《Sedation.ppt.ppt》由会员分享，可在线阅读，更多相关《Sedation.ppt.ppt（90页珍藏版）》请在三一办公上搜索。
1、Sedation,Analgesia,and Neuromuscular Blockade in the Adult ICU,Giuditta Angelini,MDUniversity of WisconsinMadison,WIGil Fraser,PharmD,FCCMMaine Medical CenterPortland,MEDoug Coursin,MD,FCCMUniversity of WisconsinMadison,WI,Objectives,Participants should be able to:Describe the SCCM guidelines for se
2、dation,analgesia,and chemical paralysisDescribe the benefits of daily awakening/lightening and sedation titration programsDevise a rational pharmacologic strategy based on treatment goals and comorbidities Participants should be able to:Describe the SCCM guidelines for sedation,analgesia,and chemica
3、l paralysisDescribe the benefits of daily awakening/lightening and sedation titration programsDevise a rational pharmacologic strategy based on treatment goals and comorbidities,What We Know About ICU Agitation/Discomfort,Prevalence50%incidence in those with length of stay 24 hoursPrimary causes:unr
4、elieved pain,delirium,anxiety,sleep deprivation,etc.Immediate sequelae:Patient-ventilator dyssynchronyIncreased oxygen consumption Self(and health care provider)injuryFamily anxietyLong-term sequelae:chronic anxiety disorders and post-traumatic stress disorder(PTSD),Recall in the ICU,Some degree of
5、recall occurs in up to 70%of ICU patients.Anxiety,fear,pain,panic,agony,or nightmares reported in 90%of those who did have recall.Potentially cruel:Up to 36%recalled some aspect of paralysis.Associated with PTSD in ARDS?41%risk of recall of two or more traumatic experiences.Associated with PTSD in c
6、ardiac surgery,Appropriate Recall May be Important,Factual memories(even unpleasant ones)help to put ICU experience into perspective Delusional memories risk panic attacks and PTSDThe optimal level of sedation for most patients is that which offers comfort while allowing for interaction with the env
7、ironment.,Need for Sedation,AnxietyPainAcute confusional statusMechanical ventilationTreatment or diagnostic proceduresPsychological response to stress,Goals of Sedation in ICU,Patient comfort and Control of painAnxiolysis and amnesiaBlunting adverse autonomic and hemodynamic responsesFacilitate nur
8、sing managementFacilitate mechanical ventilationAvoid self-extubationReduce oxygen consumption,Lack of respiratory depressionAnalgesia,especially for surgical patientsRapid onset,titratable,with a short elimination half-timeSedation with ease of orientation and arousabilityAnxiolyticHemodynamic stab
9、ility,Characteristics of an ideal sedation agents for the ICU,The Challenges of ICU Sedation,Assessment of sedationAltered pharmacologyToleranceDelayed emergenceWithdrawalDrug interaction,Sedation,Sedatives,Causes for Agitation,Undersedation,Sedatives,Causes for Agitation,Agitation&anxietyPain and d
10、iscomfortCatheter displacementInadequate ventilationHypertensionTachycardiaArrhythmiasMyocardial ischemiaWound disruptionPatient injury,Oversedation,Sedatives,Causes for Agitation,Prolonged sedationDelayed emergenceRespiratory depressionHypotensionBradycardiaIncreased protein breakdownMuscle atrophy
11、Venous stasisPressure injuryLoss of patient-staff interactionIncreased cost,Full bladderUncomfortable bed positionInadequate ventilator flow ratesMental illnessUremiaDrug side effectsDisorientationSleep deprivationNoiseInability to communicate,Correctable Causes of Agitation,Causes of Agitation Not
12、to be Overlooked,HypoxiaHypercarbiaHypoglycemiaEndotracheal tube malpositionPneumothoraxMyocardial ischemiaAbdominal painDrug and alcohol withdrawal,Sedation needs to be protocolized and titrated to goal:Lighten sedation to appropriate wakefulness daily.Effect of this strategy on outcomes:One-to sev
