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, June 13, 2018
What is the correct sequencing of analgesic and sedative drugs in the ventilated patient?
If pt is in distress, rule out and correct reversible causes as well as utilize nonpharmacological treatment if possible. Once this is done, determine the pt's needs. For pain, utilize a pain scale to assess pain level and set a goal for analgesia. If pt is hemodynamically unstable, Fentanyl or Hydromorphone can be used. If hemodynamically stable, Morphine can be used. This is repeated until pain is controlled. Scheduled and PRN doses may then be ordered. For sedation, a sedation scale may be used to assess anxiety/agitation levels. A goal for sedation may then be set. Midazolam may be used for acute agitation. If doses of analgesia and sedation meds are required more frequently than every 2 hours (or if long-term treatment is anticipated), these meds may be given as an infusion. A delirium scale may then be used to assess for delirium. Once again a goal for delirium control should be set. Once this has been done, a medication such as Haloperidol may be given. In this event, an ECG should be checked to assess for QTc prolongation.
Goals of sedation and analgesics for intubated patients should be reassessed daily, with the goal to titrate and taper the therapy as necessary, while performing SBT daily. First thing to do is to rule out or correct any reversible causes and use nonpharmacological treatment if possible. First determine a pain scale. As far as analgesics, we should first determine if the patient is hemodynamically stable or unstable. If patient is hemodynamically stable, fentanyl, hydromorphone, or morpine. If patient is hemodynamically unstable, use Fentanyl. Patient has renal impairment, use fentanyl or hydromorphone. Fentanyl infusion of 25-50 mcg/hr. Hydromorphone infusion of 0.4-0.8 mg/hr, morphine infusion of 2-4 mg/hr. Patient should receive a bolus for pain before infusion starts. When titrating off of infusions, physicians should keep in mind the potential for opioid withdrawal in patients that received high doses of infusion or if the patient received 7 continuous days of therapy. Patient should be tapered 10-30% per day to prevent withdrawal symptoms. For sedation, first determined a scale to assess agitation/anxiety and set a goal for sedation, such as Richmond Agitation Sedation Scale or Riker Sedation-Agitation Scale. Choice of sedation is based on anticipated hours of anticipated sedation. If less than 72 hours, use midazolam, propofol, or Dexmedetomidine. If greater than 72 hours, use lorazepam. For renal impairment, use lorazepam or propofol. When patient is intubated, physicians should also consider patient’s delirium status. Start with a scale such as confusion assessment method for the ICU or intensive care delirium screening checklist. If patient is NPO, Dexmedetomidine or Haloperidol. If patient is able to take PO, Aripiprazole, Haldol, quetiapine, or risperidone. Get EKG to determine QTc. SBT daily.
Most ventilated patients in the ICU require sedation to prevent ventilator dyssynchrony. Propofol can cause hypotension and should be avoided in patients that are hemodynamically unstable. Benzodiazepine such as midazolam and lorazepam have a higher risk of delirium. Dexmedetomidine can be used with alcohol withdrawal and initially causes hypertension followed by hypotension, bradycardia, dry mouth, nausea. If the patient is hemodynamically stable consider using fentanyl, morphine, hydromorphone. If the patient is hemodynamically unstable consider using fentanyl. For renal impairment consider lorazepam or propofol. Sedation is typically titrated based on the Riker sedation-agitation scale or the Richmond agitation sedation Scale. A sedation holiday has been shown to shorten the duration mechanical ventilation and length of intensive care unit stay. A Spontaneous breathing trial can be performed to test if the patient is ready to be extubated. Assess for delirium with the confusion assessment method for the intensive care unit or the Intensive Care delirium screening checklist. Delirium can be prevented with early mobilization, low-dose haloperidol, risperidone. Some studies have shown that dexmedetomidine has lower rates of delirium than benzodiazepines.
Patient's that require analgesia or sedation due to being on the ventilation fall into the greater ICU triad of patient's where the patient population needs to have 3 over arching principles that need to be met for overall success with patient care.
These are Agitation control/sedation control, analgesic control, delirum control (if necessary).
Analgesia based sedation should be attempted first due to the high frequency of patient's in the ICU have discomfort and pain due to their underlying pathology and has been shown to improve overall ventilator-free days however, that was the only known advantage with said approach, some of the disadvantages to this approach are patient's tend to have increased rates of agitated delirum as to hypnotic-based sedation.
