Sedation and analgesia in the ICU

1. Sedation and analgesia in the ICU Dr Jeju Nath Pokharel, MD Sr consultant anesthesiologist and Head Dept of Anesthesiology SGNHC, Bansbari, Kathmandu, Nepal

2. Some definitions • Pain – It is an unpleasant sensory and emotional experience associated with actual or potential tissue damage. • Analgesia - is defined as the blunting or absence of sensation of pain or noxious stimuli. (ACCM 2002) • Anxiety - a sustained state of apprehension with accompanying autonomic arousal in response to a real or perceived threat. • Delirium – an acute, potentially reversible impairment of consciousness and cognitive function that fluctuates in severity. • Agitation – it is characterized by extreme arousal,irritability, excess motor activities driven by internal sense of discomfort such as disease, pain, anxiety and delirium.

3. Background • One third of all patients in intensive care units (ICUs)worldwide are mechanically ventilated. • Common conditions in mechanically ventilated, critically ill, trauma patients are acute pain, anxiety, and delirium. • ICU patients frequently experience pain and physical discomfort from obvious factors, such as pre-existingdiseases, invasive procedures, or trauma. Pain and discomfort also can be caused by: - monitoring and therapeutic devices such as catheters, drains, and endotracheal tubes - performing routine nursing care (e.g., airway suctioning, physical therapy, dressing changes, patient mobilization) -prolonged immobility.

4. Background • unrelieved pain may contribute to inadequate sleep and disorientation, and evoke a stress response, decreased cell repair cellular immunity. • Severely ill patients in a stressful environment for prolonged periods may also experience delirium. • Delirium itself is attributed to increased length of hospital stay, increased health care costs, and higher mortality. • Additionally, the ICU patient may experience heart, lung, liver, and kidney complications, Post Traumatic Stress Disorder (PTSD), and long-term cognitive decline.

5. Background • Safe and effective management of an ICU patient’s pain and anxiety demands a delicate balance of analgesia and sedation protocols while managing delirium.

6. Why sedation and analgesia is required ? • To improve patient comfort. • Reduce stress. • Facilitate interventions. • Allow effective ventilation/oxygenation. • Encourage natural sleep. • ?? Prevent post-ICU psychosis.

7. Sedation comes from the Latin word sedare. • Sedare = to calm or to allay fear Analgesia Hypnosis ± Muscle Relaxation

8. Balancing Pain and Anxiety Treatment

9. PROMOTE NATURAL SLEEP CYCLE • Allow natural sleep at night • Stick to the schedule for sleep. • Avoid frequent waking tasks and prevent interruptions. • Use back massage to relax the patient for sleep. • Create a quiet, dark environment conducive to sleep as much as possible, lessen outside lighting, turn off lights including flashing indicators, and reduce human and mechanical noise. • Use natural sleep cues ( lighting, noise, smells, room with windows which can mimic 24 hour day to regulate day light /darkness. • Use music therapy to encourage sleep. • Facilitate patient’s familiarity with environment.

10. Employ comfort measures: • Provide complementary holistic therapies • Encourage family to stay at bedside • Remove unnecessary lines and tubes • Remove or minimize restraints • Encourage family to be at the bedside and engage the patient in activities as well as sitting quietly with the patient to promote rest

11. PATIENT ASSESSMENT

12. PATIENT ASSESSMENT

13. Pain • Pain is an unpleasant sensory or emotional experience that is associated with tissue damage or described in terms of tissue damage. (International Association for the Study of Pain,www.iasp-pain.org). • All critically ill patients have the right to adequate analgesia and management of their pain. • A patient’s pain experience in the ICU need not be memorable given effective attention and application of pain management and amnesic agents.

14. Self reporting pain assessment scale: Wong –Baker FACES Pain rating scale

15. Non – verbal reporting of pain:10 point non – verbal pain scale.

16. Non verbal reporting of pain:The Critical-Care Pain Observation Tool (CPOT)

17. Pain management algorithm

18. Some analgesics

20. Sedation • Sedatives are drugs that calm a patient down, easing agitation and permitting sleep. • Sedatives generally work by modulating signals within the central nervous system. • The appropriate target level of sedation is a calm patient that can be easily aroused with maintenance of the normal sleep-wake cycle (SCCM). • Advantage/disadvantage • Robinson et al (2008) found continuous sedative infusions for critically ill patients have been shown to increase the duration of mechanical ventilation and length of intensive care stay, despite perceived advantages. • coordinated daily interruption of sedative infusions with objective re-titration in critically ill patients has been shown to decrease the durations of mechanical ventilation and length of ICU stay.

