 2008, Bucknall & al, 2008, Tanios & al, 2009 / Kress & al, 2000 + 2003, Schweickert & al, 2004, Girard & Kress, 2008, Mehta & al, 2008, O’Connor & al, 2008, Tanios & al, 2009, Anifantaki & al, 2009, Roberts & al 2010, Miller & al, 2012 / Cigada & al, 2008, Treggiari & al, 2009 / Chlan & al, 2010

Actual practices 0

10

20

30

40

50

60

70

80

90

94

Patients on MV (%)

43

Sedation Assessment

72

Sedation Treatment 42

Analgesia Assessment

90

Analgesia T (opioids) 35

Procedural pain Assessment

Procedural pain T Oversedation state

100

22 57 day 2

day 4

Payen & al.(2007). Current Practices in Sedation and Analgesia for Mehcnically Ventilated Critically Ill Patients. Anesthesiology, 106, 687-695

day 6

Recommended care models Best external evidence

EBM Patient values and expectations

MedInfo.EBMtriadImage. Google

Individual clinical expertise

Nurses’ representation of a sedated patient • the comatose patient • comfort and nursing care • comfort and mandatory ventilation tolerance • security • present experiences

Comatose patient • deep coma = severity of the illness • the severity of a patient’s condition influences the time required for a nurse to evaluate and adapt sedation • awakening model « switch ON-OFF ?» • the risk of deep and prolonged sleep - neurological assessment not possible -  CT scan move • first 48 hours ICU: period with the most diagnostic and therapeutic procedures Kress, 2000. Bucknall, 2003. Roberts & al, 2010

Comfort and nursing care • the concept of comfort in ICU = - physiological indicators - environment and MV tolerance - prevention of anxiety and agitation during nursing care • comfort according to the nursing care organization model used in the ICU - reduce interference during care - perform care effectively Egerod, 2002. Walker & Gillen, 2006. Guttormson & al, 2010. Tanios & al, 2009

Comfort and MV tolerance • impact of nurse-physician language on observations and decisions - confusion the ideal level of sedation

- interpretation « the lack of rest = fighting against the MV »

- changes in decision making « patient adapted to the ventilator or ventilator adapted to the patient ? » Egerod, 2002

Comfort and MV tolerance • daily interruption of sedation

- reduced accumulation of sedative drugs

- faster recovery of mental status sufficiently alert “wake up and breathe” Kress & al, 2000. Sessler & Pedram, 2009. Girard & al, 2008

KRESS (2000) n128

DE JONGHE (2005) n102

20

20

15

15

10

10

5

5

0

0 MV duration

ICU LOS

Sed iv cont

HOSP LOS DIS

MV duration PS Dr

ICU LOS

Hosp LOS

Impl Prot

TREGGIARI (2009) n129 20 15

OUTCOME

10 5

0 MV duration

ICU LOS

Deep sed

Hosp LOS

Light sed

Security • avoid accidental removal of equipment (self-extubation) • identify agitated patients on awakening • false idea that restraints increase patient security • self extubation necessity of reintubation? Bouza & al, 2007. Chang & al, 2008 + 2011. Curry & al. 2008. Tanios & al, 2010. Jarachovi & al, 2011. Da Silva & al, 2012

Security Self-extubation = the patient quicker than or ... ready before the nurse?

Security • apply moderate sedation and encourage early weaning from sedation - better preservation of respiratory muscle - better level of consciousness effect on self-extubation 

• act effectively by a high pain control -  agitation, anxiety, discomfort -  security

Present experiences • preoccupation related to the technical environment • the perception that sleep is necessary for healing and « protection » • protective amnesia?

Weinert, 2001. Jacobi & al, 2002. Egerod, 2002. Payen & al, 2007. Guttormson & al, 2010

Present experiences Protective amnesia?

