Riggi · 2018. 4. 3. · Mehta S, Burr y L, Fer gusson D, et al. Dail Sedation Interruption in Mechanicall Ventilated Criticall Ill Pateints Cared for With a Sedation Protocol A Randomized

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BRINGING THE ABC(DEF)’S TO THE ICU

GINA RIGGI, PHARMD, BCPS, BCCCPCLINICAL HOSPITAL PHARMACIST- TRAUMA INTENSIVE CARE UNIT

JACKSON MEMORIAL HOSPITALMIAMI, FLORIDA

2016 ANNUAL MEETING

DISCLOSURE

I, Gina Riggi, have nothing to disclose concerning possible financial or personal relationships with commercial entities that may have a direct or indirect interest in the subject matter of this presentation.

2016 ANNUAL MEETING

OBJECTIVES

• Identify the potential adverse outcomes of an ICU stay

• Describe the components of ICU liberation

• Evaluate pharmacologic interventions used to treat pain, agitation, and delirium

• Discuss the pharmacist’s role in ABCDEF

2016 ANNUAL MEETING

ICU TRIAD

Figure 1. Reade M and Finfer S. Sedation and Delirium in the Intensive Care Unit. NEJM. 2014. 370:440-454.

2016 ANNUAL MEETING

• Approaches to management of pain, agitation and delirium are linked

• Assess patient’s pain status first before initiating sedation

• Minimize the use of analgesics and sedatives to keep the patient calm and cooperative with their care and to reduce the incidence of delirium

ICU TRIAD

2016 ANNUAL MEETINGFigure 1. Reade M and Finfer S. Sedation and Delirium in the Intensive Care Unit. NEJM. 2014. 370:440-454.

SEDATION AND ANALGESIA

NEED FOR SEDATION AND ANALGESIA

• Prevent pain and anxiety

• Improve ventilator synchrony

• Decrease oxygen consumption

• Decrease the stress response

• Avoid adverse neurocognitive events

POTENTIAL ADVERSE EFFECTS FROM SEDATION AND ANALGESIA

• Over sedation

• Reduced neurological exam

• Increased risk for delirium

• Adverse medication effect

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Oversedation Undersedation

ICU SEDATION:THE BALANCING ACT

GOAL: Patient Comfort and Ventilator Synchrony

2016 ANNUAL MEETING

ICU LIBERATION

• The ABCDEF care bundle elements individually and collectively can help

• Reduce delirium

• Improve pain management

• Reduce long-term consequences

• The interdisciplinary ICU team should reevaluate regimen DAILY

• Check for appropriateness of the regimen

• Pain and sedation requirements change over time

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2016 ANNUAL MEETING

• Assess, prevent and manage painA• Both Spontaneous Awakening Trial and Spontaneous

Breathing TrialB

• Choice of Analgesia and SedationC

• Delirium: Assess, prevent and manage painD• E: Early mobility and exercise• F: Family Engagement and empowermentEF

ABCDEF BUNDLE

2016 ANNUAL MEETING


Breathing TrialB



ABCDEF BUNDLE

2016 ANNUAL MEETING

• Valid and reliable tool for monitoring pain in medical, postoperative or trauma patients

• Pain should be assessed first before the addition of sedation therapy using an

analgosedation approach

• Vital signs should not be used alone for pain assessment, should be used as a cue for

further assessment

• Recommend preemptive analgesia and/or nonpharmacological interventions to alleviate

pain in the ICU prior to chest tube removal

• IV opioids are first line drugs choice to treat nonneuropathic pain in the ICU

2013 SCCM PAIN, AGITATION AND DELIRIUM (PAD) GUIDELINES: ANALGESIA RECOMMENDATIONS

Barr J, Fraser G, Puntillo K, et. al. Clinical Practice Guidelines for the Management of Pain, Agitation, and Delirium in Adult Patients in the Intensive Care Unit. Critical Care Medicine 2013; 41: 264-306.