If pain focused sedation is unsuccessful agitation control can be achieved with hypnotic based sedation, and finally benzodiazepine based sedation due to their ability to linger in the system for a much longer time frame that the previously mentioned sedation choices.
Always follow the PAD guidelines however, provide the best care based on the patient's clinical picture.
What is the correct sequencing of analgesic and sedative drugs in the ventilated patient? What is the correct timing or useage of these medications in the ventilated patient? Analgesic medications are primarily fentanyl or morphine with fentanyl preferred since it doesn't usually cause hypotension since it doesn't cause a histamine response leading to vasodilatation. Medications such as ketorlac, gabapentin, and carbamazepine can be used in conjunction with opioids to reduce the amount of opioids being used. Sedatives are usually propofol, versed, lorazepam, or precedex. Propofol is preferred in hemodynamically stable patients while versed and lorazepam are good for patients going through withdrawal. The BZD have higher risk for delirium. Precedex can be used for patients that are being difficult to wean from the vent. Those who are going through alcohol withdrawal, but it is only approved for 24hrs. It is very expensive if needed to be used for > 24 hours.
As for as the correct sequencing for analgesic and sedative medications. Many patients who are critically ill in the ICU are in pain and are in a hypernociceptive state to pain.
With all that being said patients should be taking of sedative meds first such as propofol or versed followed by the analgesic meds such as fentanyl that way when that are waking up they are not in pain. Patients should be on the least amount of analgesics/sedatives as possible for the least amount of time. using the RASS scale gives an objective measure for monitoring sedation. A combination approach is preferred that way to reduce the total amount of each drug and decrease the total ventilator days.
References: UpToDate The Little ICU Book Clinical Practice Guidelines for the Management of PAD in the Adult patients in the ICU. Cait Care Med 2013;41:263-306
If pt is in distress, rule out and correct reversible causes as well as utilize nonpharmacological treatment if possible. Once this is done, determine the pt's needs. For pain, utilize a pain scale to assess pain level and set a goal for analgesia. If pt is hemodynamically unstable, Fentanyl or Hydromorphone can be used. If hemodynamically stable, Morphine can be used. This is repeated until pain is controlled. Scheduled and PRN doses may then be ordered. For sedation, a sedation scale may be used to assess anxiety/agitation levels. A goal for sedation may then be set. Midazolam may be used for acute agitation. If doses of analgesia and sedation meds are required more frequently than every 2 hours (or if long-term treatment is anticipated), these meds may be given as an infusion. A delirium scale may then be used to assess for delirium. Once again a goal for delirium control should be set. Once this has been done, a medication such as Haloperidol may be given. In this event, an ECG should be checked to assess for QTc prolongation.
ReplyDeleteReferences: https://www.uptodate.com/contents/image?imageKey=EM%2F76559&topicKey=EM%2F277&search=anagesia%20sedation%20in%20ventilated%20patient&rank=1~150&source=see_link
https://www.uptodate.com/contents/mechanical-ventilation-of-adults-in-the-emergency-department?search=anagesia%20sedation%20in%20ventilated%20patient§ionRank=1&usage_type=default&anchor=H19&source=machineLearning&selectedTitle=1~150&display_rank=1#H19
Goals of sedation and analgesics for intubated patients should be reassessed daily, with the goal to titrate and taper the therapy as necessary, while performing SBT daily. First thing to do is to rule out or correct any reversible causes and use nonpharmacological treatment if possible. First determine a pain scale. As far as analgesics, we should first determine if the patient is hemodynamically stable or unstable. If patient is hemodynamically stable, fentanyl, hydromorphone, or morpine. If patient is hemodynamically unstable, use Fentanyl. Patient has renal impairment, use fentanyl or hydromorphone. Fentanyl infusion of 25-50 mcg/hr. Hydromorphone infusion of 0.4-0.8 mg/hr, morphine infusion of 2-4 mg/hr. Patient should receive a bolus for pain before infusion starts. When titrating off of infusions, physicians should keep in mind the potential for opioid withdrawal in patients that received high doses of infusion or if the patient received 7 continuous days of therapy. Patient should be tapered 10-30% per day to prevent withdrawal symptoms. For sedation, first determined a scale to assess agitation/anxiety and set a goal for sedation, such as Richmond Agitation Sedation Scale or Riker Sedation-Agitation Scale. Choice of sedation is based on anticipated hours of anticipated sedation. If less than 72 hours, use midazolam, propofol, or Dexmedetomidine. If greater than 72 hours, use lorazepam. For renal impairment, use lorazepam or propofol. When patient is intubated, physicians should also consider patient’s delirium status. Start with a scale such as confusion assessment method for the ICU or intensive care delirium screening checklist. If patient is NPO, Dexmedetomidine or Haloperidol. If patient is able to take PO, Aripiprazole, Haldol, quetiapine, or risperidone. Get EKG to determine QTc. SBT daily.