Lack of recall

Delusional memories

Hallucinations

Risks of Posttraumatic Stress Disorder Samuelson & al, 2003. Kress & al, 2003. Ely & al, 2004. Weinert & Sprenkle, 2008. Treggiari & al, 2009. Jackson & al, 2010

DIS should not be limited to an interruption of sedation

Sedation model advancement Proactiv model

Miller & al, 2012

DIS must lean towards keeping the patient in a state of awareness or awake

Patients comments 1

Hidden experiences Anxiety Fear- nightmares Feelings of isolation Loss of control Impossibility of communicating

Johnson, 2003. Johnson, 2004. Samuelson & al 2007. Hoffhuis & al, 2008. Karlsson & Forsberg, 2008. Samuelson, 2011. Ethier & al, 2011

Patients comments 2 Sleep problems General discomfort + with ET Unpleasant experience ETS Pain Thirst

Visible experiences

Nocturnal sleep

Reduce discomfort Early mobilization

Patient comfort

Equipment removal

Egerod, 2002. Walker & Gillen, 2006. Tanios & al, 2009. Guttormson & al, 2010. Miller & al, 2012

Act on pain ETS

Tools to help nurses manage moderate sedation

Common language

 Quality  changing interaction

« Watch » position Egerod, 2002. Johnson, 2003 + 2004. Walker & Gillen, 2006. Miller & al, 2012

Approach patient problem in a systematic manner

Care + decision = team responsibility

The awakening becomes an indicator of the nurse-patient relationship

Take home message Focus on pain control

Keep patient in a comfortable state of awareness Develop a multidisciplinary caring culture

Evolution of the care sedation model

Proactive attitude, everybody « pooling in the same direction » Model shifting from “tradition to evidence”, from “protection to confrontation”

Improve the patient subjective experience

Thank you for attention

Special thanks to Mrs Kathleen Grant, Béatrice Chevrier, Florence Minchin & Heidi Diaz and to Mr Emmanuel Bernaz, CHUV, Lausanne

Bibliographie •

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Egerod, I. (2002). Uncertain terms of sedation in ICU. How nurses and physicians manage and describe sedation for mechanically ventilated patients. Journal of Clinical Nursing (11), 831-840 Egerod, I. Christensen, B.V.,Johansen, L. (2006). Nurses’ and physicians’ sedation practices in Danish ICUs in 2003. A national survey. Intensive and Critical Care Nursing, 22, 22-31 Ethier, C., Burry, L., Martinez-Motta, C., Tirgari, S., Jiang, D., McDonald, E., Granton, J., Cook, D. & Mehta, S. (2011). Recall of intensive care unit stay in patients managed with a sedation protocol or a sedation protocol with daily sedative interruption: A pilot study. Journal of Critical Care. 26, 127-132 Girard, T.D., Kress, J.P., Fuchs, B.D., Thomason, J.WW., Schweickert, W.D., Pun, B.T., Taichman, D.B., Dunn, J.G., Pohlman, A.S., Kinniry, P.A., Jackson, J.C., Canonico, A.E., Light, R.W., Shintany, A.K., Thompson, J.L., Gordon, S.M., Hall, J.B., Dittus, R.S., Bernard, G.R. & Ely, E.W. (2008). Efficacy and safety of a paired sedation and ventilator weaning protocol for mechanically ventilated patients in intensive care (awakening and Breathing Controlled Trial): a randomized controlled trial. The lancet (371), 126-134 Guttormson, J.L., Chlan, L., Weinert, C.& Savik K. (2010). Factors influencing nurse sedation practices with mechanically ventilated patients: a U.S. national survey. Intensive and Critical Care Nursing, 26, 44-50 Hofhuis, J.G.M., Spronk, P.E., van Stel, H.F., Schrijvers, J.P., Rommes, J.H. & Bakker, J. (2008). Experiences of critically ill patients in the ICU. Intensive and Critical Care Nursing, 24, 300-313 Jackson, D.L., Proudfoot, C.W., Cann, K.F & Walsh, T.S. (2009). The incidence of sub-optimal sedation in the ICU: a systematic review. Critical Care, 13 Jackson, D.L., Proudfoot, C.W., Cann, K.F & Walsh, T.S. (2010). A systematic review of the impact of sedation practice in the ICU on ressource use, costs and patient safety. Critical Care, 14 , R59

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