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• Identify these causes of pain and agitation during the patient assessment

• Hypoxemia

• Full bladder

• Noise

• Frequent ICU procedures

COMMON CAUSES OF PAIN AND AGITATION

2016 ANNUAL MEETING

CRITICAL CARE OBSERVATION TOOL (CPOT)CPOT

Indicator Description ScoreFacial Expression

No muscle tension observed 0, relaxed neutralPresence of frowning, brow lowering, orbit tightening and levator contraction or any other change (e.g. opening eyes or tearing during nociceptive procedures)

1, tense

All previous facial movements plus eyelid tightly closed (the patient may present with mouth open or biting the endotracheal tube)

2, grimacing

Body movement

Does not move at all (doesn’t necessarily mean absence of pain) or normal position (movements not aimed toward the pain site or not made for the purpose of protection)

0, Absence of movements or normal position

Slow, cautious movements, touching or rubbing the pain site, seeking attention through movements

1, protection

Pulling tube, attempting to sit up, moving limbs/thrashing, not following commands, striking at staff, trying to climb out of bed

2, restlessness/agitation

Muscle tension

No resistance to passive movements 0, relaxedResistance to passive movements 1, tense/rigidStrong resistance to passive movements or incapacity to complete them 2, very tense/rigid

Compliance with the ventilator (intubated patients)

Alarms not activated, easy ventilation 0, Tolerating ventilator or movement

Coughing, alarms may be activated but stop spontaneously 1, Coughing but tolerating

Asynchrony: blocking ventilation, alarms frequently activated 2, Fighting ventilator

Table 1. Gelinas C, Fillion L, Puntillo K, et al. Validation of the Critical-Care Pain Observation Tool in Adult Patients. Am J Crit Care. 2006; 15:420-427. 2016 ANNUAL MEETING

BEHAVIORAL PAIN SCORE (BPS)BPS

Item Description ScoreFacial Expression Relaxed 1

Partially tightened (ex: brow lowering) 2Fully Tightened (ex: eyelid closing) 3Grimacing 4

Upper Limb Movement

No movement 1Partially Bent 2Fully Bent with finger flexion 3Permanently retracted 4

Compliance with mechanical ventilation

Tolerating movement 1Coughing but tolerating ventilation most of the time 2

Fighting ventilator 3Unable to control ventilation 4

Table 1. Aissaoui Y, Zeggwagh A, Zekraoui A, et al. Validation of a Behavioral Pain Scale in Critically Ill, Sedated and Mechanically Ventilated Patients. Anesth Analg. 2005; 101:1470-1476

2016 ANNUAL MEETING

SCCM PAIN CARE BUNDLE

• Assess

• Assess pain four times per shift and PRN

• Significant pain with BPS >5, or CPOT>2

• Treat

• Treat pain within 30 minutes of detecting significant pain & REASSESS:

• Non-pharmacological treatment

• Pharmacological treatment

• Prevent

• Administer pre-procedural analgesia and/or non-pharmacological interventions

• Treat pain first, then sedate

www.iculiberation.org ICU-Liberation-ABCDEF-Bundle-Implementation-Assess-Prevent-Manage-Pain

2016 ANNUAL MEETING


Breathing TrialB



ABCDEF BUNDLE

• Benefit of a sedation interruption

• Evidence for a sedation vacation in conjunction with a spontaneous breathing trial and early mobility results in decreased adverse outcomes associated with delirium and weakness

• Length of sedation interruption• A sedation interruption is considered successful if the patient responds to verbal stimulation but

does not display any failure criteria in a 4 hour period

• Potential adverse effects

• Self-extubation, removal of access

• Agitation or pain

SEDATION INTERRUPTION

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DAILY SEDATION INTERRUPTION

2016 ANNUAL MEETING

Title Daily Interruption of Sedative Infusions in Critically Ill Patients Undergoing Mechanical Ventilation

Objective Determine if daily interruption of sedative infusion in mechanically ventilated critically ill patients decreases the duration of mechanical ventilation and the length of hospital/ICU stay

Study Design Prospective randomized control trial conducted in the MICU of a single center

Population Patients that were mechanically ventilated and intubated requiring continuous intravenous infusion of sedatives

Protocol

• Daily interruption of sedative infusion beginning 48 hours after enrollment (by an investigator not directly involved in patient care)

• Continuous infusion of sedatives with interruption at the treating team’s discretion• Within each group, patients were randomized to receive propofol or midazolam. All patients received IV

morphine for analgesia

Primary OutcomeDetermine if daily interruption of sedative infusion in mechanically ventilated critically ill patients decreases the

duration of mechanical ventilation and the length of hospital/ICU stay.

Kress JP, Pohlman AS, O’Connor MF, et al. Daily Interruption of Sedative Infusions in Critically Ill Patients Undergoing Mechanical Ventilation. NEJM 2000; 342 (20): 1471- 1477.