ReplyDeletehttp://www.callhospital.org/site/main/files/file-attachments/icu_sedation_order_set_final_18feb2010.pdf
Most ventilated patients in the ICU require sedation to prevent ventilator dyssynchrony. Propofol can cause hypotension and should be avoided in patients that are hemodynamically unstable. Benzodiazepine such as midazolam and lorazepam have a higher risk of delirium. Dexmedetomidine can be used with alcohol withdrawal and initially causes hypertension followed by hypotension, bradycardia, dry mouth, nausea. If the patient is hemodynamically stable consider using fentanyl, morphine, hydromorphone. If the patient is hemodynamically unstable consider using fentanyl. For renal impairment consider lorazepam or propofol. Sedation is typically titrated based on the Riker sedation-agitation scale or the Richmond agitation sedation Scale. A sedation holiday has been shown to shorten the duration mechanical ventilation and length of intensive care unit stay. A Spontaneous breathing trial can be performed to test if the patient is ready to be extubated. Assess for delirium with the confusion assessment method for the intensive care unit or the Intensive Care delirium screening checklist. Delirium can be prevented with early mobilization, low-dose haloperidol, risperidone. Some studies have shown that dexmedetomidine has lower rates of delirium than benzodiazepines.
ReplyDeletehttps://resident360.nejm.org/pages/home?resource_collection_id=critical-care&subtopic=icu-delirium-cognition&subgroup=fast-facts
Patient's that require analgesia or sedation due to being on the ventilation fall into the greater ICU triad of patient's where the patient population needs to have 3 over arching principles that need to be met for overall success with patient care.
ReplyDeleteThese are Agitation control/sedation control, analgesic control, delirum control (if necessary).
Analgesia based sedation should be attempted first due to the high frequency of patient's in the ICU have discomfort and pain due to their underlying pathology and has been shown to improve overall ventilator-free days however, that was the only known advantage with said approach, some of the disadvantages to this approach are patient's tend to have increased rates of agitated delirum as to hypnotic-based sedation.
If pain focused sedation is unsuccessful agitation control can be achieved with hypnotic based sedation, and finally benzodiazepine based sedation due to their ability to linger in the system for a much longer time frame that the previously mentioned sedation choices.
Always follow the PAD guidelines however, provide the best care based on the patient's clinical picture.
https://journals.lww.com/ccmjournal/fulltext/2013/01000/Clinical_Practice_Guidelines_for_the_Management_of.29.aspx
What is the correct sequencing of analgesic and sedative drugs in the ventilated patient? What is the correct timing or useage of these medications in the ventilated patient? Analgesic medications are primarily fentanyl or morphine with fentanyl preferred since it doesn't usually cause hypotension since it doesn't cause a histamine response leading to vasodilatation. Medications such as ketorlac, gabapentin, and carbamazepine can be used in conjunction with opioids to reduce the amount of opioids being used.
ReplyDeleteSedatives are usually propofol, versed, lorazepam, or precedex. Propofol is
preferred in hemodynamically stable patients while versed and lorazepam are good for patients going through withdrawal. The BZD have higher risk for delirium. Precedex can be used for patients that are being difficult to wean from the vent. Those who are going through alcohol withdrawal, but it is only approved for 24hrs. It is very expensive if needed to be used for > 24 hours.
As for as the correct sequencing for analgesic and sedative medications. Many patients who are critically ill in the ICU are in pain and are in a hypernociceptive state to pain.
With all that being said patients should be taking of sedative meds first such as propofol or versed followed by the analgesic meds such as fentanyl that way when that are waking up they are not in pain. Patients should be on the least amount of analgesics/sedatives as possible for the least amount of time. using the RASS scale gives an objective measure for monitoring sedation. A combination approach is preferred that way to reduce the total amount of each drug and decrease the total ventilator days.
References:
UpToDate
The Little ICU Book
Clinical Practice Guidelines for the Management of PAD in the Adult patients in the ICU. Cait Care Med 2013;41:263-306