Fulfilling the need of icu patients
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FULFILLING THE NEED OF ICU PATIENTS
Mazen kherallah, MD, FCCP
Stress in ICU?
Psychological Stress
Environmental Stress
Spiritual Strees
Physical Stress
Psychological Stress in ICU
Psychological Stress in ICU Loss of control Fear of death or serious illness Fear of pain Overwhelming isolation Feelings of helplessness Loss of normal circadian rhythms The disruption of normal sleep patterns Sleep deprivation Disorientation and panic
Can the patient whom we thing is sedated on the ventilator hear and think?
Listen to this…
Alien, sensory rich environment
Environmental Stress in ICU
Environmental Stress in ICU Foreign environments Room temperature Continuous ambient lighting Family not continuously available for
comfort Significant noise from personnel and
medical equipment
12
12
Physical Stress in ICU Attached to equipments with tubes
or wires Intubated and ventilated Treatment or diagnostic procedures Confined (restricted) to bed Uncomfortable bed and pillow Unable to control stool habit
+ Inability to communicate
Frustration and Anger
Excessive stimulation in ICU• Monitoring• Cleaning• Suctioning• Dressing changes• Mobilization• Physical therapy
Anxiety, sleep deprivation 71% of patients in a medical surgical ICU get agitated at
least once (46% severe agitation)Pharmacotherapy 2000; 20: 75-82
Delirium in 87% with fluctuating mental status,
inattention, disorganized thinking with or without
agitationJAMA 2001; 286: 2703-2710
Recall in the ICU• Questionnaire to 80 survivors of ARDS• 80% remembered an adverse experience e.g.
nightmares, anxiety, pain, respiratory distress• 28% met criteria for PTSD
- 41% with recall of 2 frightening experiences
• Other reports suggest 4-15% PTSD in ICU survivors
Crit Care Med 2000; 28: 86-92
Crit Care Med 1998;18:651-659
Sedation Goal
ICU Sedation Goal• Stabilize hemodynamics & modulate
stress response• Reduce motor activity – tolerance of
procedures, facilitate nursing managment
• Facilitate mechanical ventilation• Facilitate sleep patterns
UndersedationUnderdosing ToleranceWithdrawal
OversedationOverdosingDrug accumulationImpaired elimination
Drug interactions Adverse side effects
Incidence of Inappropriate Sedation
Over-sedation
On Target
Under-sedation
54%
15.4%
30.6%
Kaplan L and Bailey H. Critical Care. 2000; 4(1):S110.Olson D et al. NTI Proceedings. 2003; CS82:196.
10%20%
70%
Kaplan L. and Bailey H. 2000
Olson D. et al.2003
Sedation
SedativesCauses for Agitation
Undersedation
SedationCauses for Agitation
Agitation & anxietyPain and discomfortCatheter displacementInadequate ventilationHypertensionTachycardiaArrhythmiasMyocardial ischemiaWound disruptionPatient injury
Oversedation
Sedation
Causes for Agitation
Prolonged sedationDelayed emergenceRespiratory depressionHypotensionBradycardiaIncreased protein breakdownMuscle atrophyVenous stasisPressure injuryLoss of patient-staff interactionIncreased cost
So, we want appropriate sedation, but how?
Sedation Depth
ComplicationsCostsAdverse Outcomes
Complications Adverse Outcomes
BEST OUTCOMES
ADEQUATE/OPTIMALOVERDOSING UNDERDOSING
Is Your Patient Comfortable and at Goal ?
Pain Assessment by Family?