21. Sedation assessment scales • Richmond Agitation Sedation Scale (RASS) RASS Target Sedation = 0 to -3 • Riker Sedation-Agitation Scale (SAS) SAS Target Sedation = 3 to 4 • Ramsay scale ( RS ) • VICS (Vancouver Interaction and Calmness Scale) • MAAS (Motor Activity Assessment Scale) • The AVRIPAS scale • The BLOOMSBURY Scale • HS (Harris Scale) • ATICE (Adaptation to the Intensive Care Environment).

22. Sedation assessment scales

23. Sedation assessment scale

24. Sedation assessment scales • RS (Ramsay Scale): Level Response 1 Awake and anxious, agitated, or restless 2 Awake, cooperative, accepting ventilation, oriented, tranquil 3 Awake; responds only to commands 4 Asleep; brisk response to light glabellar tap or loud noise 5 Asleep; sluggish response to light glabellar tap or loud noise stimulus but does not respond to painful stimulus 6 Asleep; no response to light glabellar tap or loud noise Figure . The Ramsay Scale. Modified from Ramsay M, Savege T, Simpson BRJ, et al. Controlled sedation with alphaxalone/alphadolone. BMJ 1974;2:656–569.

25. Non pharmacological methods of sedation • environment modification, • relaxation, back massage, and music therapy when appropriate.

26. Pharmacological method of sedation

27. Pharmacology of selected sedatives

28. Daily awakening trial • A Daily Awakening Trial (or Sedation Vacation) is titrating down continuous infusions of sedatives or holding sedation bolus until the patient is awake • Once the patient is awake and responsive, an accurate sedation, pain, and delirium assessment can be obtained • It is recommended to couple spontaneous breathing trial protocols with sedation protocols • combining a spontaneous breathing trial protocol with a daily wakening trial results in patients spending less time on mechanical ventilation, less time in coma, and less time in intensive care and the hospital.

29. Daily Awakening Trial and Spontaneous Breathing Trial

30. SEDATIVE AND ANALGESICWITHDRAWAL Benzodiazepines • dysphoria, • tremor, • headache, • nausea, • sweating, • fatigue, • anxiety, • agitation, • increased sensitivity to light and sound, • paresthesias, • muscle cramps, myoclonus, • sleep disturbances, • delirium, and • seizures. Opioids • dilation of the pupils • sweating, • lacrimation • rhinorrhea, • piloerection • tachycardia, • vomiting, • diarrhea, • hypertension, • yawning, • fever, • tachypnea, • restlessness, • irritability, • increased sensitivity to pain, • cramps, muscle aches, • anxiety.

31. DELIRIUM • Delirium, characterized by fluctuations in mental status such as inattention,disorganized thinking,hallucinations, disorientation, and an altered level of consciousness, is a frequent occurrence in the intensive care unit (ICU). • Occurs in up to 65 percent of hospitalized patients, and up to 87percent of patients admitted to the ICU. Hyperactive delirium, Hypoactive delirium, Mixed delirium

32. Agitation & delirium: an aide memoire for routine use I WATCH DEATH • Infection • Withdrawal • Acute metabolic problem • Trauma/ pain • CNS pathology • Hypoxia/Hypoglycemia • Deficiencies (B1, B12) • Endocrinopathies • Acute vascular • Toxins/ drugs • Heavy metals DELIRIUM • Drugs • Electrolyte abnormalities • Lack of drugs • Infection • Reduced sensory input • Intracranial problem • Urinary retention & fecal impaction • Myocardial infarction

33. Drugs that can cause Delirium • Anti-arrhythmics Lidocaine Mexilitine Quinidine • Antibiotics: Penicillin • Anti-cholinergics: atropine • Anti-histaminics • Beta-blockers: propranolol • Narcotics: meperidine • Morphine • Pentazocine

34. Delirium Assessment (CAM-ICU) Algorithm

35. Intensive Care Delirium Screening Checklist (ICDSC)

36. Risk Factors for Delirium • Delirium in patients usually develops between 24 and 72 hours after admission to ICU. • Risk factors before hospitalization: cognitive impairment, chronic illness (including hypertension), advanced age (over 65 years), depression, smoking, alcoholism, and severity of illness. • Risk factors during hospitalization: Congestive heart failure, sepsis, prolonged restraint use and immobility, withdrawal, seizures, dehydration, hyperthermia, head trauma, intracranial space-occupying lesions, and the use of specific medications: LORazepam/ Midazolam, Morphine/fentanyl, and Propofol.

37. Delirium Management Algorithm

38. ConclusionICU sedated pt care map

39. Thank you for attention !