13、en-day reduction in length of sedation and mechanical ventilation needs50%reduction in tracheostomiesThree-fold reduction in the need for diagnostic evaluation of CNS,Daily Goal is Arousable,Comfortable Sedation,SCCM practice guidelines can be used as a template for institution-specific protocols.Ti
14、tration of sedatives and analgesics guided by assessment tools:Validated sedation assessment tools(Ramsay Sedation Scale RSS,Sedation-Agitation Scale SAS,Richmond Sedation-agitation Scale RSAS,etc.)-No evidence that one is preferred over anotherPain assessment tools-none validated in ICU(numeric rat
15、ing scale NRS,visual analogue scale VAS,etc.),Protocols and Assessment Tools,Sedating/Analgesia Options,Rule out reversible causes of discomfort/anxiety such as hypoxemia,hypercarbia,and toxic/drug side effect.Assess comorbidities and potential side effects of drugs chosen.Target irreversible etiolo
16、gies of pain and agitation.,Strategies for Patient Comfort,Set treatment goalQuantitate sedation and painChoose the right medicationUse combined infusionReevaluate needTreat withdrawal,Overview of SCCM Algorithm,1,2,3,4,Jacobi J,Fraser GL,Coursin D,et al.Crit Care Med.2002;30:119-141.,Pain,Assess Pa
17、in Separately,Visual Pain Scales,0 1 2 3 4 5 6 7 8 9 10,No pain,Worst possible pain,Signs of Pain,HypertensionTachycardiaLacrimationSweatingPupillary dilation,Principles of Pain Management,Anticipate painRecognize painAsk the patientLook for signsFind the sourceQuantify pain Treat:Quantify the patie
18、nts perception of painCorrect the cause where possibleGive appropriate analgesics regularly as requiredRemember,most sedative agents do not provide analgesiaReassess,Nonpharmacologic Interventions,Proper position of the patientStabilization of fracturesElimination of irritating stimulationProper pos
19、itioning of the ventilator tubing to avoid traction on endotracheal tube,Address Pain,Opiates,BenefitsRelieve pain or the sensibility to noxious stimuliSedation trending toward a change in sensorium,especially with more lipid soluble forms including morphine and hydromorphone.RisksRespiratory depres
20、sionNO amnesiaPruritusIleusUrinary retentionHistamine release causing venodilation predominantly from morphineMorphine metabolites which accumulate in renal failure can be analgesic and anti-analgesic.Meperidine should be avoided due to neurotoxic metabolites which accumulate,especially in renal fai
21、lure,but also produces more sensorium changes and less analgesia than other opioids.,Pharmacology of Selected Analgesics,Opioids,Opioids,Opiate Analgesic Options:Fentanyl,Morphine,Hydromorphone,*Offset prolonged after long-term use*Active metabolite accumulation causes excessive narcosis,Morphine Me
22、tobolism,80%,10%,Morphine-3-G,Antianalgesic,Normorphine,Neurotoxicity,Morphine-6-G,Analgesic(40X),Morphine,Sample Analgesia Protocol,Numeric Rating Scale,Sedation Scoring Scales,Ramsay Sedation Scale(RSS)Sedation-agitation Scale(SAS)Observers Assessment of Alertness/Sedation Scale(OAASS)Motor Activi
23、ty Assessment Scale(MAAS),BMJ 1974;2:656-659Crit Care Med 1999;27:1325-1329J Clin Psychopharmacol 1990;10:244-251Crit Care Med 1999;27:1271-1275,The Ramsay Scale,The Riker Sedation-Agitation Scale,The Motor Activity Assessment Scale,What Sedation Scales Do,Provide a semiquantitative“score”Standardiz
24、e treatment endpointsAllow review of efficacy of sedationFacilitate sedation studiesHelp to avoid oversedation,What Sedation Scales Dont Do,Assess anxietyAssess painAssess sedation in paralyzed patientsPredict outcomeAgree with each other,BIS Monitoring,BIS Monitoring,BIS Range Guidelines,Awake,Resp
25、onds to loud commands or mild prodding/shaking,Low probability to explicit recallsUnresponsive to verbal stimuli,Burst suppression,Flat line EEG,Responds to normal voice,Axiolysis,Moderatesedation,Deep Sedation,100,80,60,40,20,0,BIS,Yes,Address Sedation,Choose the Right Drug,BenzodiazepinesPropofol-