• Surrogates were able to assess presence or absence of pain in 73.5% of patients
• Degree of pain correctly assessed in only 53% of patients
*Crit Care Med 2002;30:119-141
Signs of Pain
Hypertension Tachycardia Lacrimation Sweating Pupillary dilation
Patients who cannot communicate should be assessed through subjective observation of pain-related behaviors (movement, facial
expression, and posturing) and physiological indicators (HR, BP, RR) and the change in these parameters following analgesic therapy
Grade B recommendation
Motor Activity Assessment Scale (MAAS)*
Seven categories to describe the patient’s reaction to stimulation
*Devlin et al. Crit Care Med 1999;27:1271-1275
Score Description Definition
0 Unresponsive Does not move with noxious stimulus*
1 Responsive only to Open eyes OR raises eyebrows OR turns noxious stimuli head toward stimulus OR moves limbs
with noxious stimuli
2 Response to touch Opens eyes OR raises eyebrows OR turns or namehead towards stimulus OR moves limbs when touched or name is loudly spoken
3 Calm and cooperative No external stimulus is required to elicit movement AND patient is adjustingsheets or clothes purposefully andfollows commands
*Noxious stimuli = Suctioning OR 5 sec of vigorous orbital, sternal, or nail bed pressure
Score Description Definition
4 Restless and No external stimulus is required to elicit cooperative movement AND patient is picking at sheets
or tubes or uncovering self and follows commands
5 Agitated No external stimulus is required to elicit movement AND attempting to sit up OR moves limbs out of bed AND does not consistently follow commands (e.g. will lie down when asked but soon reverts back to attempts to sit up or move limbs out of bed
6 Dangerously agitated No external stimulus is required to elicit Uncooperative movement AND patient is pulling at tubes
or catheters OR thrashing side to side or striking at staff OR trying to climb out of bed AND does not calm down when asked
Objective assessment of sedation during:
BIS in the ICU: Key Applications
? Mechanical Ventilation
Neuromuscular Blockade
Bedside Procedures
Drug Induced Coma
GE BIS Display / BIS Sensor
GE BIS Display
BIS Sensor
BIS converts the “raw” EEG
signal to a number 0-100
BIS = 95
BIS = 70
BIS = 50
BIS = 30
Responds to normal voice
Responds to loud commands or mild prodding/shaking
100BIS
80
60
40
20
0
Low probability of explicit recall
Unresponsive to verbal stimulus
Burst suppression
BIS in Deep Sedation
Jaspers et al. Intensive Care Medicine. 1999;25(Suppl 1):S67.
• Titration to maximal Ramsay Score of 6 (unarousable)• Blinded BIS monitoring
Results:• Ramsay Score remains the same, with significant decrease of BIS values over time. • Data suggest possible accumulation of sedatives and inherent risks of over-sedation.
0
10
20
30
40
50
60
70
80
90
100
Day 1 Day 3 Day 5
BIS
Val
ue
BIS
Ram
say Score*
68
4531
6 6 6
23
4
56
* Mondello et al. Minerva Anestesiology. 2002;68(102):37-43.
Ramsay
BIS in Deep Sedation
Riker. AJRCCM 1999De Deyne. Int Care Med 1998
Unarousable
0102030405060708090
100B
ispe
ctra
l Ind
ex (B
IS)
SAS 1 Ramsay 6
• Titration to unarousable state by subjective scale• Blinded BIS monitoring
Results: • Patients were unarousable at maximal sedation score. • All patients appeared similar clinically, but displayed wide variation in
sedation level as measured objectively with BIS monitoring.
Ruling Out Reversible Causes
Sedation of agitated patients should start only after providing adequate analgesia and treating
reversible physiological causesGrade C recommendation
Pain, hypoxemia, hypoglycemia, hypotension, withdrawal from alcohol and other drugs
Correctable Causes of Agitation
Full bladder
Uncomfortable bed position
Inadequate ventilator flow rates
Mental illness
Uremia Drug side effects
Disorientation
Sleep deprivation
NoiseInability to communica
teCold room
Uncomfortable
mattress or pillow
Traction on endotrache
al tube
Sedation
SedativesCauses for Agitation
Sedation Analgesia
“ICU Sedation”
Amnesia Hypnosis Anxiolysis
Patient Comfort
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