Presentation given in Pace 2011

1. Sedation , Analgesia & Paralysis
in ICU
Dr.Venugopalan.P.P
DA,DNB,MNAMS
Chief, Emergency Medicine –MIMS
Site Director ,Masters program in EM
Executive director ,Angels international foundation

2. Objectives
Guidelines for sedation, analgesia, and
chemical paralysis
Benefits of daily awakening/lightening and
sedation titration programs
Rational pharmacologic strategy based on
treatment goals and co morbidities

3. What We Know About ICU
Agitation/Discomfort?
Prevalence
• 50% incidence in those with length of stay > 24 hours
Primary causes
• Unrelieved pain
• Delirium
• Anxiety
• Sleep deprivation.

4. ICU Agitation/Discomfort
sequelae

5. Recall in the ICU
Some degree of recall occurs in up to 70% of
ICU patients.
• Anxiety, fear, pain, panic, agony, or nightmares reported in 90% of those who
did have recall.
Potentially cruel:
• Up to 36% recalled some aspect of paralysis.
Associated with PTSD in ARDS?
• 41% risk of recall of two or more traumatic experiences.
Associated with PTSD in cardiac surgery

6. Appropriate Recall May be Important
Factual memories help to put ICU experience
into perspective
Delusional memories cause panic attacks
and PTSD
The optimal level of sedation for most
patients - Offers comfort while allowing for
interaction with the environment.

7. Why sedation in ICU?
• Anxiety
• Pain
• Acute confusional status
• Mechanical ventilation
• Treatment or diagnostic procedures
• Psychological response to stress

8. Sedation Goal
• Patient comfort
• Control of pain
• Anxiolysis and
amnesia
• Blunting adverse
autonomic and
hemodynamic
responses
• Facilitate nursing
management
• Facilitate mechanical
ventilation
• Avoid self-extubation
• Reduce oxygen
consumption

9. Ideal sedation agents
• No respiratory
depression
• Analgesia
• Rapid onset,
titratable, with a
short
elimination half-time
• Sedation with
ease of
orientation and
arousability
• Anxiolytic
• Hemodynamic
stability

10. The Challenges
• Assessment of sedation
• Altered pharmacology
• Tolerance
• Delayed emergence
• Withdrawal
• Drug interaction

11. Sedation
Causes for Agitation Sedatives

12. Undersedation
Sedatives
Causes for Agitation
Agitation & anxiety
Pain and discomfort
Catheter displacement
Inadequate ventilation
Hypertension
Tachycardia
Arrhythmias
Myocardial ischemia
Wound disruption
Patient injury

13. Oversedation
Sedatives
Causes for Agitation
Prolonged sedation
Delayed emergence
Respiratory depression
Hypotension
Bradycardia
Increased protein breakdown
Muscle atrophy
Venous stasis
Pressure injury
Loss of patient-staff interaction
Increased cost

14. Reversible Causes of Agitation
• Full bladder
• Uncomfortable
bed position
• Inadequate
ventilator flow
rates
• Mental illness
• Uremia
• Drug side effects
• Disorientation
• Sleep
deprivation
• Noise
• Inability to
communicate

15. Life threatening Causes
• Hypoxia
• Hypercarbia
• Hypoglycemia
• Endotracheal tube
malposition
• Pneumothorax
• Myocardial
ischemia
• Abdominal pain
• Drug and alcohol
withdrawal

16. Daily Goal is
Arousable,
Comfortable
Sedation
Effect of this strategy on
outcomes:
• One- to seven-day reduction in
length of sedation and mechanical
ventilation needs
• 50% reduction in tracheostomies
• Three-fold reduction in the need
for diagnostic evaluation of CNS
Sedation needs to
be protocolized and
titrated to goal:
•Lighten sedation to
appropriate
wakefulness daily.