2016 ANNUAL MEETINGKress JP, Pohlman AS, O’Connor MF, et al. Daily Interruption of Sedative Infusions in Critically Ill Patients Undergoing Mechanical Ventilation. NEJM 2000; 342 (20): 1471- 1477.


2016 ANNUAL MEETINGKress JP, Pohlman AS, O’Connor MF, et al. Daily Interruption of Sedative Infusions in Critically Ill Patients Undergoing Mechanical Ventilation. NEJM 2000; 342 (20): 1471- 1477.


2016 ANNUAL MEETING

Title Daily Sedation Interruption in Mechanically Ventilated Critically Ill Patients Cared for with a Sedation Protocol

Objective Adult patients managed with protocolized sedation and daily sedation interruption would receive less sedation and have a shorter duration of mechanical ventilation than patients that receive protocolized sedation alone

Study Design Multi-centered, randomized controlled trial, not blinded · Study period: January 2008-July 2011· Study sites: 16 centers (14 in Canada and 2 in the US)

Population · Critically ill adults in the intensive care unit (ICU)· Expected mechanical ventilation for more than 48 hours· Continuous infusion of sedatives or opioids

Study Groups · Protocolized sedation plus daily interruption (interruption groups)· Protocolized sedation alone (control group)

Primary Outcome · Time to successful extubation, defined as time from randomization to extubation for 48 hours

Secondary Outcomes · Unintended device removal, Physical restraint use, Delirium, Neuroimaging in the ICU, Tracheostomy, Barotrauma, Total doses of sedatives and analgesics while intubated, Organ dysfunction, ICU and hospital length of stay, Death

Mehta S, Burry L, Fergusson D, et al. Daily Sedation Interruption in Mechanically Ventilated Critically Ill Pateints Cared for With a Sedation Protocol A Randomized Controlled Trial. JAMA 2012; 308 (19): E1-E8.


2016 ANNUAL MEETINGMehta S, Burry L, Fergusson D, et al. Daily Sedation Interruption in Mechanically Ventilated Critically Ill Pateints Cared for With a Sedation Protocol A Randomized Controlled Trial. JAMA 2012; 308 (19): E1-E8.

“WAKE UP AND BREATHE” PROTOCOL

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• Sedation interruption should be performed in ALL patients except the following:

• Pressure control or inverse ratio ventilation

• PEEP greater than or equal to 10 cm

• Neuromuscular blockade

• FiO2 greater than or equal to 60%

• SpO2 less than 93%

• Becomes unstable

• Active ICP management

• Hypothermia management

• Actively having seizures or in status epilepticus


2016 ANNUAL MEETINGBalas M, et al. Effectiveness and Safety of the Awakening and Breathing Coordination, Delirium Monitoring/ Management, and Early Exercise/Mobility Bundle. Crit Care Med 2014.

If the patient does not meet any of the exclusion criteria then perform the sedation vacation

Stop ALL of the continuous infusion medications including Fentanyl drip daily with your AM assessment

Look for signs that the patient does or does not tolerate a sedation vacation

If the patient meets the criteria to restart continuous infusion medications, then restart the rate at HALF of the previous dose


2016 ANNUAL MEETING

“WAKE UP AND BREATHE” PROTOCOL

2016 ANNUAL MEETING

SEDATION INTERRUPTIONFAILURE CRITERIAINDICATIONS TO RESTART CONTINUOUS INFUSION MEDICATIONS

• RASS reaches >+2 for more than 5 minutes

• Respiratory rate >35 breaths/min for >5 minutes

• Pulse oximetry reading <88% for >5 minutes

• Acute cardiac arrhythmia

• ICP > 20 mmHg

• Two or more of the following:

• Heart rate increase of ≥ 20 BPM

• Heart rate less than 55 BPM

• Use of accessory muscles

• Abdominal paradox

• Diaphoresis

• Dyspnea

2016 ANNUAL MEETING

• What if your patient did not tolerate a sedation vacation yesterday?

• KEEP TRYING EACH DAY ON EVERYONE

• Analgesia and sedation needs in the ICU are dynamic

• A failed sedation vacation only indicates that we have successfully minimized our sedation

SEDATION VACATION PEARLS

2016 ANNUAL MEETING


Breathing TrialB



ABCDEF BUNDLE

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CHOICE OF ANALGESIA• Non-pharmacologic strategies play an important role in managing pain and

agitation

• IV opioids should be considered first line

• Optimize opioid regimens by assessing the following:

• Is the pain acute, chronic or both?

