Welcome to SOVAH Resident's 360!
This is where topics/questions will be posted and residents will need to comment with answers and supporting evidence for their answer. Residents will be required to post their answers and supporting evidence by midnight that evening. The questions will then be readdressed the subsequent morning before rounds in a 15-30 minute conversation.
Wednesday, April 19, 2017
What is the correct sequencing of analgesic and sedative drugs in the ventilated patient?
Mechanical ventilation prevents the patient from expressing their anxiety, pain, or delirium. For patients who are intubated and mechanically ventilated and not able to clearly communicate the source of agitation, analgesia should be the priority followed by arresting anxiety. Anxiety can manifest as apprehension or Fear of suffering, fear of death, loss of control, and frustration due to this inability to communicate. Nonverbal Evidence of pain may include grimacing, diaphoresis, hyperventilation or tachycardia. For distress due to pain, opioids are preferred; for anxiety, benzodiazepines should be first line. Combination therapy is appropriate for more complex patients: a benzodiazepine plus an opioid is appropriate for a patient whose agitation is due to anxiety and pain. Sedation scales such as the RASS scale can be utilized to guide the dosage ,frequency and efficacy of drug therapy. Daily sedation holidays and intermittent sedation versus continuous infusion have proven to be valuable in reducing the time spent on ventilation and length of stay en toto.
Per Chapter 19 of the Critical Care Book on "Use of sedatives, Analgesics, and Neuromuscular Blockers"
- Perform Patient assessment and optimize ICU environment- optimize patient comfort and tolerance of the ICU environment like light and noise, optimize mechanical ventilation settings for patient-ventilator synchrony, provide preemptive analgesia to alleviate pain and associated painful procedures
- Establish treatment goals. Use the Richmond Agitation Sedation Scale to assess level of sedation. Identify Delirium using a validated delirium assessment instrument.
- Implement a structures, patient-focused management strategy, select analgesic and sedative drugs based on patient needs and unique characteristics (such as alcohol or substance abuse), drug allergies, organ dysfunction (renal or hepatic), need for rapid onset and offset of action, anticipated duration, prior response.
1. Focus first on patient characteristics as above 2. Focus first on analgesia then sedation. Use opiods as primary analgesics, but consider adding adjunctive agents and interventions. 3. Evaluate and manage severe agitation, including a search for causative factors and perform rapid tranquilization 4. Identify delirium, correct precipitating factors, and administer appropriate medications to reduce the intensity and duration of delirium. 5. Titrate analgesic and sedative drugs to a defined target, using the lowest effective dose and aiming for light level of sedation 6. Implement a structured strategy to avoid accumulation of medications/metabolites: utilize scheduled interruption of medications or intermittent dosing of analgesic and sedative drugs. Perform safety screen to select proper candidates for interruption of sedation. 7. Link reductions in analgesic and sedative drugs to spontaneous breathing trials and to early mobilization 8. Avoid potential adverse effects of anagesic and sedative drugs, quickly identify and manage adverse effects that occur
- Recognize and take steps to ameliorate analgesic and sedative drugs withdrawal during de-escalation of therapy
Individuals on mechanical ventilation should be assessed for pain, agitation and delirium. Initially, analgesia for pain will be provided based upon hemodynamic stability; with hemodynamically unstable patient's receiving hydromorphone or fentanyl, and hemodynamically stable individuals receiving morphine. There should be frequent reassessments of analgesia and adjustment of medications based upon that assessment. Midazolam will be used for delirium with frequent reassessments and titration of medication. If the patient demonstrates delirium, Haldol would be appropriate to administer with electrocardiogram monitoring to assess for prolongation of QTC. All medications should be initially administered intermittently, however, if required more frequently than every 2 hours, continuous infusions may be considered. Continues infusions for analgesia should be fentanyl and for sedation, propofol or midazolam.
Use of analgesics prior to sedation medications appears to be the consensus of literature review. Using the RASS scale with physical exam aid in evaluation of a patient who can’t communicate. Treatment of pain often reduces anxiety and agitation. However if a patient is not in pain, or the analgesics do improve physical presentation, then sedating medications should be tried. With these medications, a daily sedation holiday has been shown to decrease time on ventilator and hospital stay.
One of the main goals for patients on mechanical ventilation is to keep them free from pain and anxiety that is achieved by proper administration of analgesics and sedatives . The first step is the pain management that is usually achieved by opioids followed by anxiety management with benzodiazepines because uncontrolled pain can further increase anxiety and it becomes a vicious cycle. If the patient is stable ,the best drug will be morphine and fentanyl for hemodynamically unstable patients . As far as sedation is concerned, propofol and versed are the best choices. Both the analgesics and sedatives can de escalated everyday for spontaneous breathing trial and could be restarted if the patient fails the trial and become anxious.
