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Sedation & Paralytic Therapy in the ICU

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Sedation & Paralytic Therapy in the ICU Leanna R. Miller, RN, MN, CCRN-CSC, PCCN-CMC, CEN, CNRN, NP Education Specialist LRM Consulting Nashville, TN – PowerPoint PPT presentation

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Title: Sedation & Paralytic Therapy in the ICU


1
Sedation Paralytic Therapy in the ICU
  • Leanna R. Miller, RN, MN, CCRN-CSC, PCCN-CMC,
    CEN, CNRN, NP
  • Education Specialist
  • LRM Consulting
  • Nashville, TN

2
Objectives
  • Identify the purpose for pain, sedation,
    paralysis management in the ICU patient
  • Analyze and compare assessment methods for
    determining appropriate pain, sedation
    paralysis management.
  • Recognize and apply the different
    pharmacotherapeutics used in the ICU for pain,
    sedation, paralysis.

3
Goals of Critical Care Management
  • Save the salvageable and relieve suffering
  • Peaceful dignified death without prolonging
    life
  • Curative therapy should not supplant palliation
    of pain
  • Use of state-of-the-art interventions
  • Aggressive fast paced therapy according to need
  • Quality pain management mandatory for all patients

4
Consciousness/Sedation
The Balance of Analgesia, Sedation, and
Paralytics to promote comfort
5
What is Sedation?
  • Several Clinical Definitions
  • process of establishing a state of calm
  • promoting a sense of well-being
  • reduction of anxiety and agitation through the
    use of pharmacotherapy
  • Sedation is NOT analgesia
  • 80 of Doctors and 40 of ICU nurses answered
    that benzodiazepines provided analgesia (1990s)

6
Pathophysiology Response of Stress and Anxiety
  • Cardiovascular
  • Release of systemic epinephrine and
    norepinephrine
  • Elevated HR and BP
  • Increased cardiac O2 demand
  • Decrease end-organ perfusion
  • Endocrine
  • Release of Cortisol, Glucagon, Glucose
  • Hyperglycemia

7
Pathophysiology Response of Stress and Anxiety
  • Neurological
  • Increased response and activation of peripheral
    pain fibers
  • Increased sensation to pain
  • Release of neurotransmitters in the brain
  • Pain
  • Agitation
  • Delirium

8
Pathophysiology Response of Stress and Anxiety
  • Immune
  • Increased levels of prostaglandins, cortisol,
    glucose, cytokines,
  • Increase anti-inflammatory response
  • Decrease wound healing

SIGNIFICANT STRESS IN THE ICU PATIENT OVERALL
CAUSES ORGAN ISCHEMIA AND DECREASED HEALING
9
Analgesia
  • Clinical Definition
  • The absence of pain through the use of
    pharmacotherapy
  • Acute and chronic pain in the ICU activates the
    stress response
  • Patients with analgesia can still experience
    anxiety

10
PAIN THERAPY - Myth One size fits all or Set
and forget therapy. Its essentially a maintenance
therapy
11
Truths
  • Majority of ICU patents suffer moderate/severe
    pain
  • 40 are delirious cannot communicate
  • 50 are either physically/emotionally distressed
  • 10-20 have no hopes of cure --- end-of-life in
    ICU
  • Balance between pain relief maintaining
    alertness
  • Multidisciplinary team for multimodal therapies.

12
Pain in ICU
  • Repeated episodes of acute pain? localized
  • Surgery/tissue inflammation immobility
  • catheter/ apparatus discomfort/ nasogastric
    orogastric tubes
  • endotracheal intubation/ suctioning/ chest tubes
  • phlebotomy/vascular access/physiotherapy
  • routine turning positioning the patient

13
Types of pain in ICU
  • Somatic most common localized ? opiates
  • Visceral cramping colicky ? anticholinergics
  • Neuropathic burning / shooting ?
    antidepressants
  • Mixed type ? combination therapy
  • Sustained or chronic pain of varying degrees

14
Inherent Problems
  • difficult to differentiate due to lack of
    communication
  • untreated pain affects all body systems
  • synergistic effect of pain on anxiety,
    depression, sleep
  • all modalities are unpredictable have adverse
    effects
  • pain therapy to be tailored to individual needs.