17. Protocols and Assessment Tools
Sedation
o Validated sedation
assessment tools (Ramsay
Sedation Scale [RSS],
o Sedation-Agitation Scale
[SAS]
o Richmond Sedation-agitation
Scale [RSAS]
No evidence that one is preferred over
another
Pain
o Numeric rating scale
[NRS]
o Visual analogue scale
[VAS]
Pain assessment tools - none validated
in ICU

18. Sedation/Analgesia
ICU
Rule out reversible causes of
discomfort/anxiety such as hypoxemia,
hypercarbia, and toxic/drug side effect.
Assess co-morbidities and potential side
effects of drugs chosen.
Target irreversible etiologies of pain and
agitation.

19. Strategies for Patient Comfort
• Set treatment goal
• Quantitate
sedation and pain
• Choose the right
medication
• Use combined
infusion
• Reevaluate need
• Treat withdrawal

20. ALGORITHM FOR SEDATION AND ANALGESIA OF MECHANICALLY VENTILATED PATIENTS
Yes
Reassess goal daily,
Titrate and taper therapy to maintain goal,
Consider daily wake-up,
Taper if > 1 week high-dose therapy & monitor
for withdrawal
No
Set Goal
for
Analgesia
Hemodynamically Unstable
Fentanyl 25 - 100 mcg IVP Q 5-15 min, or
Hydromorphone 0.25 - 0.75 mg IVP Q 5 - 15 min
Hemodynamically stable
Morphine 2 - 5 mg IVP Q 5 - 15 min
Repeat until pain controlled, then scheduled doses
+ prn
Set Goal
for
Sedation
Acute Agitation #
Midazolam 2 - 5 mg IVP Q 5 - 15 min until
acute event controlled
Ongoing Sedation #
Lorazepam 1 - 4 mg IVP Q 10-20 min until
at goal then Q 2 - 6 hr scheduled + prn, or
Propofol start 5 mcg/kg/min, titrate Q 5 min
until at goal
Set Goal
for Control
of Delirium
Haloperidol 2 - 10 mg IVP Q 20 - 30 min,
then 25% of loading dose Q 6hr x 2-3 days,
then taper
IVP Doses
more of ten than Q
2hr?
Consider continuous
infusion opiate or
sedative
> 3 Days Propofol?
(except neuro pt.)
Convert to
Lorazepam
Yes
Benzodiazepine or Opioid:
Taper Infusion Rate by
10-25% Per Day
Yes
Doses
approximate for
70kg adult
Rule out and Correct Reversible Causes
Use Non-pharmacologic Treament,
Optimize the Environment
Use Pain Scale * to
Assess for Pain
Use Sedation Scale **
to Assess for
Agitation/Anxiety
Use Delirium Scale *** to
Assess for Delirium
Is the Patient Comfortable & at Goal?
Lorazepam via
infusion?
Use a low rate and IVP
loading doses
1
2
3
4
Jacobi J, Fraser GL, Coursin D, et al. Crit Care Med. 2002;30:119-141.

21. Assess Pain Separately
Pain

22. Visual Pain Scales
0 1 2 3 4 5 6 7 8 9 10
No pain Worst possible
pain

23. Signs of Pain
• Hypertension
• Tachycardia
• Lacrimation
• Sweating
• Pupillary dilation

24. Pain Management
• Anticipate
• Recognize
• Quantify
Recognize
Pain

25. Treat Pain
oQuantify the pain perception
oCorrect the correctable causes
oUse appropriate analgesics
• Remember- most sedative agents
do not provide analgesia
• Reassess

26. Non-pharmacological
Methods
• Proper position of the patient
• Stabilization of fractures
• Elimination of irritating stimulation
• Proper positioning of the ventilator
tubing to avoid traction on
endotracheal tube

