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The Art of Sedation in ICU. Yasser Zaghloul MD PhD, FCARCSI (Ireland). Sedation comes from the Latin word sedare . Sedare = to calm or to allay fear. Hypnosis. Analgesia. ± Muscle Relaxation. Sedation comes from the Latin word sedare . Sedare = to calm or to allay fear. Hypnosis.

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the art of sedation in icu

The Art of Sedation in ICU

Yasser ZaghloulMD PhD, FCARCSI(Ireland)

slide2

Sedation comes from the Latin word sedare.

  • Sedare = to calm or to allay fear

Hypnosis

Analgesia

± Muscle

Relaxation

slide3

Sedation comes from the Latin word sedare.

  • Sedare = to calm or to allay fear

Hypnosis

Analgesia

± Muscle

Relaxation

why sedation is necessary
Why sedation is necessary?
  • To improve patient comfort.
  • Reduce stress.
  • Facilitate interventions.
  • Allow effective ventilation.
  • Encourage sleep.
  • ?? Prevent post-ICU psychosis.
inadequate sedation
Inadequate Sedation
  • All ICU patients suffer from severe sleep deprivation.
  • REM sleep is 6% ( Normal 25 %).
  • Stress  neuroendocrine response

( ACTH, GH, Aldosterone, Adrenaline, .....)

  • Release of cytokines  inflammatory response.
non pharmacological interventions
Non-pharmacological interventions
  • Good nursing.
  • Psychological:

- Explanation. - Reassurance.

  • Physical:

- Touching & message. - Environment

- Prevent constipation - Physiotherapy.

- Tracheostomy.

sedation analgesia medications
Sedation-Analgesia Medications
  • IV Anaesthetics:

- Prpofol - Thiopentone.

- Ketamine - Etomidate.

  • Benzodiazepines:

- Midazolam.

- Lorazepam

sedation analgesia medications1
Sedation-Analgesia Medications
  • Opiodis:

- Morphine

- Fentanyl.

- Remifentanil

  • α-2 receptors agonists:
    • Clonidine.
    • Dexmedetomidine .
sedation analgesia medications2
Sedation-Analgesia Medications
  • Others:

- Inhalation anaesthetics (Sevoflurane).

- Phenothiazines.

- Butyrophenones (Haloperidol).

- Local Anaesthetics.

choice of the sedative drug
Choice of the sedative drug
  • Short-term Vs long-term sedation.
  • Pain & painful Procedures.
  • Organ problems (Renal, hepatic, brain, CVS).
  • Drug withdrawal (Alcohol, heroin, .....)
  • Prescriber & Prescription.
which medication
Which Medication?

Soliman et al, Brit J Anaesth 2001;87:186-92

iv anaesthetics thiopentone
IV Anaesthetics; Thiopentone
  • Acts on the GABAA.
  • Zero order kinetics (accumulation).
  • Provides a cerebral protection effect.
  • Main uses in ICU:

- High ICP.

- Status epilepticus

iv anaesthetics propofol

OH

(CH3)2CH

CH(CH3)2

IV Anaesthetics; Propofol

2,6 di-isopropyl phenol

Short-term sedation (< 48 h)

iv anaesthetics propofol1
IV Anaesthetics; Propofol
  • Mechanisms of actions:

- Acts on GABAA receptors in the hippocampus.

- Inhibits of NMDA.

  •  IOP, ICP & CMRO2.
iv anaesthetics propofol2
IV Anaesthetics; Propofol
  • Decreases (10 – 30%):

- HR.

- SBP, DBP & MAP.

- SVR.

- CI.

- SV.

target concentrations with diprifusor tci
Target concentrations with ‘Diprifusor’ TCI

Full ‘Diprivan’ PFSis loaded correctly

Finger grip Tag = PMR(Programmaable Magnetic Resonance*)

Aerial

‘Diprifusor’ TCI SubsystemRecognition software/electronics‘Diprifusor’ TCI Software/2 microprocessors

Pumpsoftware

Pump hardware

target concentrations with diprifusor tci1

Calculated concentration

(automatic calculation and display by system)

Target concentration

(selected by anaesthetist, displayed)

5

2

3

4

1

Target concentrations with ‘Diprifusor’ TCI

1200

8

End

↑ Tc

Titration

6

6

Age

Wt.

Tc

4

Infusion rate (ml/h)

Blood concentration (µg/ml)

100

4

50

2

0

0

16

0

4

8

12

20

24

28

Start; 6µg/ml

Time (hours)

iv anaesthetics propofol3
IV Anaesthetics; Propofol
  • Propofol infusion syndrome:

- Rare but fatal.