15
Assessment of pain in ICU
  • Pain as the 5th vital sign- requires frequent
    evaluation
  • Cognitive impairment/delirium markers
  • Behavioral (facial, FACS)
  • Physiological (BP, HR, RR)
  • Creative assessments (teaching hand movements,
    blinking
  • Subjective quantification (numeric/graphic scales
    W-B faces)

16
Assessment of pain in ICU
17
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18
Treatment of Pain
  • treatment of perceived prevention of
    anticipated pain
  • Opiates principal agents in ICU
  • - potent / lack ceiling effects
  • - mild anxiolytic sedative
  • - relieves air hunger suppresses cough in
  • respiratory failure
  • - improved patient ventilator synchrony
  • - effective antagonist naloxone
  • lack amnesic effects /additional sedatives
    required

19
Treatment of Pain
  • adjuvant / non-pharmacological / multimodal
    therapies
  • Simple Relaxation must begin preoperatively
  • Jaw relaxation
  • Progressive muscle relaxation
  • Simple imagery
  • Music (either patient preferred or easy
    listening are effective in reducing mild to
    moderate pain
  • Complex Relaxation must begin preoperatively
  • Biofeedback
  • imagery

20
Causes of Pain in the ICU?
21
The Messengers of Pain
  • Direct tissue damage stimulates pain fibers
  • Local Inflammatory mediators
  • Bradykinin, Prostaglandins, Cytokines
  • Tissue Injury
  • Histamine
  • Serotonin
  • TNF

22
WHY IS THIS IMPORTANT?
23
Common Analgesic Drugs in the CVICU
Drug Dose Onset Peak Duration
Morphine Renal 1 - 4 mg 5 min 20 min 4 - 5 hrs
Fentanyl Liver 25 100 mcg 1 - 2 min 3 - 5 min 30 - 60 min
Remifentanil Plasma .5 40 mcg/kg/h lt1 min lt1 min 3 - 10 min
Dilaudid Liver .25 2 mg 10 - 15 min 15 - 30 min 2 - 3 hrs
Toradol Liver 15 30 mg Immediate 1 - 3 min 6 - 8 hrs
24
A Focus on Morphine
  • First narcotic to be used
  • Narcotic standard
  • Relies on good kidney function for excretion
  • Stimulates mast cells to release histamine
  • Itching
  • Rash
  • Hypotension
  • Acute Asthma episode
  • No longer used frequently due to newer drugs

25
A Focus on Fentanyl
  • 100x stronger then Morphine
  • Fastest metabolizing narcotic used in the CVICU
  • Chest Wall Rigidity
  • can cause shortness of breath and difficulty
    weaning
  • occurs most often with high IV bolus doses
  • Decreases BP and HR

26
A Focus on Remifentanil
  • Newest synthetic narcotic derived from Fentanyl
  • Eliminated by plasma esterases
  • Metabolism not dependent on liver or kidney
    function
  • Elimination not dose dependent
  • Advantages
  • Organ independent metabolism
  • Lack of accumulation
  • Provides analgesia and sedation in ventilated
    patient
  • Disadvantages
  • Expensive
  • Severe withdrawal
  • Rebound hyperalgesia

27
A Focus on Toradol
  • Is a potent IV/IM NSAID
  • Decreases sternal incision pain and inflammation
  • Like many NSAIDs can be nephrotoxic
  • Know your patients BNP and Creatinine
  • Can cause GI bleeding
  • Usually not given if the patient is
  • Age gt75
  • Elevated creatinine
  • Chest tube bleeding
  • Low platelets

28
Sedation in ICU
  • used in the agitated, ventilated for procedure
    discomfort
  • to avoid self extubation removal of catheters
  • NM blockade mandates analgesia sedation
  • control of pain before sedation
  • all have side effects dose dependent
  • analgesics are not sedatives/ Sedatives are not
    analgesics

29
Common Sedatives in the ICU
Drug Dose Onset Peak Duration
Ativan Liver .5 - 2mg 5 min. 60-90 min 6 - 8 hrs
Versed Liver 1 - 2mg 1.5 - 5 min Rapid 2 - 6 hrs
Propofol Liver Starts at 25 mcg/kg/min lt40 sec. 3-5 min 10 - 15 min
Precedex Plasma .2-.7 mcg/kg/hr (3mcg/kg/hr) 15 - 30 min 30 min 60 - 120 min
Ketamine 2 7 mcg/kg/min 30 s 1 min 5 - 10 min
30
A Focus on Precedex
  • Only sedative used that does not cause
    respiratory depression
  • Patients can be weaned and extubated while on
    Precedex
  • Usual titration range 0.2 0.7mcg/kg/hr
  • MD order gt0.7mcg/kg/hr
  • Titrate by 0.1-0.2mcg/kg/hr q30-45min
  • Can cause SEVERE bradycardia and hypotension
  • Very expensive!

