An overview of sedation practices in medical ICU

1. Dr. Abhijit S. Nair
Consultant Anesthesiologist
CITIZENS HOSPITALS
Hyderabad

2.  Sedation scores
 Problems of sedation
 To evolve a sedation protocol
 Emphasize on documentation

3.  Pharmacology of drugs
 Dosing
 Preparation/ storage etc

5.  Tube tolerance
 Ventilator synchronization
 Reduce agitation ( withdrawal etc)
 Pain relief
 Facilitate interventions

6.  Sleep deprivation
 Increased stress
 Increased inflammatory mediators

7. Over-sedation
Vs
Under-sedation

8.  Prolongs ICU stay
 Prolongs weaning
 Risk factor for delirium ( BZDs )
 ?CIPN
 Hemodynamic disturbances

9. Undersedation:
 hyper-catabolism
 immunosuppression
 Hyper-coagulability
 increased sympathetic activity
 Accidental extubation
 Hyperglycemia
 PTSD
Consales G, Chelazzi C, Rinaldi S, De Gaudio A R. Bispectral index compared to Ramsay score for
sedation monitoring in intensive care units. Minerva Anestesiol 2006; 72: 329–36

10.  Counselling ( family, primary, nursing staff )
 Psychologist
 Psychiatrist
 Music
 Feeding
 Adequate hydration
NOT FOR VENTILATED PATIENTS

11.  Short acting ( plasma t 1/2 & context sensitivity )
 Amnesia
 Analgesia
 Less accumulation in peripheral tissues
 Hemodynamically stable
 No withdrawal effects
 No respiratory depression
 Bronchodilator
 CHEAP

12.  Narcotics
 Benzodiazepines
 Miscellaneous

13. Respiratory
depression
ConfusionVasodilation
Gut motility
depression
Opioids

17. Propofol
Hypertriglyceridemia
CVS depression
Hypotension
2-agonists
Hypotension
Bradycardia
Benzodiazepines
Hypotension
Respiratory depression
Agitation/Confusion
Ketamine
Hypertension
Secretions
Dysphoria
General
Over sedation
Delayed awakening/extubation

18. “the inability to communicate verbally does not negate
the possibility that an individual is experiencing pain
and is in need of appropriate pain-relieving
treatment”

20.  Suctioning
 Positioning/ bed making
 Procedures ( including removals )

23.  Ramsay sedation score
 Bloomsbury sedation score
 RASS
 Sedation Agitation Scale

28.  RAAS & SAS >>> Most valid and reliable
sedation assessment tool in adult ICU

29.  Auditory evoked potential
 BIS
 Narcotrend Index
 Patient State index
 State Entropy
 Scoring scales
Not
recommended
by SCCM

31.  Brain function monitoring not recommended
for non- comatose, non-paralysed patients
 Brain function monitoring recommended along
with sedation scores in patients who are
paralysed in ICU
 EEG monitoring recommended in patients with
non-convulsive seizure activity, suspected
seizure activity

32.  Syndrome characterized by the acute onset of
cerebral dysfunction with a change or
fluctuation in baseline mental status,
inattention, and either disorganized thinking or
an altered level of consciousness
 Up to 80 % adults on ventilator experience
delirium
 Costly affair
Gupta N, de Jonghe J, Schieveld J, et al: Delirium phenomenology:
What can we learn from the symptoms of delirium? J Psychosom
Res 2008; 65:215–222

34.  Prolonged ICU stay
 Prolonged sedation
 Benzodiazepines
 Alcoholics, Chronic smokers
 Elderly
 Organ dysfunction

35.  Acutely fluctuating mental status
 Inattention
 Disorganized thinking
 Altered mentation
 With/ without agitation

36. DELIRIUM Hyperactive
Hypoactive

40.  Neuroleptic agents ( No evidence )
 α 2 agonists ( limited evidence )
 Treat the cause
 SCCM doesn’t support or recommend use of
prophylactic methods to prevent ICU delirium
( No evidence )
Early mobilization is the only proven
way to prevent ICU delirium

43.  Propofol / Dexmedetomidine : Short duration
sedation( 24-48 hours )
 Fentanyl ( long duration, > 48 hours )
 Avoid BZD infusion
 SEDATION HOLIDAY

44.  Interruption of sedation ( preferably
daily )
 Assess neurological status
 Restart after assessment or if
agitation increased
 Shown to reduce duration of
ventilation & ICU stay
Kress JP, Pohlman AS, O’Conner MF, et al. Daily interruption of sedation
infusions in critically ill patients undergoing mechanical ventilation. N Engl J
Med 2000; 342: 1471–7

45.  > 48 hours
 ? High dose
 metabolic acidosis, rhabdomyolysis
 Arrhythmias
 myocardial & renal failure
 hepatomegaly
 Death

46.  Pain/ sedation assessment infrequently done
 Implementation of recommendations not
possible ( although discussed )
 No documentation of scores
 Scores not addressed??
 Sedation Holiday is practiced most of the
times

48.  Protocol for addressing Pain, Agitation, Delirium in
ICU
 Monitor Pain, Agitation & Delirium ( Scoring
systems )
 Document SCORES

49.  Use non-benzodiazepine sedative
 Light level of sedation is associated with
improved clinical outcomes
 Adequate analgesia for procedures
 Review medications daily

50.  Sedation Holiday
 Early mobilization
 Brain function monitoring recommended if
NDMR used
 Brain function monitoring not recommended in
non-comatose patients
 CONDUCIVE ENVIRONMENT IN ICU