27. ALGORITHM FOR SEDATION AND ANALGESIA OF MECHANICALLY VENTILATED PATIENTS
Yes
Reassess goal daily,
Titrate and taper therapy to maintain goal,
Consider daily wake-up,
Taper if > 1 week high-dose therapy & monitor
for withdrawal
No
Set Goal
for
Analgesia
Hemodynamically Unstable
Fentanyl 25 - 100 mcg IVP Q 5-15 min, or
Hydromorphone 0.25 - 0.75 mg IVP Q 5 - 15 min
Hemodynamically stable
Morphine 2 - 5 mg IVP Q 5 - 15 min
Repeat until pain controlled, then scheduled doses
+ prn
Set Goal
for
Sedation
Acute Agitation #
Midazolam 2 - 5 mg IVP Q 5 - 15 min until
acute event controlled
Ongoing Sedation #
Lorazepam 1 - 4 mg IVP Q 10-20 min until
at goal then Q 2 - 6 hr scheduled + prn, or
Propofol start 5 mcg/kg/min, titrate Q 5 min
until at goal
Set Goal
for Control
of Delirium
Haloperidol 2 - 10 mg IVP Q 20 - 30 min,
then 25% of loading dose Q 6hr x 2-3 days,
then taper
IVP Doses
more of ten than Q
2hr?
Consider continuous
infusion opiate or
sedative
> 3 Days Propofol?
(except neuro pt.)
Convert to
Lorazepam
Yes
Benzodiazepine or Opioid:
Taper Infusion Rate by
10-25% Per Day
Yes
Doses
approximate for
70kg adult
Rule out and Correct Reversible Causes
Use Non-pharmacologic Treament,
Optimize the Environment
Use Pain Scale * to
Assess for Pain
Use Sedation Scale **
to Assess for
Agitation/Anxiety
Use Delirium Scale *** to
Assess for Delirium
Is the Patient Comfortable & at Goal?
Lorazepam via
infusion?
Use a low rate and IVP
loading doses
1
2
3
4
Jacobi J, Fraser GL, Coursin D, et al. Crit Care Med. 2002;30:119-141.

28. Address Pain
Is the Patient Comfortable & at Goal?
Set Goal
for
Analgesia
Hemodynamically Unstable
Fentanyl 25 - 100 mcg IVP Q 5-15 min, or
Hydromorphone 0.25 - 0.75 mg IVP Q 5 - 15 min
Hemodynamically stable
Morphine 2 - 5 mg IVP Q 5 - 15 min
Repeat until pain controlled, then scheduled doses
+ prn
Use Pain Scale * to
Assess for Pain
Reassess goal daily,
Titrate and taper therapy to maintain goal,
Consider daily wake-up,
Taper if > 1 week high-dose therapy & monitor
for withdrawal

29. Opiates
Benefits
•Relieve pain or the sensibility to
noxious stimuli
•Sedation trending toward a
change in sensorium

30. Opiates - Risks
•Respiratory depression
•NO amnesia
•Pruritus
•Ileus
•Urinary retention

31. Opiates- Risks
• Histamine
release -
morphine
•Morphine
metabolites
which
accumulate in
renal failure .
• Meperidine should
be avoided due to
neurotoxic
metabolites which
accumulate in
renal failure

32. Pharmacology of Selected Analgesics
Agent Dose (iv) Half-life Metabolic pathway Active
metabolites
Fentanyl 200 g 1.5-6 hr Oxidation None
Hydromorphone 1.5 mg 2-3 hr Glucuronidation None
Morphine 10 mg 3-7 hr Glucuronidation Yes (Sedation
in RF)
Meperidine 75-100 mg 3-4 hr Demethylation &
hydroxylation
Yes
(neuroexcitation
in RF)
Codeine 120 mg 3 hr Demethylation &
Glucuronidation
Yes ( analgesia,
sedation)
Remifentanil 3-10 min Plasma esterase None
Keterolac 2.4-8.6 hr Renal None

33. Opiate Analgesic Options: Fentanyl, Morphine, Hydromorphone
Fentanyl Hydromorphone Morphine
Rapid onset X
Rapid offset X*
Avoid in renal disease X**
Preload reduction X
Avoid in hemodynamic
X
instability
Equivalent doses 100 mcg 1.5 mg 10 mg
* Offset prolonged after long-term use
** Active metabolite accumulation causes excessive narcosis

