It seems often that history and tradition guide much of what we do on a day-to-day basis in our practice of medicine. This is particularly true in the intensive care unit as we administer sedatives and analgesics medications to our patients on ventilators continuously on a daily basis. For instance, in days past patient's required significant quantities of sedative medication with the use of more primitive ventilator strategies compared to the more modern microprocessor driven devices that we now have. We sedate patient’s for therapeutic reasons, humanistic reasons, and protective reasons. We want the patient to be calm and not excessively agitated and using increased and excessive amounts of energy. We want to provide analgesia to relieve pain. We do not want patient's removing lines or extubating themselves. Pain is the most common memory patients have of the her intensive care unit stay. The ‘ICU Triad’ recognizes that pain agitation and delirium, and therefore approaches to their management, are inextricably linked. Sedatives should be used only when pain and delirium have been addressed.
It is very important to evaluate our sedation practices and their long-term effects on patient's after they leave the intensive care unit and attempt to resume a normal life. Prospective studies confirm that the majority of patients her treated in the intensive care unit have pain which makes the assessment of pain and the provision of adequate analgesia central components to their intensive care unit care. Best means to assess pain severity is by validated pain scales such as the Behavior Pain Scale and the Critical Care Pain Observation Tool. These tools provide the ability to perform structured and repeatable assessments and are the best available methods for assessing pain.
Evidence from multiple randomized trials support use of the minimum possible level of sedation. It is clear that over-sedation leads to and increases length of stay both on the mechanical ventilator and in the intensive care unit. This leads to increased immobility, critical illness myopathy, and neuropathy. It is said that for every day of immobility in the intensive care that there is 3 to11% loss of muscle strength at 1 year post discharge. Minimizing sedation among patients in the intensive care unit provides clinical benefit and results in more ventilator and ICU free days.
Once again pain is the most common complaint of patients in the intensive care unit and should be addressed initially with and opiate medication. This can be an intermittently dosed medication or by a continuous infusion. With further assessment the patient may be felt to be demonstrating anxiety or agitation and at this point the addition of a medication for sedation may seem to be appropriate. The use of propofol or midazolam in the case of propofol failure may seem appropriate at this time. An alternative is the use of dexmedetomidine. One must be aware of the potential for the development of delirium. Delirium In the DSM-IV has four domains: Disturbance of consciousness, change in cognition, change over a short time, and fluctuation. The NIH defines delirium as a sudden severe confusion and rapid change in brain function that occurs with physical and mental illness. The most common feature may be inattention. Delirium is nonspecific but generally reversible, a manifestation of acute illness that appears to have many causes including recovery from a sedated or over sedated state. The pathophysiology of delirium may include association with the use of GABAa agonist and anticholinergic drugs, one reason that benzodiazepines have fallen somewhat out of favor. This is a frequent and serious event in critically ill patient is leading to serious increase in morbidity and mortality. A diagnosis of delirium is associated with and increase if mortality estimated as 10 percent and a decrease and long term cognitive function. There are 2 distinct forms of delirium, hypoactive and agitated or hyperactive.
Monitoring the level of sedation is important and a RASS or Richmond agitation sedation Scale score of-2 to 0 is in most cases appropriate. This is a range of asking the patient to briefly awaken with eye contact to voice for less than 10 seconds to being alert and calm. It is important to communicate with nursing what your intention and goals of sedation are. Sedation must be increased or decreased as needed for procedures, planned extubation or other changes in the patient's status. Communication with nursing staff is critical to achieve optimum results with your patients.
Remember the “ABCDE bundle” spontaneous awakening, breathing coordination, attention to choice of sedation, delirium monitoring, and early mobilization and exercise.
Please refer to the article from the new England Journal of Medicine which is attached the reference: 370;5 444-452 1/30 2014
In addition please refer to the NEJM Resident360 on ventilator sedation.
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