Sedation in the ICU
Brenda Pun, MSN, RN, ACNP ICU Delirium and Cognitive Impairment Study Group Vanderbilt University Medical Center Nashville, Tennessee www.icudelirium.org
Need for Sedation and Analgesia • Prevent pain and anxiety • Decrease oxygen consumption • Decrease the stress response Decrease the stress response • Patient‐ventilator synchrony • Avoid adverse neurocognitive sequelae - Depression, PTSD, anxiety Rotondi AJ, et al. Crit Care Med. 2002;30:746‐752. Weinert C. Curr Opin in Crit Care. 2005;11:376‐380. Kress JP, et al. Am J Respir Crit Care Med. 1996;153:1012‐1018.
Potential Drawbacks of Sedative and Analgesic Therapy • Oversedation: – Failure to initiate spontaneous breathing trials (SBT) leads to increased duration of mechanical ventilation (MV) – Longer duration of ICU stay – Burst suppression (EEG)—linked to ↑ 6 month mortality – PTSD
• Impede assessment of neurologic function • Increase risk for delirium • Numerous agent‐specific adverse events Watson, et al., CCM 2008; 36: 3171‐77 Kress, JP, et al., AJRCCM 2003; 168:1457‐1461 Kollef MH, et al. Chest. 1998;114:541‐548. Pandharipande PP, et al. Anesthesiology. 2006;104:21‐26.
1
ICU Sedation: It’s a Balancing Act
Consequences of Suboptimal Sedation Inadequate sedation/analgesia
• Anxiety • Pain • Patient‐ventilator dyssynchrony d h • Agitation – Self‐removal of tubes/catheters
• Care provider assault • Myocardial ischemia • Family dissatisfaction
Excessive sedation • Prolonged mechanical ventilation, ICU LOS – Tracheostomy – DVT, VAP
• • • •
Additional testing Added cost Inability to communicate Cannot evaluate for delirium
What are we trying to achieve?
2
“Cooperative” sedation • Calm & easily arousable state while minimizing pain, anxiety, or agitation unless contraindicated • Easy transition from sleep to wakefulness & task performance when aroused1 performance when aroused • Able to resume rest when not stimulated1 • Allows for interaction in care decisions2 • Reduces risk of drug‐induced complications3 1Bekker AY, et al. Neurosurgery 2Burns
2005;57(1 Suppl 1):1‐10 AM, et al. Drugs 1992;43:507‐515
3Sedation. Encyclopedia of Medicine. Ed. Jacqueline L. Longe. Thomson Gale, 2002. eNotes.com
What About the New SCCM Guidelines? • Clinical practice guidelines for Pain, Agitation, and Delirium (PAD) – To be published 2012
• Not prescriptive or a specific protocol—a guide N t i ti ifi t l id • Allows for liberty in implementation • ABCDE bundle provides the first steps in creating a framework or backdrop for implementation of these guidelines
Assessment
3
What is “oversedation”? • N=274 patients from 2001 to 2003 • Sedatives were given during 85% of measured intervals • 1 in 3 were unarousable (32%) • 1 in 5 had no spontaneous motor activity (21%) • Little variation over 24 hours in LOC, motor activity, or drug dose given
Weinert CR, et al. Crit Care Med. 2007;35:393‐401.
Determining Level of Consciousness
Assessing Agitation and Sedation • Sedation-Agitation Scale (SAS) – Riker RR, et al. Crit Care Med. 1999;27:1325‐1329. – Brandl K, et al. Pharmacotherapy. 2001;21:431‐436.
• Richmond Agitation Agitation-Sedation Sedation Scale (RASS) – Sessler CN, et al. Am J Respir Crit Care Med. 2002;166(10):1338‐1344. – Ely EW, et al. JAMA. 2003;289:2983‐2991.
4
Richmond Agitation Sedation Scale (RASS) Score
State
+ 4
Combative
+ 3
Very agitated
+ 2
Agitated
+1 + 1
Restless
0
Alert and calm
‐1
Drowsy
eye contact > 10 sec
‐2
Light sedation
eye contact 20mg/day = 100% probable!
Pandharipande PP, et al. Anesthesiology; 104:21-26, 2005.
Analgosedation • 140 critically ill adult patients undergoing mechanical ventilation in single center • Randomized, open‐label trial – Both groups received bolus morphine (2.5 or 5 mg) – Group 1: No sedation (n = 70 patients) ‐ morphine prn – Group 2: Sedation (20 mg/mL propofol for 48 h, 1 mg/mL midazolam thereafter) with daily interruption until awake (n = 70, control group)
• Endpoints – Primary ¾ Number of days without mechanical ventilation in a 28‐day period
– Other ¾ Length of stay in ICU (admission to 28 days) ¾ Length of stay in hospital (admission to 90 days)
Strøm T, et al. Lancet. 2010;375:475‐480.
Analgosedation Results • Patients receiving no sedation had – More days without ventilation (13.8 vs 9.6 days, P = 0.02) – Shorter stay in ICU (HR 1.86, P = 0.03) – Shorter stay in hospital (HR 3.57, P = 0.004) – More agitated delirium (N = 11, 20% vs N = 4, 7%, P = 0.04)
• No differences found in – Accidental extubations – Need for CT or MRI – Ventilator‐associated pneumonia
Strøm T, et al. Lancet. 2010;375:475‐480.
13
Maximizing Efficacy of Targeted Sedation and Reducing Neurological Dysfunction (MENDS) • Double‐blind RCT of dexmedetomidine vs lorazepam • 103 patients (2 centers) – 70% MICU, 30% SICU patients (requiring MV > 24 hours) – Primary outcome: Days alive without delirium or coma
• Intervention – Dexmedetomidine 0.15–1.5 mcg/kg/hr – Lorazepam infusion 1–10 mg/hr – Titrated to sedation goal (using RASS) established by ICU team
• No daily interruption
Pandharipande PP, et al. JAMA. 2007;298:2644‐2653.
MENDS Delirium: All Patients
Pandharipande PP, et al. Crit Care. 2010;14:R38.
14
MENDS: Survival in Septic ICU Patients
Pandharipande PP, et al. Crit Care. 2010;14:R38.
Reduced Delirium Prevalence with Dexmedetomidine vs Midazolam (SEDCOM)
Patients With Delirium, %
100
Dexmedetomidine versus Midazolam, P
