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Sedation Monitoring in ICU

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... fatty acids, protein catabolism, and sympathetic tone. ... persistent catabolism. Agitation: deleterious effect on patients. Ventilator dysynchrony, ... – PowerPoint PPT presentation

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Title: Sedation Monitoring in ICU


1
Sedation Monitoring in ICU
  • 2006/07/31
  • ??? Ri???
  • ???? ?????

2
Case
  • 51y/o ???
  • PHx
  • Gout, chronic alcoholic hepatitis for 20yrs
  • 2005/11 advanced esophageal ca
  • Neoadjuvant CCRT
  • 2006/03/06 subtotal esophagectomy gastric tube
    reconstruction jejunostomy

3
Present Illness
  • 2006/07/04 Ischemic bowel and intestinal
    strangulation septic shock
  • Emergent OP perforation repair jejunostomy
  • Wd condition
  • 7/05 Wet dressing bid?7/07 q8h
  • 7/10
  • Turbid wd, Fascial suture tear!
  • N/S 500ml irrigation bid suction
  • 7/12 N/S 4000ml irrigation qd suction
  • 7/20 DC irrigation

4
Distress and agitation in ICU
  • Factors
  • Sleep deprivation, environment, extreme anxiety,
    delirium, adverse drug effect, and pain
  • Hormonal effects
  • increase catecholamines, growth hormone,
    prolactin, vasopressin, cortisol, glucagons,
    fatty acids, protein catabolism, and sympathetic
    tone.
  • ?ischemia, fluid and electrolyte disturbances,
    and decreased wound healing.

5
  • Stress response
  • tachycardia
  • increased myocardial oxygen consumption,
  • hypercoagulability,
  • immunosuppression
  • persistent catabolism
  • Agitation deleterious effect on patients
  • Ventilator dysynchrony,
  • an increase in oxygen consumption,
  • and inadvertent removal of devices and catheters

6
Under- /Over-sedation
  • Under
  • ventilator asynchrony,
  • increase in oxygen consumption,
  • unwanted removal of devices and catheters,
  • resource waste, and
  • posttraumatic stress disorder.
  • Over
  • excessive mechanical ventilation,
  • pneumonia, lung injury,
  • neuromuscular irregularities.
  • Dyssynchronized melatonin secretion? sleep
    pattern derangement? delirium

7
2002 SCCM Guideline for Sedation in ICU
  • Clinical practice guidelines for the sustained
    use of sedatives and analgesics in the critically
    ill adult, Society of Critical Care Medicine,
    Crit Care Med 2002 Vol. 30, No. 1
  • The use of sedation guidelines, an algorithm,or a
    protocol is recommended. (Grade B)
  • The titration of the sedative dose to a defined
    endpoint is recommended with systematic tapering
    of the dose or daily interruption with
    retitration to minimize prolonged sedative
    effects. (Grade A)

8
  • Multidisciplinary development and implementation
    of sedation guidelines
  • ?a defined sedation goal and a protocol-driven
    sedation plan
  • ? direct drug costs (from 81.54 to 18.12 per
    patient per day),
  • ? ventilator time (317 to 167 hours), and
  • ? the lengths of ICU stay (19.1 to 9.9 days) and
    total stay
  • without a change in mortality

9
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10
Assessment? Goal? Therapy
11
Goal
  • Mechanical ventilation
  • Pressure support ventilation, CPAP, SIMV
  • good pt cooperation
  • Ramsay 2, GCSC 13-15, SAS 4, RASS 0
  • Assisted controlled
  • Ramsay 3, GCSC 8-12, SAS 3, RASS -1-3
  • Pressure controlled
  • Ramsay 4-5, GCSC 8-12, SAS 2, RASS -4
  • Agitation and delirium
  • Ramsay 2-3, SAS 3-4, RASS 0-2
  • IICP
  • Ramsay 5, SAS 1, RASS -5

12
An ideal sedation scale
  • Good reliability and validity
  • determination of the degree of sedation and
    agitation,
  • behavioral descriptors,
  • Applicability
  • require minimal training
  • easy to score
  • For diverse patient population
  • guide the titration of therapy to a defined
    sedation endpoint

13
Subjective methods
  • The Ramsay Scale
  • The Glasgow Coma Scale modified by Cook and
    Palma, GCSC
  • The Sedation Agitation Scale, SAS
  • The Richmond Agitation and Sedation Scale, RASS
  • The Bloomsbury sedation scale
  • the Adaptation to the Intensive Care Environment
    (ATICE) scale
  • The Avripas sedation scale
  • the Comfort scale for pediatric patients.