34. Numeric Rating Scale
Sample Analgesia Protocol

36. Sedation- Assessment
• Ramsay Sedation
Scale (RSS)
• Sedation-agitation
Scale (SAS)
• Observers
Assessment of
Alertness/Sedation
Scale (OAASS)
• Motor Activity
Assessment Scale
(MAAS)
BMJ 1974;2:656-659
Crit Care Med 1999;27:1325-1329
J Clin Psychopharmacol 1990;10:244-251
Crit Care Med 1999;27:1271-1275

37. The Ramsay Scale
Scale Description
1 Anxious and agitated or restless, or both
2 Cooperative, oriented, and tranquil
3 Response to commands only
4 Brisk response to light glabellar tap or loud
auditory stimulus
5 Sluggish response to light glabellar tap or loud
auditory stimulus
6 No response to light glabellar tap or loud
auditory stimulus

38. The Riker Sedation-Agitation Scale
Score Description Definition
7 Dangerous
agitation
Pulling at endotracheal tube, trying to
strike at staff, thrashing side to side
6 Very agitated Does not calm despite frequent verbal
commands, biting ETT
5 Agitated Anxious or mildly agitated, attempting to sit
4 Calm and
cooperative
Calm, awakens easily, follows commands
3 Sedated Difficult to arouse, awakens to verbal
stimuli, follows simple commands
2 Very sedated Arouse to physical stimuli, but does not
communicate spontaneously
1 Unarousable Minimal or no response to noxious stimuli

39. The Motor Activity Assessment Scale
Score Description Definition
6 Dangerous
agitation
Pulling at endotracheal tube, trying to strike at
staff, thrashing side to side
5 Agitated Does not calm despite frequent verbal
commands, biting ETT
4 Restless and
cooperative
Anxious or mildly agitated, attempting to sit
3 Calm and
cooperative
Calm, awakens easily, follows commands
2 Responsive to
touch or name
Opens eyes or raises eyebrows or turns head
when touched or name is loudly spoken
1 Responsive only to
noxious stimuli
Opens eyes or raises eyebrows or turns head
with noxious stimuli
0 Unresponsive Does not move with noxious stimuli

40. What sedation Scale do?
•Provide a semi quantitative “score”
•Standardize treatment endpoints
•Allow review of efficacy of sedation
•Facilitate sedation studies
•Help to avoid over sedation

41. But scales Do not ....
• Assess anxiety
• Assess pain
• Assess sedation in paralyzed patients
• Predict outcome
• Agree with each other

42. BIS Monitoring
Used to asses
Sedation levels

43. BIS Range Guidelines
Awake
Responds to normal voice Axiolysis
Responds to loud commands
or mild prodding/shaking
Low probability to explicit recalls
Unresponsive to verbal stimuli
Burst suppression
Flat line EEG
Moderate
sedation
Deep Sedation
100
80
60
40
20
0
BIS

44. ALGORITHM FOR SEDATION AND ANALGESIA OF MECHANICALLY VENTILATED PATIENTS
Yes
Reassess goal daily,
Titrate and taper therapy to maintain goal,
Consider daily wake-up,
Taper if > 1 week high-dose therapy & monitor
for withdrawal
No
Set Goal
for
Analgesia
Hemodynamically Unstable
Fentanyl 25 - 100 mcg IVP Q 5-15 min, or
Hydromorphone 0.25 - 0.75 mg IVP Q 5 - 15 min
Hemodynamically stable
Morphine 2 - 5 mg IVP Q 5 - 15 min
Repeat until pain controlled, then scheduled doses
+ prn
Set Goal
for
Sedation
Acute Agitation #
Midazolam 2 - 5 mg IVP Q 5 - 15 min until
acute event controlled
Ongoing Sedation #
Lorazepam 1 - 4 mg IVP Q 10-20 min until
at goal then Q 2 - 6 hr scheduled + prn, or
Propofol start 5 mcg/kg/min, titrate Q 5 min
until at goal
Set Goal
for Control
of Delirium
Haloperidol 2 - 10 mg IVP Q 20 - 30 min,
then 25% of loading dose Q 6hr x 2-3 days,
then taper
IVP Doses
more of ten than Q
2hr?
Consider continuous
infusion opiate or
sedative
> 3 Days Propofol?
(except neuro pt.)
Convert to
Lorazepam
Yes
Benzodiazepine or Opioid:
Taper Infusion Rate by
10-25% Per Day
Yes
Doses
approximate for
70kg adult
Rule out and Correct Reversible Causes
Use Non-pharmacologic Treament,
Optimize the Environment
Use Pain Scale * to
Assess for Pain
Use Sedation Scale **
to Assess for
Agitation/Anxiety
Use Delirium Scale *** to
Assess for Delirium
Is the Patient Comfortable & at Goal?
Lorazepam via
infusion?
Use a low rate and IVP
loading doses
1
2
3
4
Jacobi J, Fraser GL, Coursin D, et al. Crit Care Med. 2002;30:119-141.