Mechanical ventilation prevents the patient from expressing their anxiety, pain, or delirium. For patients who are intubated and mechanically ventilated and not able to clearly communicate the source of agitation, analgesia should be the priority followed by arresting anxiety. Anxiety can manifest as apprehension or Fear of suffering, fear of death, loss of control, and frustration due to this inability to communicate. Nonverbal Evidence of pain may include grimacing, diaphoresis, hyperventilation or tachycardia. For distress due to pain, opioids are preferred; for anxiety, benzodiazepines should be first line. Combination therapy is appropriate for more complex patients: a benzodiazepine plus an opioid is appropriate for a patient whose agitation is due to anxiety and pain. Sedation scales such as the RASS scale can be utilized to guide the dosage ,frequency and efficacy of drug therapy. Daily sedation holidays and intermittent sedation versus continuous infusion have proven to be valuable in reducing the time spent on ventilation and length of stay en toto.
ReplyDeletePer Chapter 19 of the Critical Care Book on "Use of sedatives, Analgesics, and Neuromuscular Blockers"
ReplyDelete- Perform Patient assessment and optimize ICU environment- optimize patient comfort and tolerance of the ICU environment like light and noise, optimize mechanical ventilation settings for patient-ventilator synchrony, provide preemptive analgesia to alleviate pain and associated painful procedures
- Establish treatment goals. Use the Richmond Agitation Sedation Scale to assess level of sedation. Identify Delirium using a validated delirium assessment instrument.
- Implement a structures, patient-focused management strategy, select analgesic and sedative drugs based on patient needs and unique characteristics (such as alcohol or substance abuse), drug allergies, organ dysfunction (renal or hepatic), need for rapid onset and offset of action, anticipated duration, prior response.
1. Focus first on patient characteristics as above
2. Focus first on analgesia then sedation. Use opiods as primary analgesics, but consider adding adjunctive agents and interventions.
3. Evaluate and manage severe agitation, including a search for causative factors and perform rapid tranquilization
4. Identify delirium, correct precipitating factors, and administer appropriate medications to reduce the intensity and duration of delirium.
5. Titrate analgesic and sedative drugs to a defined target, using the lowest effective dose and aiming for light level of sedation
6. Implement a structured strategy to avoid accumulation of medications/metabolites: utilize scheduled interruption of medications or intermittent dosing of analgesic and sedative drugs. Perform safety screen to select proper candidates for interruption of sedation.
7. Link reductions in analgesic and sedative drugs to spontaneous breathing trials and to early mobilization
8. Avoid potential adverse effects of anagesic and sedative drugs, quickly identify and manage adverse effects that occur
- Recognize and take steps to ameliorate analgesic and sedative drugs withdrawal during de-escalation of therapy
Individuals on mechanical ventilation should be assessed for pain, agitation and delirium. Initially, analgesia for pain will be provided based upon hemodynamic stability; with hemodynamically unstable patient's receiving hydromorphone or fentanyl, and hemodynamically stable individuals receiving morphine. There should be frequent reassessments of analgesia and adjustment of medications based upon that assessment. Midazolam will be used for delirium with frequent reassessments and titration of medication. If the patient demonstrates delirium, Haldol would be appropriate to administer with electrocardiogram monitoring to assess for prolongation of QTC. All medications should be initially administered intermittently, however, if required more frequently than every 2 hours, continuous infusions may be considered. Continues infusions for analgesia should be fentanyl and for sedation, propofol or midazolam.
ReplyDeleteUse of analgesics prior to sedation medications appears to be the consensus of literature review. Using the RASS scale with physical exam aid in evaluation of a patient who can’t communicate. Treatment of pain often reduces anxiety and agitation. However if a patient is not in pain, or the analgesics do improve physical presentation, then sedating medications should be tried. With these medications, a daily sedation holiday has been shown to decrease time on ventilator and hospital stay.
ReplyDeleteOne of the main goals for patients on mechanical ventilation is to keep them free from pain and anxiety that is achieved by proper administration of analgesics and sedatives . The first step is the pain management that is usually achieved by opioids followed by anxiety management with benzodiazepines because uncontrolled pain can further increase anxiety and it becomes a vicious cycle. If the patient is stable ,the best drug will be morphine and fentanyl for hemodynamically unstable patients . As far as sedation is concerned, propofol and versed are the best choices. Both the analgesics and sedatives can de escalated everyday for spontaneous breathing trial and could be restarted if the patient fails the trial and become anxious.
ReplyDeletehttps://res-2.cloudinary.com/medstro/image/upload/v1487791743/daxcohhfxfudihgdc0fn.gif?utm_medium=referral&utm_source=r360&utm_campaign=criticalcare
ReplyDeletehttps://res-2.cloudinary.com/medstro/image/upload/v1487791938/sviwalkxzp15tvtklr33.gif?utm_medium=referral&utm_source=r360&utm_campaign=criticalcare