26、2 agonists,Pharmacokinetics/dynamicsLorazepam:onset 5-10 minutes,half-life 10 hours,glucuronidatedMidazolam:onset 1-2 minutes,half-life 3 hours,metabolized by cytochrome P450,active metabolite(1-OH)accumulates in renal diseaseBenefitsAnxiolyticAmnesticSedatingRisksDeliriumNO analgesiaExcessive sedat
27、ion:especially after long-term sustained usePropylene glycol toxicity(parenteral lorazepam):significance uncertain-Evaluate when a patient has unexplained acidosis-Particularly problematic in alcoholics(due to doses used)and renal failureRespiratory failure(especially with concurrent opiate use)With
28、drawal,Sedation Options:Benzodiazepines(Midazolam and Lorazepam),Pharmacology:GABA agonistPharmacokinetics/dynamics:onset 1-2 minutes,terminal half-life 6 hours,duration 10 minutes,hepatic metabolismBenefitsRapid onset and offset and easily titratedHypnotic and antiemeticCan be used for intractable
29、seizures and elevated intracranial pressureRisksNot reliably amnestic,especially at low dosesNO analgesia!HypotensionHypertriglyceridemia;lipid source(1.1 kcal/ml)Respiratory depressionPropofol Infusion Syndrome-Cardiac failure,rhabdomyolysis,severe metabolic acidosis,and renal failure-Caution shoul
30、d be exercised at doses 80 mcg/kg/min for more than 48 hours-Particularly problematic when used simultaneously in patient receiving catecholamines and/or steroids,Sedation Options:Propofol,Sedation-agitation Scale,Riker RR et al.Crit Care Med.1999;27:1325.,Sample Sedation Protocol,Sedation Options:D
31、exmedetomidine,Alpha-2-adrenergic agonist like clonidine but with much less imidazole activityHas been shown to decrease the need for other sedation in postoperative ICU patientsPotentially useful while decreasing other sedatives to prevent withdrawalBenefitsDoes not cause respiratory depressionShor
32、t-actingProduces sympatholysis which may be advantageous in certain patients such as postop cardiac surgeryRisksNo amnesiaSmall number of patients reported distress upon recollection of ICU period despite good sedation scores due to excessive awarenessBradycardia and hypotension can be excessive,nec
33、essitating drug cessation and other intervention,Benzodiazepines,Propofol,Propofol Dosing,3-5 g/kg/min antiemetic5-20 g/kg/min anxiolytic20-50 g/kg/min sedative hypnotic100 g/kg/min anesthetic,Problems with Current Sedative Agents,Alpha-2 Receptors,Brain(locus ceruleus),Spinal Cord,Peripheral vascul
34、ature,SedationAnxiolysisSympatholysis,Analgesia,Vasoconstriction,DEX:Dosing,Loading infusion0.25-1 g/kg(10-20 min),Maintenance infusion0.2-0.7 g/kg/hr,Use Continuous and Combined Infusion,Plasma Level,Load,Maintenance,Repeated Bolus,Plasma levels,Opioid+Hypnotic Infusion,Fentanyl+Midazolam or Propof
35、ol,Analgesia,AmnesiaAnxiolysisHypnosis,Continuous Infusion Regimens,Fentanyl 25-250 g/h,Midazolam 0.5-5 mg/hr,Propofol 15-50 g/kg/min,Choose the Right Drug,Sedation,Analgesia,Amnesia,Anxiolysis,Hypnosis,Propofol,Patient Comfort,Benzodiazepines,-2 agonists,Opioids,Altered PharmacologyMidazolam and Ag
36、e,Harper et al.Br J Anesth,1985;57:866-871,Delayed Emergence,Overdose(prolonged infusion)pK derived from healthy patientsDrug interactionIndividual variationDelayed eliminationLiver(Cp450)Kidney dysfunctionActive metabolites,Opiate and Benzodiazepine Withdrawal,Frequency related to dose and duration
37、32%if receiving high doses for longer than a weekOnset depends on the half-lives of the parent drug and its active metabolites Clinical signs and symptoms are common among agentsCNS activation:seizures,hallucinations,GI disturbances:nausea,vomiting,diarrheaSympathetic hyperactivity:tachycardia,hyper