• Route of administration

• Hemodynamic instabilitySituation Preferred Intervention

Acute pain Fentanyl IV Push until pain resolves

Acute pain that persists/recurs Fentanyl infusion plus fentanyl IV Push for breakthrough

Acute pain in chronic opioid user Account for previous opioid use when using IV opioid

Planned transition out of ICU and patient on IV opioid infusion

Start scheduled oral/enteral opioid therapy plus intermittent IV opioid

2016 ANNUAL MEETINGwww.iculiberation.org/Bundles/Pages/Choice-of-Medication.aspx

ANALGESIA MEDICATION OPTIONS• Histamine release upon administration• Hypotension • Accumulation of metabolite in renal failure• Sedative properties• Adverse Effect: Constipation (Always start a bowel regimen unless

contraindicated)

Morphine

• Preferred agent when rapid control is needed• Good agent for hemodynamically unstable patients• Rare adverse effect: chest wall rigidity• Sedative properties• Adverse Effect: Constipation (Always start a bowel regimen unless

contraindicated)

Fentanyl

• Approximately 7.5 times more potent than morphine• Good agent for hemodynamically unstable patients• Sedative properties• Adverse Effect: Constipation (Always start a bowel regimen unless

contraindicated)

Hydromorphone

2016 ANNUAL MEETING

CONVERSION BETWEEN OPIOIDS

Generic name Route Equivalent Dose

Morphine IV 10mg

Hydromorphone IV 1.5mg

Fentanyl IV 100mcg

Morphine PO 30mg

Hydromorphone PO 7.5mg

2016 ANNUAL MEETING

• Valid and reliable sedation assessment tool for measuring quality and depth of sedation in adult ICU patients

• Non-benzodiazepine sedatives should be used when possible over benzodiazepines in mechanically ventilated patients

• Non-benzodiazepines are associated with improved clinical outcomes including shorter length of stay in the ICU and shorter days of mechanical ventilation

• Analgesia should always be assessed first before adding sedation

2013 PAD GUIDELINES:SEDATION RECOMMENDATIONS


2016 ANNUAL MEETING

SEDATION

2016 ANNUAL MEETING

Title Dexmedetomidine vs midazolam or propofol for sedation during prolonged mechanical ventilation. Two randomized controlled trials

ObjectiveTo determine the efficacy of dexmedetomidine vs. midazolam or propofol in maintaining sedation,reducing duration of mechanical ventilation and improving patient interaction with nursing

Selection Criteria

Patients were included if they met the following criteria: • 18 years or older • Invasive mechanical ventilation for greater than 24 hours• Clinical need for light to moderate sedation (RASS -3 to 0) Randomization within 72 hours of ICU admission and within 48 hours of starting continuous sedation

PopulationTwo prospective randomized, double-blinded controlled trials (MIDEX and PRODEX) conducted in the ICU’s of 44 different medical centers

Intervention

• MIDEX: randomized to continue current sedation with midazolam or switched to dexmedetomidine

• PRODEX: randomized to continue current sedation with propofol or switched to dexmedetomidine

• Study medications were titrated in a stepwise fashion by nursing

Primary Outcome• Proportion of time in target sedation range (RASS 0 to -3) without the use of rescue therapy• Duration of mechanical ventilation

Secondary Outcomes• Length of ICU stay• Ability to cooperate with care• Ability to communicate pain

Jakob SM, Ruokonen E, Grounds RM, et al. Dexmedetomidine vs midazolam or propofol for sedation during prolonged mechanical ventilation. Two randomized controlled trials. JAMA 2012; 307 (11): 1151-1160.

SEDATION

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SEDATION

2016 ANNUAL MEETING

SEDATION

2016 ANNUAL MEETING

Title Effect of sedation with dexmedetomidine vs lorazepam on acute brain dysfunction in mechanically ventilated patients. The MENDS randomized controlled trial.

ObjectiveDetermine if dexmedetomidine reduces the duration of delirium and coma in mechanically ventilated ICU patients in comparison to benzodiazepines.

Selection CriteriaMedical and surgical ICU patients requiring mechanical ventilation for longer than 24 hours. Excluded patients: Neurological disease, Liver disease, AMI, Heart block, Severe dementia

BDZ dependence

Study DesignProspective, double-blinded, randomized trial conducted in the medical and surgical ICU’s of 2 tertiary care centers

Intervention

• Patients were randomized to receive dexmedetomidine or lorazepam infusions • Infusion rates were titrated by the nurse to achieve a RASS goal set by the medical team.• Maximum infusion doses:

• Dexmedetomidine: 1.5 ug/kg/hr• Lorazepam: 10 mg/hr

• Infusions were allowed for a maximum duration of 120 hours and patients were then switched to the standard sedation medications used in the particular ICU.

