Role of sedation in critical care



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Role of sedation in critical care

  • Role of sedation in critical care

  • Elements of sedation

  • Levels of sedation

  • Choosing a sedation plan

  • Choosing the right drug

  • Preventative medicine



Medical illness

  • Medical illness

  • Post-operative care

  • Diagnostic imaging

  • Invasive procedures

  • Mechanical ventilation



Anesthesia

  • Anesthesia

  • Analgesia

  • Anxiolysis

  • Amnesia



Definition

  • Definition

    • Loss of sensation & loss of consciousness
  • Examples (Intravenous anesthetics)

    • Etomidate
    • Ketamine
    • Propofol
    • Thiopental


Definition

  • Definition

    • Inability to sense pain
  • Examples

    • Non-sedating Analgesics
      • Lidocaine/L.M.X. 4
      • Acetaminophen
      • NSAIDs (Ibuprofen, Ketorolac)
    • Sedating Analgesics
      • Narcotics (Fentanyl, Morphine, Oxycodone, Methadone)
      • Ketamine


Definition

  • Definition

    • Relief of apprehension, fear, and/or agitation
  • Examples

    • Benzodiazepines (Midazolam, Lorazepam, Diazepam)
    • Chloral Hydrate


Definition

  • Definition

  • Examples

    • Benzodiazepine
    • Ketamine


Awake

  • Awake



Purposeful response to verbal stimulation

  • Purposeful response to verbal stimulation

  • Airway patent

  • Spontaneous ventilation adequate

  • Cardiovascular function unaffected



Difficult to arouse

  • Difficult to arouse

  • Purposeful response only to painful stimulation

  • Airway may be obstructed

  • Spontaneous ventilation may be impaired

  • Cardiovascular function usually unaffected



Loss of consciousness

  • Loss of consciousness

  • Positive pressure ventilation

  • Cardiovascular function may be affected



Remember mnemonic AMPLE!!

  • Remember mnemonic AMPLE!!

  • A llergies

  • M edications

  • P ast Medical History

  • L ast Meal

  • E vents leading to sedation



Drug allergies

  • Drug allergies

  • Environmental allergies

    • Egg & soy allergy no Propofol
  • Contrast allergies



Knowing current medications & therapeutic interventions can help tailor your sedation plan…

  • Knowing current medications & therapeutic interventions can help tailor your sedation plan…

    • Sedatives already being used
    • Vasoactive medications
    • Neuromuscular blockers
    • Respiratory medications
    • Hemofiltration/dialysis
    • And so on…


Know current patient problem list and significant past medical/surgical history

  • Know current patient problem list and significant past medical/surgical history

    • Respiratory (hypoxia, pneumothorax)
    • Cardiovascular (hypotension, myocardial dysfunction)
    • Neurologic (increased ICP, seizure disorder)
    • Hepatic/Renal failure


Past history of sedation

  • Past history of sedation

    • Medications used in the past
    • Prior adverse events with sedation
    • Ability to manage airway (Pierre Robin, croup, mediastinal mass, prior radiation, asthma)
  • Family history of problems with sedation



ASA Physical Status Score

  • ASA Physical Status Score

    • ASA I : normally healthy patient
    • ASA II: mild systemic disease
    • ASA III: severe systemic disease
    • ASA IV: severe systemic disease that is a constant threat to life
    • ASA V: moribund patient not expected to survive without operation


Mallampati/Samsoon Classification

  • Mallampati/Samsoon Classification

    • Class I: soft palate, uvula, pillars
    • Class II: soft palate, portion of uvula
    • Class III: soft palate, base of uvula
    • Class IV: hard palate only
  • Other predictors of difficult airway

    • Obesity with short neck
    • Reduced neck movement
    • Inability to protrude the lower teeth
    • Reduced mouth opening
    • Receding mandible
    • Thyromental distance of less than 3 fingers


Full stomach is a risk of aspiration during sedation!!!

  • Full stomach is a risk of aspiration during sedation!!!

  • NPO status

    • Last solid intake > 6 to 8 hours
    • Last opaque liquid/formula intake > 4 hours
    • Last clear liquid/breastmilk intake > 2 hours
  • These guidelines do not apply for patients with GI disturbances



Full stomachs include the following…

  • Full stomachs include the following…

    • Any patient with material in their stomach
      • Food
      • Medications
      • Contrast
      • Charcoal
      • Blood
    • Any patient with delayed gastric emptying
      • Morbid obesity
      • Small bowel obstruction
      • Pyloric stenosis
      • GI dysmotility
      • And so on…


Know why your patient needs sedation!!

