Sangeeta Mehta MD, FRCPC CCCF Nov 9, 2018 Comfort without sedation
Sangeeta Mehta MD, FRCPC
CCCF
Nov 9, 2018
Comfort without sedation
Disclosures
• I have no disclosures or conflicts of interest
To review…
• Why should we avoid sedation?
• Is it possible?
• How? What are the alternatives?
361 ICUs, 20 countries
5183 receiving MV > 12 h
68% received sedative for >3 hrs within 24 hrs
Use of sedatives associated with
Longer duration of MV
Longer weaning time
Longer ICU stay
CHEST 2005;128:496
Observational study, 242 mechanically ventilated adults
Duration of MV:
- infusion 185 190h
- intermittent 56 76h p<0.001
Infusion group:
- more patients tracheostomized
- ICU and hospital LOS
CHEST 1998;114:541
AJRCCM 2012
Time to extubation Survival
Deep sedation = RASS -3 (movement/eye opening to voice but no eye contact) to -5 (unarousable)
Crit Care Medicine June 2018
Sedation Index – calculated over 48H
Sum of negative RASS scores
# of RASS measurements
Agitation component
Sedation component
Probability of Extubation
Probability of survival
Every 1-point ↑ in SI• Delayed extubation by one day• ↑ risk of dying in 6 months by 30%
The Ideal
Scenario
PADIS GuidelinesCCM Sept 2018
• We suggest using light sedation (vs deep sedation) in critically ill, mechanically ventilated adults (conditional recommendation, low quality of evidence)
• In critically ill, intubated adults, DSI protocols and NP-targeted sedation can achieve and maintain a light level of sedation (ungraded)
• We suggest using propofol over a benzodiazepine for sedation in mechanically ventilated adults after cardiac surgery (conditional recommendation, low quality of evidence)
• We suggest either propofol or dexmedetomidine over benzodiazepines for sedation in critically ill, mechanically ventilated adults (conditional recommendation, low quality of evidence)
Symptom based management
Pain
Fear
Anxiety
Agitation
Sleep
ALWAYS
• Non-pharmacologic management
ONLY IF NEEDED
• Pharmacologic management
• Sedative adjuncts
• (Physical restraint)
All patients managed
with RN driven
sedation/analgesia protocol
Daily interruptionSedation/analgesia
No daily interruption
randomized
N=430
16 centers
Surgical and medical pts
JAMA 2012
Crit Care Med 2015
ICU Memory ToolDay 28
I remember…. N=121
Admission to hospital 47%
Being in ICU 74%
getting enough sleep in ICU 66%
breathing tube 53%
having my trachea suctioned 36%
Pain 29%
Panic 32%
Feeling confused 47%
Feeling anxious/frightened 54%
Hallucinations 40%
Nightmares 34%
Remember feeling fearful
Yes - bothered none or little 19%
Yes - bothered moderately - extremely 81%
Remember feeling something bad will happen
Yes - bothered none or little 16%
Yes - bothered moderately - extremely 84%
Remember not being able to sleep
Yes - bothered none or little 16%
Yes - bothered moderately - extremely 84%
Remember being in pain
Yes - bothered none or little 14%
Yes - bothered moderately - extremely 86%
CCM 2002;30:746
Questions to ask yourself daily…
• Does my patient need sedation?
• Why does my patient need sedation?
140 MV patients
morphine prn
Propofol x 48 h then midazolam infusion
morphine prn
DI in both groupsLocal weaning protocol, no SBT
Ramsay 3-4
No sedation group
• 4.2 fewer MV days
• shorter ICU and hospital LOS
• more agitated delirium – 20% vs 7%
• more haldol
• Sedative infusions in 18%, mainly ARDS
Lancet Resp Med Oct 2017
Time to successful extubation (h)
8 hours vs 50 hours
Can we avoid sedation?
Can we avoid sedation?
Not in all patients
When sedation is necessary….
• Use lowest doses
necessary to achieve
your clinical goals
• Stop sedation as
quickly as possible
When sedation is necessary….