31
A Focus on Ketamine
  • dissociative anesthetic ? light sedation
    amnesia
  • used as an adjunct for patients with uncontrolled
    pain or inadequately sedated
  • rarely used in the CVICU due to myocardial
    depressant properties
  • monitor for hallucinations and vivid dreams

32
Assessment of Pain and Sedation
33
Sedation scoring systems
  • Assess levels to vary according to course of ICU
    stay
  • Observational scales - 4 levels min, mod, deep,
    GA
  • Addenbrooke sedation scale 0-7 (vocal, tracheal
    suction)
  • Ramsay sedation scale 1-6 (vocal, glabellar
    tap)--aim for 3-4
  • Direct information- ideal to assess analgesia
    sedation
  • BIS for deep sedated paralyzed

34
RASS ASSESSMENT
  • 4 Combative, violent, danger to self/staff
  • 3 Very agitated, pulls lines, tubes, aggressive
  • 2 Agitated frequent non-purposeful movement,
    fights the vent
  • 1 Restless / Anxious but not aggressive or
    vigorous
  • 0 Alert and calm
  • -1 Drowsy, not fully alert but can stay awake,
    eyes open to voice for gt10sec
  • -2 Light sedation, wake and makes eye contact for
    lt 10 sec
  • -3 Moderate sedation, moves/opens eyes to voice
    but no eye contact
  • -4 Deep sedation, no response to voice but moves
    or opens eyes to physical stimulation
  • -5 Unarousable, no response to stimuli

35
BIS monitor
36
BIS Monitoring
37
BIS Monitor
  • BIS monitor utilizes EEG waveforms.
  • reading is monitored from the patients forehead.
  • excessive muscle activity can interfere with EEG
    detection

38
Bispectral Index
  • BIS an attempt to objectively monitor patients
    sedation
  • processed EEG measurement that gives a score to
    help determine the patients response to sedation
  • useful to help titrate medication
  • proper sensor placement is key to accurate
    monitoring

39
Sensor Application
Apply sensor on forehead at angle Circle 1
Centered, 2 inches above nose Circle 4
Directly above eyebrow Circle 3 On temple,
between corner of eye and
hairline
Press around the edges of each circle to assure
adhesion
Press each circle for 5 seconds
40
BIS Placement
  • Make sure the forehead is clean and dry!
  • Label the sensor with date/time
  • Replace sensor every 24 hours and PRN

41
BIS Monitor
  • implement BIS monitoring on all patients with
    paralytic drips infusing
  • purpose of BIS monitor is to provide a direct
    measurement of the SEDATIVE effects on the brain.
  • goal for BIS Monitoring will be 40 60.
  • studies have indicated that this is a safe range
    for no memory recall.

42
BIS Monitoring
43
Troubleshooting the BIS
  • If the BIS increases suddenly or is higher than
    expected
  • Consider
  • Is the sedative dose sufficient?
  • Is there an increase in stimulation?
  • When was the last analgesic given?
  • Is the patient adequately paralyzed? TOF?
  • Is the patient having a seizure

44
Troubleshooting the BIS
  • If the BIS decreases suddenly or is lower than
    expected
  • Consider
  • Has there been a decrease in stimulation or
    increase in sedation/analgesia?
  • Is the patient significantly hypothermic?
  • Has there been a sudden significant drop in BP?

45
BIS Monitoring
  • Always consider the overall picture of the
    patient
  • Ex if nothing significant has changed with
    patient and BIS number suddenly reflects very
    different readings then fall back to your overall
    assessment of the patient

46
REMEMBER!
  • Look at the BIG PICTURE!
  • Do Not Forget
  • You are treating a patient not just the number

47
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48
Sedation Vacation
  • Assess for daily awakening
  • Exclusions
  • Increased ICP
  • Neuromuscular blockade
  • Significant ventilation support
  • CABG, immediate post-op

49
Sedation Vacation
  • Is patient awake and calm?
  • SAS 3 4
  • RASS 0 to -1
  • If no, restart sedation _at_ ½ previous dose
  • If yes, proceed to spontaneous breathing trial
    (SBT)

50
Sedation Vacation
  • Assess for SBT
  • Calm co-operative
  • Hemodynamically stable
  • PEEP lt 8
  • FiO2 lt 0.60
  • pH gt 7.34
  • SpO2 gt 90

51
Sedation Vacation
  • SBT Termination Criteria
  • RR gt 35/min for gt 5 minutes
  • SpO2 lt 90 for gt 2 minutes
  • New ectopy
  • HR change 20 from baseline
  • BP change 20 from baseline
  • Accessory muscle use
  • Increased anxiety/diaphoresis

52
Sedation Vacation
  • Conduct SBT for 1 minute
  • Mode CPAP
  • PEEP 0
  • PS _at_ least 5 10
  • FiO2 unchanged

53
Paralytics in the ICU
  • Paralysis the loss of voluntary muscular
    function due to the administration of a paralytic
  • Neuromuscular Blockade Agent (NMB) Drugs that
    obstruct transmission of nerve impulses to the
    muscle
  • Neuromuscular Blockade agents DO NOT BLOCK THE
    TRANSMISSION OF PAIN!!!!