45. Set Goal
for
Sedation
Address Sedation
Acute Agitation #
Midazolam 2 - 5 mg IVP Q 5 - 15 min until
acute event controlled
Ongoing Sedation #
Lorazepam 1 - 4 mg IVP Q 10-20 min until
at goal then Q 2 - 6 hr scheduled + prn, or
Propofol start 5 mcg/kg/min, titrate Q 5 min
until at goal
IVP Doses
more often than Q
2hr?
Consider continuous
infusion opiate or
sedative
> 3 Days Propofol?
(except neuro pt.)
Convert to
Lorazepam
Benzodiazepine or Opioid:
Taper Infusion Rate by
10-25% Per Day
Use Sedation Scale **
to Assess for
Agitation/Anxiety
Lorazepam via
infusion?
Use a low rate and IVP
loading doses
Yes
Reassess goal daily,
Titrate and taper therapy to maintain goal,
Consider daily wake-up,
Taper if > 1 week high-dose therapy & monitor
for withdrawal
Is the Patient Comfortable & at Goal?

46. How to Sedate ?
• Benzodiazepines
• Propofol
• -2 agonists
Sedatives-
Options

47. Benzodiazepines
(Midazolam & Lorazepam) Anxiolysis
Amnesia
Sedation
Pharmacokinetics/dynamics
•Lorazepam: onset 5 - 10
minutes, half-life 10 hours,
glucuronidated
•Midazolam: onset 1 - 2
minutes, half-life 3 hours,
metabolized by cytochrome
P450, active metabolite (1-
OH) accumulates in renal
disease
Benefits

48. Benzodiazepines
(Midazolam & Lorazepam)
• Delirium
• NO analgesia
• Excessive sedation: especially after long-term
sustained use
• Propylene glycol toxicity (parenteral
lorazepam)
- Significance uncertain
- Evaluate when a patient has
unexplained acidosis
- In alcoholics (due to doses used)
and renal failure
• Respiratory failure (concurrent opiate
use)
• Withdrawal

49. Propofol
Pharmacology: GABA
agonist
Pharmacokinetics/
dynamics: onset 1 - 2
minutes, terminal
half-life 6 hours,
duration 10 minutes,
hepatic metabolism
Benefits
Rapid
onset
&Offset
Hypnotic
and
Antiemetic
Reduce ICP
OPTION
2

50. Propofol • No amnesia- especially
at low doses
• NO analgesia!
• Hypotension
• Hypertriglyceridemia;
lipid source (1.1 kcal/ml)
• Respiratory depression
• Propofol Infusion
Syndrome

51. • Cardiac failure,
rhabdomyolysis, severe
metabolic acidosis, and
renal failure
• Caution : at a doses > 80
mcg/kg/min for more
than 48 hours
• Problematic when used
simultaneously in patient
receiving catecholamines
and/or steroids
P
O
P
O
F
O
L
I
N
F
U
S
I
O
N
Syndrome

52. Propofol Dosing
• 3-5 g/kg/min antiemetic
• 5-20 g/kg/min anxiolytic
• 20-50 g/kg/min sedative hypnotic
• >100 g/kg/min anesthetic

53. Dexmedetomidine
Alpha-2-
adrenergic agonist
Decrease the
need for other
sedation
Useful while
decreasing other
sedatives to
prevent
withdrawal
Rapid onset
Benefits
No Respiratory depression
Sympatholytic action
Option -3