Primary Outcome• Days alive without delirium or coma• Percentage of days spent within 1 RASS point of sedation goal

Secondary Outcomes

• Length of stay with ventilation, in the ICU and in the hospital• Neuropsychological testing after ICU discharge• 28 day mortality • 12 month survival

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.

SEDATION

2016 ANNUAL MEETING

• Maintaining light levels of sedation in adult ICU patients is associated with improved clinical outcomes • Shorter length of stay in the ICU • Shorter duration of mechanical ventilation

• Goal is light sedation (awake and cooperative)• Want the least amount of medication to achieve the desired effect

• Historical concerns with light sedation are not supported by current evidence • Patient will harm self if not heavily sedated• It is better if patient does not remember this experience• Care will be compromised if patient moves around and is not controlled• Patients are in less pain if they are more deeply sedated

SEDATION


2016 ANNUAL MEETING

SEDATION• Evidence from randomized, controlled trials consistently supports the use of the

minimum possible sedation

• A minority of patients have an indication for deep continuous sedation

• Intracranial hypertension

• Severe respiratory failure (example: acute respiratory distress syndrome)

• Refractory status epilepticus

• Prevention of awareness for patients receiving neuromuscular blockers

• Deep sedation is only appropriate for the patients mentioned above

• When used inappropriately deep levels of sedation result in increased ventilator associated pneumonia, accelerated deconditioning, promotion of skin breakdown, may increase incidence of post traumatic stress disorder, prolonged time on mechanical ventilation

Reade M and Finfer S. Sedation and Delirium in the Intensive Care Unit. NEJM. 2014. 370:440-454.

2016 ANNUAL MEETING

PROPERTIES OF AN IDEAL SEDATIVE

Rapid onset and rapid

offset

Predictable dose-response

relationship

Ease of administration

Lack of drug accumulation

Few side effects

Minimal drug interactions

Cost-effectiveness

Promotion of natural sleep

2016 ANNUAL MEETINGwww.iculiberation.org/Bundles/Pages/Choice-of-Medication.aspx

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SEDATIVE AGENTS• Sedative, analgesic and sympatholytic properties (NO amnestic properties)• Adverse effects: bradycardia and hypotension• Does not produce respiratory depression• Decreased incidence of delirium, shorter length of mechanical ventilation, and the ability to

assess cognitive function

Dexmedetomidine

• Anesthetic agent with hypnotic, anxiolytic and amnestic properties • Neuroprotective and antiepileptic properties• Adverse effects: hypotension, respiratory depression, hypertriglyceridemia, and acute

pancreatitis, propofol related infusion syndromePropofol

• Sedative, amnestic, anxiolytic properties• Accumulate in obese patients due to increased adipose tissue and in patients with liver

dysfunction (cirrhosis)• May accumulate the metabolite of midazolam in patients with renal dysfunction and elderly• Good agent for deeper levels of sedation

Midazolam

• Sedative, amnestic, anxiolytic properties• Increased effect in renal failure and elderly patients• Adverse effect: propylene glycol toxicity • Good agent for deeper levels of sedation

Lorazepam

2016 ANNUAL MEETING

RICHMOND AGITATION SEDATION SCALE (RASS)RASS

Term Description Score

Combative Overly combative, violent, immediate danger to staff +4

Very Agitated Pulls or removes tubes or catheter; aggressive +3

Agitated Frequent non-purposeful movement; fights ventilator +2

Restless Anxious but movements not aggressive vigorous +1

Alert and Calm 0

Drowsy Not fully alert, but has sustained awakening -1

Light Sedation Briefly awakens with eye contact to voice -2

Moderate Sedation Movement or eye opening to voice -3

Deep Sedation No response to voice, but movement or eye opening to physical stimulation

-4

Unarousable No response to voice or physical stimulation -5

Table 1. Sessler C, Gosnell M, Grap M, et al. The Richmond Agitation-Sedation Scale: Validity and Reliability in adult intensive care unit patients. Am J Respir Crit Care Med. 2002; 166:1338-1344.