  • Know why your patient needs sedation!!

  • Is it safe to sedate your patient??

  • What kind of sedation are you trying to achieve??

    • Analgesia, anxiolysis, amnesia, or a combination
  • Anticipated duration of therapy



There is no magic cocktail…all drugs have potential complications

  • There is no magic cocktail…all drugs have potential complications

  • Drugs to consider should fit your goals for sedation with minimum risk to the patient

  • Considerations when choosing a drug

    • Route of administration
    • Onset of action
    • Duration of action
    • Contraindications
    • Therapeutic advantages


Anesthetics:

  • Anesthetics:

    • Propofol, Ketamine, Pentobarbital
  • Analgesics:

    • Fentanyl, Morphine
  • Anxiolytics:

    • Midazolam, Lorazepam, Diazepam
  • Other:

    • Dexmedetomidine, Clonidine


Onset: 30 sec

  • Onset: 30 sec

  • Duration: 3-10 min

  • Dose: 1 mg/kg

    • Infusion: 50-150 mcg/kg/min
  • Disadvantages: respiratory depression, hypotension, bradycardia, NO analgesia, metabolic acidosis with prolonged infusion



Onset: 30 sec (IV), 3-4 min (IM)

  • Onset: 30 sec (IV), 3-4 min (IM)

  • Duration: 5-10 min (IV), 12-25 min (IM)

  • Dose: 0.5-1 mg/kg (IV), 4-5 mg/kg (IM)

    • Infusion: 5-20 mcg/kg/min
  • Analgesia and amnesia

    • preserves upper airway tone and reflexes
  • Disadvantages: excess secretions, increased ICP, emergence reaction



Onset: 3-5 min (IV)

  • Onset: 3-5 min (IV)

  • Duration: 15-45 min

  • Dose: 1-2 mg/kg

  • Disadvantages: NO reversal agent, no analgesia (enhances pain perception)



Onset: 2-3 min

  • Onset: 2-3 min

  • Duration: 30-60 min

  • Dose: 1 mcg/kg

  • 100x more potent than morphine

  • Available reversal agent

    • Naloxone
  • Disadvantages: no amnesia/ anxiolysis, “steel chest”



Onset: 5-10 min (IV)

  • Onset: 5-10 min (IV)

  • Duration: 4-6 hours

  • Dose: 0.05-0.1 mg/kg

  • Available reversal agent:

    • Naloxone
  • Disadvantages: no amnesia/ anxiolysis, histamine release



Onset: 2-6 min

  • Onset: 2-6 min

  • Duration: 45-60 min

  • Dose: 0.05-0.1 mg/kg

  • Available reversal agent

    • Flumazenil
  • Retrograde amnesia

  • Disadvantages: NO analgesia, paradoxical reactions



Onset: 1-1.5 hours (oral)

  • Onset: 1-1.5 hours (oral)

  • Duration: variable but LONG (oral)

  • Dose: 0.1-0.8 mg/kg/day (oral)

  • Useful for tapering

  • Disadvantages: accumulation, long half-life, avoid rapid IV push



Onset:15-30 min (IV)

  • Onset:15-30 min (IV)

  • Duration: 3-4 hours (up to 12 hrs)

  • Dose: 0.05-0.1 mg/kg

  • Disadvantages: mixed with propylene glycol

    • Anion gap metabolic acidosis, osmolar gap
    • Avoid infusions


IV alpha-2 agonist

  • IV alpha-2 agonist

    • 1700x more selective for alpha 2
  • Onset: 15-30 min

  • Duration: 60-120 min

  • Dose: load with 0.5-1 mcg/kg

    • Infusion of 0.3 – 1.5 mcg/kg/hr
  • Disadvantages: bradycardia, only approved for 24 hr infusions



Centrally acting alpha-2 agonist

  • Centrally acting alpha-2 agonist

  • Onset: 30-60 min (oral)

  • Duration: 6-10 hours

  • Dose: 0.05 mg/day (oral)

  • Can convert to transdermal patch

  • Eases withdrawal & decreases anesthetic requirements



All drugs should be used judiciously!!!

  • All drugs should be used judiciously!!!