54
Paralytics in the CVICU
  • Sedation and Analgesics must always be given
    FIRST
  • Must use sedatives with an Amnesic affect
  • Benzodiazepines (VERSED)
  • High dose Propofol
  • Paralytics are always given LAST

55
Why Do We Paralyze?
  • Decreases O2 demand
  • ARDS
  • Prevent Patient-Ventilator dysynchrony
  • VDR ventilators
  • BiVent
  • Prevents Shivering in hypothermia patients
  • Shivering increases O2 demand
  • Raises patients temperature
  • Open chest

56
Checklist for chemical paralysis
  • Must be adequately sedated first before paralytic
    administered
  • Must have anxiolytic drip that has amnesic
    properties
  • Must have analgesic drip infusing
  • Must have lubrication for eyes/eye bubbles

57
Common CVICU Paralytics
Drug Dose Onset Peak Duration
Vecuronium .08 - .1 mg/kg 1 min 3-5 min 15-25 min
Pancuronium .04 -.1 mg/kg 30-45 sec 3-4 min 35-65 min
Succinylcholine .6 mg/kg 30-60 sec 1-2 min 4-10min
Nimbex 3 mcg/kg/min 1-2 min 2-5 min 25-44 min
58
A Focus on Vecuronium
  • A non-depolarizing NMB
  • Will NOT increase K
  • Full recovery from paralytic 25-40min
  • Frequently used in the CVICU for intubation or as
    a bolus drug before Nimbex
  • Rarely used as a drip in the absence of Nimbex
  • 0.8-1.2mck/kg/min

59
A Focus on Succinylcholine
  • A depolarizing NMB
  • Can increase K 0.5-1mEq/L
  • KNOW YOUR PATIENTS K before administering
  • Does your patient have any renal disease?
  • Metabolized by plasma cholinesterase
  • Very rapid metabolism 5min
  • Does not rely on kidney or liver function

60
A Focus on Nimbex
  • Is our primary titrating NMB used in the CVICU
  • Is also metabolized in the blood
  • Standard dose is 3mcg/kg/min
  • Titrate range 0.5-5mcg/kg/min
  • Metabolism 45min
  • Changes with hypothermia?

61
Successful Paralysis How do we know?
  • Assessment
  • Movement
  • Spontaneous Breaths
  • Peripheral Nerve Stimulator

62
Peripheral Nerve Stimulators
  • Peripheral Nerve Stimulator A device that
    delivers a determine electrical current to create
    a muscular contraction
  • Used to determine the amount of neuromuscular
    blockade a patient has
  • An increase in NMB will show a decrease response
    to a peripheral nerve stimulator at a set current

63
Train of Four
  • Train of Four 4 consecutive impulses generated
    from the peripheral nerve stimulator resulting in
    4 muscular twitches
  • of twitches seen degree of NMB
  • No blockade 4 twitches
  • Total blockade 0 twitches
  • GOAL IS 1-2 TWITCHES
  • Increase drip by 10 if gt2 twitches
  • Decrease drip by 10 if lt1 twitch

64
Train of Four Facial Nerve
  • Place one electrode on the face at the outer
    canthus of the eye (positive/red electrode)
  • Place the second electrode 2 cm below and
    parallel with the tragus of the ear
    (negative/black electrode)
  • Watch and feel for facial nerve contraction

65
Train of Four Ulnar Nerve
66
Train of Four
  • Must have 2x baseline TOFs before starting NMBs
  • Ulnar nerve is more preferred but facial nerve is
    easier to see/assess
  • Use alcohol pad to wipe clean and dry the skin
    before applying electrode
  • Electrodes must be changed 24 hrs
  • Possibly inaccurate in hypothermia patients

67
Helpful tips for TOF
  • If checking the thumb ensure the leads are
    placed on the ulnar side of the arm(this is where
    the nerve lies)
  • Be careful with applying maximum MAs when leads
    are placed on the face this can lead to
    burns/scarring
  • Check your battery
  • Change your electrodes q24h

68
Putting it all Together
  1. start BIS Monitoring
  2. get a Baseline TOF on two locations
  3. start Sedation and Analgesic Drips
  4. titrate medication up until BIS 40-60
  5. bolus paralytic
  6. start paralytic drip
  7. check TOF q30min until 1-2 twitches
  8. monitor TOF and BIS and titrate drips to endpoints

69
CRUCIAL POINT
  • Prior to the administration of any paralytic
    agent - sedation MUST be administered first. If
    paralytic will be continued as an infusion,
    sedation MUST also be continued.
  • Sedation MUST be a drug that has amnesic
    properties.