38、tension,tachypnea,sweating,feverNo prospectively evaluated weaning protocols available10-20%daily decrease in dose20-40%initial decrease in dose with additional daily reductions of 10-20%Consider conversion to longer acting agent or transdermal delivery form,Significance of ICU Delirium,Seen in 50%o
39、f ICU patients Three times higher risk of death by six monthsFive fewer ventilator free days(days alive and off vent.),adjusted P=0.03Four times greater frequency of medical device removalNine times higher incidence of cognitive impairment at hospital discharge,Delirium,Acute onset of mental status
40、changes or a fluctuating course&2.Inattention&,or,Courtesy of W Ely,MD,3.Disorganized Thinking,4.Altered level of consciousness,Risk Factors for Delirium,Primary CNS DxInfectionMetabolic derangementPainSleep deprivationAgeSubstances including tobacco(withdrawal as well as direct effect),Diagnostic T
41、ools:ICU,Routine monitoring recommended by SCCMOnly 6%of ICUs use Confusion Assessment Method(CAM-ICU)or Delirium Screening Checklist(DSC)Requires Patient ParticipationCognitive Test for DeliriumAbbreviated Cognitive Test for DeliriumCAM-ICU,Ely.JAMA.2001;286:2703-2710.,Delirium Screening Checklist,
42、No Patient ParticipationDelirium Screening Checklist,Bergeron.Intensive Care Med.2001;27:859.,Treatment of Delirium,Correct inciting factor,but as for painrelief need not be delayed while identifying causative factorControl symptoms?No evidence that treatment reduces duration and severity of symptom
43、sTypical and atypical antipsychotic agentsSedatives?Particularly in combination with antipsychotic and for drug/alcohol withdrawal deliriumNo treatment FDA approved,Haloperidol,No prospective randomized controlled trials in ICU delirium 700 published reports involving 2,000 patientsThe good:Hemodyna
44、mic neutralityNo effect on respiratory driveThe bad:QTc prolongation and torsades de pointesNeuoroleptic malignant syndrome-only three cases with IV haloperidolExtrapyramidal side effects-less common with IV than oral haloperidol,Atypical Antipsychotics:Quetiapine,Olanzapine,Risperidone,Ziprasidone,
45、Mechanism of action unknownLess movement disorders than haloperidolEnhanced effects on both positive(agitation)and negative(quiet)symptomsEfficacy=haloperidol?One prospective randomized study showing equal efficacy of olanzapine to haldol with less EPSIssuesLack of available IV formulationTroublesom
46、e reports of CVAs,hyperglycemia,NMSTitratability hampered-QTc prolongation with ziprasidone IM-Hypotension with olanzapine IM,Neuromuscular Blockade(NMB)(Paralytics)in the Adult ICU,Used most often acutely(single dose)to facilitate intubation or selected proceduresIssuesNO ANALGESIC or SEDATIVE prop
47、ertiesConcurrent sedation with amnestic effect is paramount analgesic as neededNever use without the ability to establish and/or maintain a definitive airway with ventilationIf administering for prolonged period(6-12 hours),use an objective monitor to assess degree of paralysis.,Neuromuscular Blocka
48、de in the ICU,Current use in ICU limited because of risk of prolonged weakness and other complicationsMaximize sedative/analgesic infusions as much as possible prior to adding neuromuscular blockadeIndicationsFacilitate mechanical ventilation,especially with abdominal compartment syndrome,high airwa
49、y pressures,and dyssynchronyAssist in control of elevated intracranial pressuresReduce oxygen consumptionPrevent muscle spasm in neuroleptic malignant syndrome,tetanus,etc.Protect surgical wounds or medical device placement,Neuromuscular Blocking Agents,Two classes of NMBS:Depolarizers-Succhinylchol
50、ine is the only drug in this class-Prolonged binding to acetylcholine receptor to produce depolarization(fasciculations)and subsequent desensitization so that the motor endplate cannot respond to further stimulation right awayNondepolarizers-Blocks acetylcholine from postsynaptic receptor competitiv