14
Ramsay Scale
  • The most commonly scale used today

15
SAS, Sedation-Agitation scale
  • Stratification of agitation in more categories
    than the Ramsay scale

16
RASS, Richmond Agitation and Sedation Scale
  • studied in diverse pt. population (different
    ICUs, ventilated and non-ventilated)
  • Stratification of agitation and sedation in more
    categories than the Ramsay scale and the SAS

17
Bloomsbury Sedation Scale
  • Recommendations for dosing sedatives
  • reliability not tested

18
GCSC, Glasgow Coma Scale modified by Cook and
Palma
  • useful in mechanically ventilated patients
  • Absence of agitation scoring
  • Unuseful to monitor sedation in agitated patients

19
ATICE, the Adaptation to the Intensive Care
Environment scale
20
  • Useful in mechanically ventilated patients
  • Delirium is not assessed
  • Further studies needed in surgical pt

21
Avripas sedation scale
  • the predetermined standardized sedation goals
    based on the patients weaning classification.

22
The Comfort Scale
  • For pediatric ICU patients
  • Behavioral and physiologic factors related to
    pediatric distress
  • Too Complex

23
Objective methods
  • in chemically paralyzed patients
  • barbiturate coma
  • patients requiring very deep sedation

24
Objective methods
  • Pharmacokinetic methods
  • Physiologic parameters
  • lower oesophageal sphincter contractility
    measurement
  • heart rate variability measurement
  • Neurophysiologic methods
  • Frontalis muscle electromyograms
  • auditory evoked potentials, AEP
  • Electroencephalography, EEG
  • Bispectral Index, BIS
  • Patient State Index, PSI
  • Entropy
  • Narcotrend

25
AEP
  • the latency of the early cortical response
    ?indicator of depth of anesthesia and awareness.
  • Increasing iv anesthetics latencies ? and
    amplitudes ?
  • Previous experience in OR
  • 95 medical and/or surgical ICU patients
  • AEP closest correlation with the Ramsay than
    Cohen, Cambridge, Bloomsbury, and Newcastle
    sedation scores

26
EEG analysis
  • 3 predominant methods
  • time domain analysis methods analyse the changes
    in the EEG signal in respect to time,
  • frequency domain analysis methods analyse the
    changes in the EEG potentials in respect to
    frequency
  • bispectral analysis methods analyse EEG signal
    in respect to its amplitude, its frequency and
    its correlation between phase angle and the
    frequency range of the included waves.

27
PSI
  • 4-channel EEG
  • ?Patient State Analyzer self-norming technique
  • ?values 0 to 100
  • Previous experience in OR
  • useful in assessing patients receiving a
    combination of propofol and sufentanil.
  • the influence of muscle activity uncertain.

28
BIS, Bispectral Index
29
BIS
  • Recommending results
  • good relationship with subjective monitoring
    tools
  • a decreased use of opioids and analgesics using
    BIS-guided sedation therapy
  • Conflicting results
  • poor correlation with subjective monitoring tools
  • intra-individual variation in BIS values even in
    chemically paralyzed patients
  • underestimation of sedation in non-chemically
    paralyzed patients.
  • the use of the BIS monitor in the ICU is still
    unclear.

30
Case
  • 51y/o ???
  • PHx
  • Gout, chronic alcoholic hepatitis for 20yrs
  • 2005/11 advanced esophageal ca
  • Neoadjuvant CCRT
  • 2006/03/06 subtotal esophagectomy gastric tube
    reconstruction jejunostomy

31
Present Illness
  • 2006/07/04 Ischemic bowel and intestinal
    strangulation septic shock
  • Emergent OP perforation repair jejunostomy
  • Wd condition
  • 7/05 Wet dressing bid?7/07 q8h
  • 7/10
  • Turbid wd, Fascial suture tear!
  • N/S 500ml irrigation bid suction
  • 7/12 N/S 4000ml irrigation qd suction
  • 7/ DC irrigation

32
Sedation condition
33
  • When patients exhibit signs of anxiety or
    agitation, the first priority is to identify and
    treat any underlying physiological disturbances,
    such as hypoxemia, hypoglycemia, hypotension,
    pain, and withdrawal from alcohol and other
    drugs.
  • Sedation of agitated critically ill patients
    should be started only after providing adequate
    analgesia and treating reversible physiological
    causes. (Grade C)

34
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35
  • Better match between analgesic and psychoactive
    drugs administered and patients requirements.
  • Improvement process in quality and safety
  • a decrease in duration of sedation
  • decrease duration of ventilation
  • decrease nosocomial infections rate

36
Thank you for your participation!
  • References
  • Sedation monitoring in ICU, S. Rinaldi et al,
    Current Anaesthesia Critical Care (2006)article
    in press
  • Sedation Assessment in Critically Ill Adults
    20012004 Update, Brian D Watson and Sandra L
    Kane-Gill, Ann Pharmacother 2004381898-906.
  • Impact of systematic evaluation of pain and
    agitation in an intensive care unit, G. Chanques
    et al, Crit Care Med 2006 Vol. 34, No. 6
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