• Intermittent sedation
• Sedation protocols
• Sedation scales
• Daily sedation interruption
• Propofol/Dexmedetomidine
• Multi-modal approach
• Use lowest doses
necessary to achieve
your clinical goals
• Stop sedation as
quickly as possible
Avoid benzodiazepines IndicationsPalliationSeizuresSevere anxietyProcedural amnesia
Project IMPACT 2003-2009. Propensity matching AJRCCM 2014
Co-operation and communication
• 4 multicentre trials (N=1461) compared dex with midazolam or propofol
• Secondary outcomes: nurses’ assessment of arousal, co-operation and ability to
communicate pain using VAS
• In all 4 trials patients who received dex were significantly more arousable, more co-
operative and better able to communicate their pain than those who received propofol or
midazolam (p ≤ 0.001 in all cases)
Pharmacologic options for agitated patients...
Short duration…
• Sedative infusions
• (Physical restraint)
Longer duration…
• Antipsychotics– Haldol, risperidone, quetiapine, loxapine
• Clonidine
• Propranolol
• Benzodiazepines– Clonazepam, lorazepam
• Non-opioid analgesics
• Sleep aids
Non pharmacologic multi-component interventions
• Individualised care
• Reorientation
• Attention to sensory
deprivation
• Familiar objects
• Nutrition/ hydration
• Mobilisation
• Sleep hygiene
• Comprehensive Geriatric
Assessment
• Mood: assessment for
depression/anxiety
• Family presence
• Cognitive stimulation
• Fresh Air
Day 3
N=155
Day 28
N=121
Day 90
N=100
Had enough sleep in the ICU 51% 66% 71%
Reasons for inadequate sleep
Noise
Bright lights
Loud speaking
People entering room
47%
31%
41%
45%
50%
40%
45%
26%
41%
33%
33%
37%
Crit Care Med 2016
Minerva Anesthesiol 2012
Very poor
27%
Poor
41%
Good
17%
Very Good
13%
Excellent
2% Very poor
25%
Poor
32%
Good
17%
Very Good
13%
Excellent
13%
Quality Quantity
Patient assessment of sleep in the ICU
Possible Improvements for the ICU % Patients
Closing Doors/Blinds at Night 42
No Unnecessary Interruptions 40
Use of Sleeping Pills 33
Dimmed Lights in the Entire Unit 27
Visible Clock in room 25
Removal of Monitors and Alarms Overnight 25
Patients’ perceptions of Intensive care
• 76 patients, Lucca, Italy
• Patients reported
– Insufficient sleep (61%)
– Uncomfortably hot (37%) and cold (28%)
– Lonely or isolated (46%)
Simini, The Lancet 1999
Experience Remember with stress
Noise from ventilators 32%
Noisy and bad sleeping nights 54%
Lack of privacy in hygiene 43%
Communication difficulties 59%
Brightness from artificial lights 33%
Losing time orientation 37%
Crit Care 2005
464 patients
Urner, Ferreyro, Doufle, Mehta. Resp Care 2018 – In press
Essentials of comfort management - 1
• Keep your patients awake and engaged
• Symptom based management
• Pain, anxiety, agitation, sleep
• Intermittent/prn rather than continuous
• Analgesia-first strategy
– Objective assessment of pain
– Minimal or no sedation
Essentials of comfort management - 2
• De-medicalize/mobilize
• Non-pharmacologic support
• Family presence
• If sedation is needed
– Favour propofol/dexmedetomidine
– Use adjunctive agents
• Be vigilant for iatrogenic withdrawal
• Sleep promotion
Vincent JL et al. Int Care Med 2016;42:962
• Anxiety because I felt I needed to get my restraints off
• A nurse - a man - he came and tied my hands really tight
• When in restraints thought an electronic [slruder] treatment was
coming
• I was terrified for my life. I felt restrained.
• Dream that someone was hand cuffing pt to a table/chair
• Pt remembers being restrained & pleading to have restraints
removed
• A male nurse tied my hand very tight after I called him over to help
me turn as I was very uncomfortable
• The feeling of restraint was upsetting and made him feel violated.
Felt he was yelled at
• Saw images of vampires who tied her arms down in order to suck
blood from her central line
SLEAP StudyMemories of Physical Restraint