70
Drugs that have amnesic effects
  • Benzodiazepine class
  • Examples
  • Versed
  • Propofol (in high doses) dose will be individual
    to patient

71
Intravenous Medicines commonly used in CVICU
  • SEDATION
  • Ativan
  • Versed
  • Propofol
  • Precedex
  • Amnesic properties
  • Amnesic in high doses only
  • DOES NOT have amnesic properties
  • ANALGESIA
  • Morphine
  • Fentanyl
  • Dilaudid
  • Toradol

72
Case Study
  • You are caring for a patient that has an open
    chest, they are on a Nimbex, Fentanyl Versed
    gtts
  • VSs
  • BP 160/90
  • HR 128
  • Vent Settings SIMV 12, TV 450, PEEP 5, PS 10,
    Spontaneous RR 12, 02 saturation 98, TOF 2/4
  • Is anything wrong here?

73
Case Study
  • Patient has open chest, Nimbex, Fentanyl Versed
    gtts
  • VSs
  • 105/68
  • HR 80 Paced
  • Vent settings SIMV 12, TV 600, PEEP 5, PS 10,
    Spontaneous RR 16
  • TOF 2/4
  • Is anything wrong here?

74
Case Study
  • Patient has open chest, has experienced excessive
    blood loss through chest tubes, Nimbex
    Propofol gtts(5 mcg/kg/hr)
  • VSs
  • BP labile 70s to 100s systolic
  • HR 80s paced
  • Vent settings SIMV 12, TV 400, PEEP 5, PS 5,
    Spontaneous RR 14, 02 saturation 98
  • TOF 0/4
  • Is anything wrong here?

75
SCCM task force recommendations
  • Benzodiazepines most popular for sedation
  • Short term sedation
  • Midazolam lt3h (amnesic/ hypotension)
  • propofol infusion syndrome/ pancreatitis
  • Long term lorazepam lt20h /diazepamgt96h (not for
    infusion)
  • Delirium haloperidol - neuroleptic syndrome/
    torsade pointes
  • Antagonist- flumazenil 0.2mg-1mg (withdrawal
    seizures)

76
ReCap of Key Points
  • Sedation
  • Patient may still experience pain, goal is
    anti-anxiety/ relaxation, goal is usually to
    give amnesia
  • Analgesia
  • Used to treat pain, no anti-anxiety properties
  • Paralytics
  • Used to decrease skeletal muscle movement,
    imperative that amnesic drugs be used in
    combination with analgesic meds, MUST sedate
    before paralyzing

77
ReCap of Key Points
  • BIS Monitor
  • Used to strictly assess patients sedation level
  • Goal is 40-60
  • Peripheral Nerve Stimulator
  • Used to strictly assess patients paralytic state
  • TOF goal is 1-2/4

78
Putting it all Together
  1. start BIS Monitoring
  2. get a Baseline TOF on two locations
  3. start Sedation and Analgesic Drips
  4. titrate medication up until BIS 40-60
  5. bolus paralytic
  6. start paralytic drip
  7. check TOF q30min until 1-2 twitches
  8. monitor TOF and BIS and titrate drips to endpoints

79
Final Thoughts
  • give sedation/analgesia before paralytics
  • BIS assess for sedation
  • TOF assess for adequate NMB
  • If in doubt it never hurts to ask!

80
References
  • Gelinas C. Management of pain in cardiac surgery
    ICU patients have we improved over time?
    Intensive Crit Care Nurs. 200723(5)298-303.
  • Girard TD, Shintani AK, Jackson JC, et al. Risk
    factors for post-traumatic stress disorder
    symptoms following critical illness requiring
    mechanical ventilation a prospective cohort
    study. Crit Care. 200711(1)R28.
  • Jacobi J, Fraser GL, Coursin DB, et al. Clinical
    practice guidelines for the sustained use of
    sedatives and analgesics in the critically ill
    adult. Crit Care Med. 200230(1)119-141.
  • Pandharipande PP, Pun BT, Herr DL, et al. Effect
    of sedation with dexmedetomidine vs lorazepam on
    acute brain dysfunction in mechanically
    ventilated patients the MENDS randomized
    controlled trial. JAMA. 2007298(22)2644-2653.
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