2016 ANNUAL MEETING

RIKER’S SEDATION-AGITATION SCALE (SAS) SAS

Term Description ScoreDangerous agitation Pulling at ET tube, trying to remove catheters, climbing over bed rail, striking

at staff, thrashing side to side7

Very agitated Does not calm, despite frequent verbal reminding of limits; requires physical restraints, biting ET tube

6

Agitated Anxious or mildly agitated, attempting to sit up, calms down to verbal instruction

5

Calm and Cooperative

Calm, awakens easily, follows commands 4

Sedated Difficult to arouse, awakens to verbal stimuli or gentle shaking but drifts off again, follow simple commands

3

Very Sedated Arouses to physical stimuli but does not communicate or follow commands, may move spontaneously

2

Unarousable Minimal or no response to noxious stimuli, does not communicate or follow commands

1

Table 1. Bandl K, Langley K, Riker R et al. Confirming the reliability of the sedation-agitation scale administered by ICU nurses without experience in its use. Pharmacotherapy. 2001; 21:431-436.

2016 ANNUAL MEETING

MEDICATION EFFECTS

Drug Blood Pressure Heart Rate Respiration

Opioids ↓ ↓ ↓↓

Benzodiazepines ↓ -- ↓

Propofol ↓↓ ↓ ↓↓

Dexmedetomidine ↓↓ ↓ --

2016 ANNUAL MEETING

MEDICATION EFFECTS

Drug Analgesia Anxiolysis Amnesia Hypnosis

Opioids +++ -- -- +

Benzodiazepines -- ++ +++ +++

Propofol -- - ++ +++

Dexmedetomidine + + + ++

2016 ANNUAL MEETING

• Risk factors for opioid and benzodiazepine withdrawal

• Frequency associated with dose and duration

• Typically associated with one week or more of high dose therapy

• Signs and Symptoms

• Seizures, hallucinations, GI disturbances, fever, sweating, increased heart rate, tachypnea, increased blood pressure

• There is not a standard weaning protocol

• Consider a daily reduction of medications 10-20%

• Make sure that PRN medications are ordered when the continuous infusion medications are discontinued

MEDICATION WITHDRAWAL

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Breathing TrialB



ABCDEF BUNDLE

2016 ANNUAL MEETING

DELIRIUM

• Delirium is experienced by 50%–80% of mechanically ventilated patients

• Delirium is experienced by 20%–50% of patients with illness of lower severity

• Delirium results in:

• Prolonged hospitalization

• Increased mortality

• Increased cost

• Long-term effects on the patient include long-term cognitive impairment

http://www.iculiberation.org/Bundles/Pages/Delirium.aspx2016 ANNUAL MEETING

• Perform early mobilization of adult ICU patients whenever feasible to reduce the incidence and duration of delirium

• Pharmacologic delirium prevention protocol is not recommended

• Recommend using a combined nonpharmacologic and pharmacologic delirium prevention protocol

• Medication management is not recommended to prevent delirium in adult ICU patients

• Dexmedetomidine is not recommended to prevent delirium in adult ICU patients

2013 PAD GUIDELINES: ANALGESIA RECOMMENDATIONS


2016 ANNUAL MEETING

DELIRIUM• Identified by the following Key Features

• Disturbance in attention and awareness

• Disturbance in cognition

• Development over a short period of time and tendency to fluctuate during the day

• Disturbance not better explained by a preexisting, established or evolving neurocognitive disorder

• Evidence from patient’s history, physical examination and/or laboratory results that the disturbance is caused by a medical condition, substance intoxication or withdrawal, or medication/toxin side effect

• Associated but nondiagnostic symptoms of ICU delirium include: Hallucinations and delusions

• Abnormal psychometric activity

• Emotional disturbances

• Sleep disturbances

2016 ANNUAL MEETINGhttp://www.iculiberation.org/Bundles/Pages/Delirium.aspx

DELIRIUM

• Medications have the potential to contribute to delirium

• The ABCDEF bundle suggests the following approach to delirium management:

• Stop

• Review medications

• Plan to reduce drug exposure

• Consider sedatives

• THINK

• Medicate• SCCM guideline suggests nonbenzodiazepine sedatives


DELIRIUM• Toxic situations and medications: Congestive Heart Failure, shock,

dehydration, new onset organ failure (e.g. liver or kidney), deliriogenicmedications (e.g. benzodiazepines, anticholinergics, and steroids)T

• HypoxemiaH• Infection/ sepsis (nosocomial), inflammation, immobilizationI• Non-pharmacologic delirium mitigation strategies N• K+ or other electrolyte imbalancesK