54. Dexmedetomidine
No Amnesia
Excessive awareness
Bradycardia ,Hypotension

55. Alpha-2 Receptors
Brain
(locus ceruleus)
Spinal Cord
Peripheral
vasculature
Sedation
Anxiolysis
Sympatholysis
Analgesia
Vasoconstriction

56. DEX: Dosing
Maintenance infusion
0.2-0.7 g/kg/hr

57. Sample Sedation Protocol
Sedation-agitation Scale
Riker RR et al. Crit Care Med. 1999;27:1325.

58. Use Continuous and Combined Infusion
Plasma
Level
Load
Maintenance

59. Repeated Bolus
Plasma
levels

60. Choose the Right Drug
Sedation Analgesia
Amnesia Hypnosis Anxiolysis
Propofol
BenPzaotideinatz eCpoinmefsort
-2 agonists
Opioids

62. Neuromuscular
Blockade (NMB) Caution
• NO ANALGESIC or SEDATIVE
properties
• Add sedation with amnestic
effect .
• Analgesic as needed
• Never use without the ability
to establish and/or maintain a
definitive airway with
ventilation
• If administering for prolonged
period (> 6 - 12 hours), use an
objective monitor to assess
degree of paralysis.
Used most often
acutely (single dose)
to facilitate intubation
or selected
procedures

63. NMB
Limited use because of
risk of prolonged weakness
and other complications
Maximize
sedative/analgesic
infusions as much as
possible prior to adding
neuromuscular blockade
Current
concepts

64. NMB • Facilitate mechanical
ventilation [abdominal compartment
syndrome, high airway pressures, and
dyssynchrony]
• High Frequency Ventilation,
Prone ventilation
• Elevated intracranial
pressures
• Reduce oxygen consumption
• Prevent muscle spasm
[neuroleptic malignant syndrome, tetanus, etc.]
• Protect surgical wounds or
medical device placement
When to Use it?

65. NMB agents
•Depolarizers
Two classes •Non depolarizers

66. NMB agents • Succhinylcholine is
the only drug in this
class
• Depolarization
(fasciculations) and
desensitization of
the motor endplate
• Motor Paralysis
Depolarizers
Prolonged binding
to acetylcholine
receptor

67. NMB Agents • Benzylisoquinoliniums
• Curare
Atracurium,
Cisatracurium,
Mivacurium,
Doxacuronium
• Aminosteroids
• Pancuronium,
Vecuronium,
Rococuronium
Non
depolarizers
Competitive
inhibitors of
postsynaptic
receptors

68. NMB Agents for
intubation
Rocuronium
• Onset -45 seconds
• Nondepolarizer with about an hour
duration and 10% renal elimination
• Dose is 1.2 mg/kg
Succinylcholine
• Onset 30 seconds
• Duration of 10 minutes
• All or none train of four after
administration due to desensitization
• prolonged in patients with abnormal
plasma cholinesterase
• Dose is 1 - 2 mg/kg
Need rapid onset
paralysis
Not usually used
for continuous
maintenance
infusions

69. Succinylcholine Severe K+ releases
• Denervation injury
• Stroke
• Trauma
• Burns of more than 24
hours
Problems
•Potassium
release- 0.5 to 1
meq/liter
•Bradycardia
•Increases intra
gastric, ocular and
cranial pressures
•Anaphylaxis
•Muscle pain

70. NDMR
•Pancuronium -
tachycardia
•Vecuronium -
renally excreted
active metabolites
•Elimination of
cisatracurium is not
affected by organ
dysfunction
Infusion doses
•Pancuronium
0.05 - 0.1 mg/kg/h
•Vecuronium 0.05
- 0.1 mg/kg/h
•Cisatracurium
0.03 - 0.6 mg/kg/h

71. Monitoring
NMBAs
Methods:
•NMBA dose reduction
or cessation once
daily if possible
• Clinical evaluation:
Assess skeletal muscle
movement and
respiratory effort
•Peripheral nerve
stimulation
To prevent
prolonged
weakness
associated with
excessive NMBA
administration