  • Commonly seen relative contraindications and adverse effects

    • Ketamine  increased ICP, excess salivation, emergence reaction
    • Propofol  hypotension, acidosis
    • Dexmedetomidine  bradycardia, arrhythmia
    • Benzodiazepine  hypotension


Not all side effects are harmful

  • Not all side effects are harmful

  • Considerations for choice of drug

    • Ketamine  bronchodilator
    • Pentobarbital or Midazolam  anti-convulsant
    • Diazepam  muscle relaxation




An 8 year old known asthmatic is in the ED having received continuous albuterol nebs, steroids, and subcutaneous epinephrine. You check on him and find him unresponsive with a RR of 6 and very poor air movement. An RT runs in with a ABG showing pH 6.9, pCO2 190. What medications do you consider for intubation & sedation?

  • An 8 year old known asthmatic is in the ED having received continuous albuterol nebs, steroids, and subcutaneous epinephrine. You check on him and find him unresponsive with a RR of 6 and very poor air movement. An RT runs in with a ABG showing pH 6.9, pCO2 190. What medications do you consider for intubation & sedation?



A transport team has just arrived to pick up a 4 year old child with severe stridor. On exam she is alert, sitting in Mom’s lap & maintaining her sats, but has severe retractions with every breath and drooling. She appears frightened, and the paramedic asks you to order something to sedate her so that she can be strapped to the gurney. What is your response?

  • A transport team has just arrived to pick up a 4 year old child with severe stridor. On exam she is alert, sitting in Mom’s lap & maintaining her sats, but has severe retractions with every breath and drooling. She appears frightened, and the paramedic asks you to order something to sedate her so that she can be strapped to the gurney. What is your response?



You consult in the ED on a 7 year old who has presented with sore throat and noisy breathing. He has received 2 gm of chloral hydrate 1/2 hour before for an attempted CT scan of the neck. In the ED you find him in the back room with his mother, with a sat probe on his finger not attached to a monitor. He has retractions and poor air movement with every breath. What happened and what would you do?

  • You consult in the ED on a 7 year old who has presented with sore throat and noisy breathing. He has received 2 gm of chloral hydrate 1/2 hour before for an attempted CT scan of the neck. In the ED you find him in the back room with his mother, with a sat probe on his finger not attached to a monitor. He has retractions and poor air movement with every breath. What happened and what would you do?



You are taking care of a 9 mo post-op cardiac patient who is intubated and requiring sedation. She initially had issues with heart block and required pacing but is now in a sinus rhythm of 110. She has been difficult to sedate with Fentanyl & Midazolam and the nurses ask you if you can add a 3rd agent. What agents would you want to avoid in this patient and what do you need to consider?

  • You are taking care of a 9 mo post-op cardiac patient who is intubated and requiring sedation. She initially had issues with heart block and required pacing but is now in a sinus rhythm of 110. She has been difficult to sedate with Fentanyl & Midazolam and the nurses ask you if you can add a 3rd agent. What agents would you want to avoid in this patient and what do you need to consider?



You are called to the ED to see a 6 year old trauma patient who luckily has a normal head CT but unfortunately has a severely displaced tib-fib fracture. The orthopedic surgeons are gathering equipment to reduce and splint the fracture. What drugs do you think about using and what else do you consider?

  • You are called to the ED to see a 6 year old trauma patient who luckily has a normal head CT but unfortunately has a severely displaced tib-fib fracture. The orthopedic surgeons are gathering equipment to reduce and splint the fracture. What drugs do you think about using and what else do you consider?



Optimize your patient prior to sedation

  • Optimize your patient prior to sedation

    • Correct acidosis
    • Keep euvolemic
    • Know “AMPLE”
  • Anticipate difficulties and be prepared

    • Bag, mask, oxygen, +/- airway box
    • Suction
    • Normal saline/Lactated Ringer’s
    • Monitors – O2, CO2, CR monitor, BP
  • Titrate medications to effect…it is easier to give more drug than it is to remove it!!!



Many situations require sedation in the ICU

  • Many situations require sedation in the ICU

  • Components of sedation include anesthesia, analgesia, anxiolysis, & amnesia

  • There are several levels of sedation

  • Remember mnemonic “AMPLE” when evaluating a patient for sedation

  • Choosing the right drug involves knowing the goals of sedation alongside drug profile for sedatives

  • Always anticipate possible complications & be prepared to deal with them



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