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DELIRIUM

• Non-pharmacologic management

• Pain: Monitor and/or manage pain using an objective scale

• Orientation: Talk about a day, date, place; discuss current events; provide caregivers names; use clock and calendar in room

• Sensory: Determine need for hearing aids and/or eyeglasses

• Sleep: Noise reduction, day-night variation, “time-out” to minimize interruptions of sleep, promoting comfort and relaxation

2016 ANNUAL MEETING www.ICUdelirium.org

DELIRIUM

2016 ANNUAL MEETING www.ICUdelirium.org

INTENSIVE CARE DELIRIUM SCREENING CHECKLIST (ICDSC)


ISDSC

Altered Level of Consciousness Exaggerated response to normal stimulationNormal wakefulnessResponse to mild or moderate stimulationResponse only to intense and repeated stimulationNo response

1 point0 points1 pointStop assessmentStop assessment

Inattention Difficulty in following commandsEasily distracted by external stimuliDifficulty in shifting focus

1 point if any present

Disorientation Mistake in either time, person or place 1 point for any abnormality

Hallucination Evidence of hallucinations Delusions or gross impairment of reality

1 point for either

Psychomotor agitation or retardation

HyperactiveHypoactive

1 point for either

Inappropriate speech or mood Inappropriate, disorganized, or incoherent speechInappropriate mood related to events or situation

1 point for any abnormality

Sleep/wake cycle disturbance Sleeping < 4 hours/nightWaking frequently at night Sleeping more than 4 hours during the day

1 point for any

Symptom fluctuation Fluctuation of any of the above items over a 24 hour period 1 point for any

DELIRIUMTitle Effectiveness and Safety of the Awakening and Breathing Coordination, Delirium

Monitoring/Management and Early Exercise Mobility Bundle

Objective Determine if implementing an ABCDE components as a bundle would prove safe and effective if applied to every critically ill patient, every day, regardless of mechanical ventilation status

Study Design 18 month prospective, cohort before-after study conducted between November 2010 and May 2012

PopulationAdult patients ≥19 Medical or surgical ICU

Protocol Intervention RASS score of -3 or higher underwent the delirium screening with CAM-ICUCAM-ICU and RASS assessments recorded every 8 hours

Primary Outcome Ventilator free days

Secondary Outcomes

• Prevalence, duration, and percent of ICU days of delirium/coma• 28-day ICU and total hospital mortality• Time to discharge from ICU and hospital• Number of patients who experienced a change in residence • Percent of ICU time in physical restraints

2016 ANNUAL MEETINGBalas M, et al. Effectiveness and Safety of the Awakening and Breathing Coordination, Delirium Monitoring/ Management, and Early Exercise/Mobility Bundle. Crit Care Med 2014.

DELIRIUM

2016 ANNUAL MEETING

DELIRIUM

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THE CURRENT DEBATE

• No longer centers on the importance of SAT and SBT

• How to sustain the process daily

• Who should be the champion?

2016 ANNUAL MEETING

THE PHARMACIST’S ROLE

2016 ANNUAL MEETING

TitlePharmacist Leadership in ICU Quality Improvement: Coordinating Spontaneous Awakening and Breathing Trial

ObjectiveDetermine the feasibility and sustainability of a rounds-based, non-nurse, non-RT driven interdisciplinary QI program to improve the process measures resulting in conduction and coordination of our SAT/SBT protocol

Methods• Pharmacist led education• Daily discussion on rounds• Weekly performance reports to staff

Population MICU patients at a single center

InterventionPharmacist provided 4 separate education sessions during shift change on Tuesdays/Thursdays to the nursing staff

Primary Outcome Number of SAT

Secondary Outcomes

• SAT safety screen• SBT safety screens• SBTs• Analgesia and sedation use• Sustainability of the program for an 8 month period

Stolllings J, et al. Pharmacist Leadership in ICU Quality Improvement: Coordinating Spontaneous Awakening and Breathing Trials. Annals of Pharmacotherapy. 2015. 49(8) 883–891.


2016 ANNUAL MEETING


• Create a protocol for how and when to titrate sedation

• Create education for the nursing staff

• Educate and empower your nursing colleagues

• Make ‘sedation rounds’ each day with the physicians, nurse manager and bedside nurse

2016 ANNUAL MEETING

JHS ANALGESIA AND SEDATION PROTOCOL

Continuous analgesia/sedation protocol

2016 ANNUAL MEETING

SAMPLE TITRATION PARAMETERS

Fentanyl

Initiate infusion at 50 mcg/hour (usual dose 50-300 mcg/hour), to maintain CPOT goal less than or equal to 2 or to control shivering or ICP above 20 mmHg. Assess CPOT score in 30 minutes and in 4 hours. Titrate infusion rate every 4 hours per protocol below:

CPOT: 3 to 8 Give bolus, if ordered and increase rate by 25 mcg/hour. Reassess in 30 minutes and in 4 hours.