- 1st described in children.

- Infusion ≥ 5 mg/kg/hr or ≥ 48 hours.

propofol infusion syndrome
Propofol Infusion Syndrome
  • Clinical features:

- Cardiomyopathy with acute cardiac failure.

- Myopathy.

- Metabolic acidosis, K+

- Hepatomegaly.

  • Inhibition of FFA entry into mitochondria  failure of its metabolism.
iv anaesthetics ketamine1
IV Anaesthetics - Ketamine
  • Phencyclidine derivative.
  • High lipid solubility (5–10 times > thiopental) crosses BBB faster.
  • Non-competitive antagonism at NMDA receptor
iv anaesthetics ketamine2
IV Anaesthetics - Ketamine
  •  HR, BP.
  •  CBF, ICP & CMRO2.
  • Bronchial smooth muscle relaxant.
  • Excellent analgesic.
  • Dose: 5-30 µg/kg/min.
opioids morphine
Opioids; Morphine
  • Isolated in 1803 by the German pharmacist Friedrich Adam.
  • Named it 'morphium' after Morpheus, the Greek god of dreams.
opioids morphine1
Opioids - Morphine
  • Plasma levels do not correlate with clinical effect.
  • Low lipid solubility causes slow equilibration across BBB.
  • Metabolized in the liver by conjugation.
  • Morphine-6-glucuronide (active).
remifentanil
Remifentanil
  • Piperidine derivative.
  • Selective mu-receptor agonist.
  • Potency similar to fentanyl.
  • Terminal half-life < 10 min.
  • Rapid blood-brain equilibrium.
  • Metabolised by non-specific esterases.
plasma concentration after long term infusion

Fentanyl 262 min

Alfentanil 59 min

Sufentanil 34 min

Remifentanil 3.7 min

Plasma concentration after long term infusion

After 240 min

Context –sensitive half-time

100

75

Time to 50% drop in concentration at effect site (minutes)

50

25

0

0

100

200

300

400

500

600

Duration of infusion (minutes)

unwanted side effects of opioids
Unwanted side-effects of opioids

Opioids

Confusion

Vasodilation

Respiratorydepression

Gut motilitydepression

benzodiazepines midazolam
Benzodiazepines; Midazolam
  • Water-soluble  lipid soluble in the body.
  • Produces sedation, anxiolysis and amensia.
  • Withdrawal agitation.
2 adrenergic agonists
α2-Adrenergic agonists

Clonidine

Dexmedetomidine

2 agonists
α2 – agonists
  • Sedation-hypnosis:

by an action on α2-receptors in the locus ceruleus.

  • Analgesia:

by an action on α2-receptors within the locus ceruleus and the spinal cord

2 agonists dexmedetomidine
α2 – agonists; Dexmedetomidine
  • 94% protein bound.
  • Narrow therapeutic range (0.5 - 1.0 ng/mL)
  • It undergoes conjugation & N-methylation.
  • Approved only for sedation ≤ 24 h.
2 agonists1
α2 – agonists
  • Haemodynamics Effects:

-  heart rate.

- Initial  then  BP.

-  SVR.

-  CO

  • No respiratory depression
unwanted side effects of sedative agents
Unwanted side-effects of sedative agents

General

Over sedation

Delayed awakening/extubation

  • 2-agonists
  • Hypotension
  • Bradycardia

Benzodiazepines

Hypotension

Respiratory depression

Agitation/Confusion

Propofol

Hypertriglyceridemia

CVS depression

Hypotension

  • Ketamine
  • Hypertension
  • Secretions
  • Dysphoria
assessment of sedation
Assessment of Sedation
  • Ramsay Sedation Score.
  • Motor Activity Assessment Scale
  • Richmond Agitation–Sedation Scale.
  • Sedation – Agitation Score.
  • Modified Glasgow Coma Score.
the art of sedation
* Under sedation:

Fighting the ventilator.

V/Q mismatch.

Accidental extubation.

Catheter displacement.

CV stress  ischemia.

Anxiety, awareness.

Post-traumatic stress disorder.

* Over sedation:

Tolerance, tachyphylaxis.

Withdrawal syndrome.

Delirium.

Prolonged ventilation.

CV depression.

 neuro testing.

Sleep disturbance.

The Art of Sedation
thank you

Thank You

Yasser Zaghloul