72. Monitoring NMBAs • Train of four response consists
of four stimulae of 2 Hz, 0.2
msec in duration, and 500
msec apart.
• Comparison of T4 (4th twitch)
and T1 with a fade in strength
means that 75% of receptors
are blocked.
• Only T1 or T1 and 2 is used for
goal in ICU and indicates up to
90% of receptors are blocked.
Peripheral
nerve
stimulation

73. Complications of NMB Agents
Associated with inactivity:
• Muscle wasting, deconditioning, decubitus
ulcers, corneal drying
Associated with inability to assess
patient:
• Recall, unrelieved pain, acute neurologic
event, anxiety

74. Complications of NMB Agents
Associated with loss of respiratory
function:
• Asphyxiation from ventilator malfunction or
accidental extubation, atelectasis, pneumonia
Other:
• Prolonged paralysis or acute NMBA related myopathy
- Related to decreased membrane excitability or
even muscle necrosis
- Risk can be compounded by concurrent use of
steroids.

75. Monitoring Sedation During Paralysis
• Bispectral index
• Titrating to appropriate sedation to the least
amount required, not proven to achieve the
goal.
• Potential for baseline neurologic deficit and
EEG interference in ICU patients

76. Monitoring Sedation During Paralysis…
No randomized controlled studies to support
reliable use in ICU.
Other neuromonitoring (awareness)
modalities are likely to be developed.
Cessation of NMB as soon as safe in
conjunction with other patient parameters
should be a daily consideration.

77. Sample NMBA Protocol

79. ICU Delirium
Seen in > 50% of ICU patients
Three times higher risk of death by six months
Four times greater frequency of medical
device removal
Nine times higher incidence of cognitive
impairment at hospital discharge

80. Delirium
1.Acute onset of mental status changes or a
fluctuating course
&
2. Inattention
&
or
Courtesy of W Ely, MD
3. Disorganized
Thinking
4. Altered level of
consciousness

81. Risk Factors for Delirium
Primary CNS Dx
Infection
Metabolic derangement
Pain
Sleep deprivation
Age
Substances including tobacco (withdrawal as well as direct
effect)

82. Diagnostic Tools: ICU
Routine monitoring recommended
• Confusion Assessment Method (CAM-ICU) or
Delirium Screening Checklist (DSC)
Requires Patient Participation
• Cognitive Test for Delirium
• Abbreviated Cognitive Test for Delirium
• CAM-ICU
Ely. JAMA. 2001;286: 2703-2710.

84. Delirium Screening Checklist
No Patient Participation
• Delirium Screening Checklist
Bergeron. Intensive Care Med. 2001;27:859.

85. Treatment of Delirium
Correct inciting factor
Control symptoms?
• No evidence that treatment reduces duration and severity
of symptoms
• Typical and atypical antipsychotic agents
• Sedatives?
- Particularly in combination with antipsychotic and for
drug/alcohol withdrawal delirium
No treatment FDA approved

86. Haloperidol
The good:
• Hemodynamic neutrality
• No effect on respiratory drive
The bad:
• QTc prolongation and torsades de pointes
• Neuoroleptic malignant syndrome
• Extrapyramidal side effects

87. Atypical
Antipsychotics: Mechanism of action
unknown
Less movement
disorders than
haloperidol
Enhanced effects on
both positive (agitation)
and negative (quiet)
symptoms
Quetiapine
Olanzapine
Risperidone
Ziprasidone

88. Efficacy =
haloperidol?
• Lack of available IV
formulation
• Troublesome reports of
CVAs, hyperglycemia, NMS
• Titratability hampered
QTc prolongation with
ziprasidone IM
- Hypotension with
olanzapine IM
Atypical
Antipsychotics:

89. Summary
• Patient discomfort in ICU should be addressed
appropriately and seriously
• Protocol based practice will bring up excellent
results.
• Assess and Manage Sedation and Analgesia
• Paralysis should be restricted to indicated
cases
• Address delirium and withdrawals

90. Thank you
for your
patient
listening