CPOT: 0 to 2 Reassess every 4 hours. Once CPOT is maintained at 0 to 2 for 8 hours, decrease rate by 25 mcg/hour every 4 hours

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SAMPLE TITRATION PARAMETERS

Propofol

Initiate infusion at 5 mcg/kg/min (Usual dose 5-50 mcg/kg/min), to maintain RASS goal 0 to -2 or to control shivering or ICP above 20 mmHg. Assess RASS score in 5 minutes. Titrate infusion per protocol below:

RASS: +4 to +1 Increase rate by 5 mcg/kg/min. Reassess in 5 minutes

RASS: 0 to -2 Reassess every 4 hours. Once RASS is maintained at 0 to -2 for 8 hours, decrease rate by 2.5 mcg/kg/min every 4 hours

RASS: -3 to -5 Decrease by 5 mcg/kg/min and reassess in 30 minutes and in 4 hours

2016 ANNUAL MEETING


2016 ANNUAL MEETING

THE PHARMACIST’S ROLEPerform your own assessments!

• Example: Procedure for RASS Assessment

• Observe patient

• Patient is alert, restless or agitated (score 0 to +4)

• If not alert, state patient’s name and say to open eyes and look at speaker.

• Patient awakens with sustained eye opening and eye contact (score −1)

• Patient awakens with eye opening and eye contact, but not sustained (score −2)

• Patient has any movement in response to voice but no eye contact. (score −3)

• When no response to verbal stimulation, physically stimulate patient by shaking shoulder and/or rubbing sternum.

• Patient has movement to physical stimulation. (score −4)

• Patient has no response to any stimulation (score −5)

2016 ANNUAL MEETING

SEDATION/DELIRIUM ASSESSMENT

2016 ANNUAL MEETING

DELIRIUMDrug Initiation & Titration

Dose Initiation Titration Max Dose

Administration Monitoring

Haloperidol 2.5 – 5 mg q6hr PRN

Initiatie or ↑ dose of standing antipsychotic and continue same PRN dose

35 mg PO – tabsIM – short-acting injectionIV

QTc interval at BASELINE and with every dose change or addition of other QTc prolonging agents

Extrapyramidal symptoms Anticholinergic effects

Scheduled Antipsychotic Initiation & TitrationDose Initiation Titration Wean Max

DoseAdministration Monitoring

Quetiapine 25 mg BID ↑ by 25-50 mg BID every other day

↓ by 25 – 50 mg every other day or by 25 – 50% every other day

400 mg PO – immediate release (IR) tabs QTc interval at BASELINE and with every dose change or addition of other QTc prolonging agents

Extrapyramidal symptoms (dystonia, dyskinesia, akathesia, etc.)

Anticholinergic effects Somnolence

Olanzapine 5 mg daily ↑ by 5 mg daily every other day

20 mg PO – tabsIM – short-acting injection

Chlorpromazine 25 mg QID ↑ by 25-50 mg QID every other day

400 mg PO – tabs, solutionIV – administer in NS bag over 30 min

Risperidone 0.5 mg BID ↑ by 0.5-1 mg BID every other day

6 mg PO – tabs, solution Order solution if patient cannot swallow – DO NOT CRUSH TABS

Cogentin Initiation & Titration (if needed)Benztropine 1 mg BID ↑ by 0.5 mg BID if patient experiencing EPS 6 mg PO – tabs Anticholinergic effects

2016 ANNUAL MEETING

BRINGING THE ABC(DEF)’S TO THE ICU

GINA RIGGI, PHARMD, BCPS, BCCCPCLINICAL HOSPITAL PHARMACIST- TRAUMA INTENSIVE CARE UNIT

JACKSON MEMORIAL HOSPITALMIAMI, FLORIDA

2016 ANNUAL MEETING

Riggi · 2018. 4. 3. · Mehta S, Burr y L, Fer gusson D, et al. Dail Sedation Interruption in Mechanicall Ventilated Criticall Ill Pateints Cared for With a Sedation Protocol A Randomized

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