PACT Module Sedation. Intensive Care Training Program Radboud University Medical Centre Nijmegen

Transcription

1 PACT Module Sedation Intensive Care Training Program Radboud University Medical Centre Nijmegen

2 Important concepts Prolonged use of sedatives associated with significant side effects - drug holiday & sedation scales The concept op analgosedation Dexmedetomidine and delirium Sleep deprivation

3 The four step model of sedation What is the main problem? Give the medication with the ideal profile Is sedation the best solution? How long is sedation necessary?

4 Renal failure Midazolam Lorazepam =/ Morphine Fentanyl =/ Remifentanyl = Propofol =/ Dexmedetomidine Fospropofol

5 Propylene glycol toxicity 19% of patients receiving iv diazepam or lorazepam Clinical deterioration, unexplained metabolic acidosis with increased anion gap and hyperosmolality, lactic acidosis, hypotension Treatment with alcohol infusion combined with hemodialysis or 4-methylpyrazole Wilson KC. Chest 2005;128:

6 Propofol infusion syndrome Bradycardia and cardiac failure Metabolic acidosis Hyperkalemia Rhabdomyolysis

7 Stop sedatives every day Medical ICU Pregnancy and CPR excluded Daily stop N = 68 Ramsay 3-4 Conservative N = 60 Propofol N = 31 Midazolam N = 37 Propofol N = 31 Midazolam N = 29 Morphine Morphine Morphine Morphine Length of MV, ICU and Hospital Accumulative dose sedative + complications Kress JP. NEJM 2000;342:

8 Daily sedative stop Conservative Daily stop ,0 13,0 Days ,0 4,0 9,0 6,0 0 Duration MV ICU stay Hospital stay

9 Daily sedative stop Midazolam conservative Propofol conservative Midazolam daily stop Propofol daily stop Midazolam Propofol Morphine

10 Complications Conservative Daily stop Days awake (%) CT scan or neurological test 16 6 Auto-extubation 2 4 Tracheostomy 12 16

11 Delier and PTSD Conservative (n = 19) Daily stop (n = 13) P-value Total impact of events score Avoidance subscale score 27.3 ± ± ± ± PTSD Recollection of awakening PAIS T score

12 Awakening and Breathing Controlled trial MC (N = 4) RCT comparing daily SAT + SBT versus patient-targeted sedation + SBT Adult patients 18 years old with MV > 12 hours Excluded if admitted after CPR, MV > 2 weeks, moribund or profound neurological deficit Primary outcome: ventilator-free-days (D28) Girard TD. Lancet 2008;371:

13 N = minutes N = 167 Girard TD. Lancet 2008;371:

14 Awakening and Breathing Controlled trial No baseline differences between groups SAT/SBT group had 3.1 ( ) more ventilator-free days compared to control group They were discharged 4.3 days earlier from the hospital and had a decreased 1 year mortality rate (44 versus 58%) Girard TD. Lancet 2008;371:

15 Awakening and Breathing Controlled trial Similar duration of delirium but 1 day less coma in SAT/SBT group Increased incidence of self-extubation (10 versus 4%) but similar rate for requiring reintubation Tendency to decreased tracheostomy (13 versus 20%, p = 0.06) Girard TD. Lancet 2008;371:

16 Girard TD. Lancet 2008;371:

17 Daily interruption versus no sedation Expected duration of MV > 24 hrs No sedation (N=70) vs propofol/midazolam with daily interruption (N=70) Both groups bolus doses of morphine Primary outcome: ventilator free days at D 28 StrØm T. Lancet 2010;375:

18 Daily interruption versus no sedation 30,0 Difference 4.2 days (95% CI , p = 0.02) Ventilator free days at D 28 22,5 15,0 7,5 13,9 9,6 0 No sedation Daily interruption Shorter LOS ICU and Hospital but higher incidence agitated delirium (20 vs 7%) StrØm T. Lancet 2010;375:

19 Frontal EMG monitoring BIS and Entropy TM confounded by frontal EMG activity Development of Responsiveness Index (RI 0 = completely unresponsive, 100 = fully responsive) based on frontal EMG responsiveness Development set (N = 30) - Test set in cardiac surgery patients (N = 15) Walsh TS. BJA 2011;107:

20 Development SE - state entropy RE - response entropy Test Walsh TS. BJA 2011;107:

21 Walsh TS. BJA 2011;107:

22 Dexmedetomidine α2 adrenoreceptor agonist Sedation and anxiolysis via receptors within locus ceruleus Analgesia via receptors in the spinal cord Attenuation of the stress response without significant respiratory depression

23 N = 106 % patients within 1 point target RAAS score Sedation up to 5 days Pandharipande PP. JAMA 2007;298:

24 N = 106 Pandharipande PP. JAMA 2007;298:

25 Dexmedetomidine and delirium prevalence Riker RR. JAMA 2009;301:

26 Dexmedetomidine and ICU length of stay Dexmedetomidine Midazolam 8 7,6 6 5,6 5,9 Days 4 2 3,7 0 Time to extubation ICU length of stay Bradycardia most notable adverse effect Riker RR. JAMA 2009;301:

27 Antipsychotics for ICU delirium Girard TD. Crit Care Med 2010;38:

28 Antipsychotics for ICU N = 36 delirium Devlin JW. Crit Care Med 2010;38:

29 Remifentanyl Selective μ-opioid receptor agonist Rapid onset of action (1 minute) Metabolised by non-specific plasma esterases Context-sensitive half-time of 2-3 minutes independent of duration of infusion

30 Analgesic-based sedation in the ICU Breen D. Crit Care 2005;9:R200-R210

31 Time to extubation Tan JA. Anaesthesia 2009;64:

32 Length of ICU stay Tan JA. Anaesthesia 2009;64:

33 Remifentanyl vs fentanyl during MV N = 60 Prospective Randomized Double Blind study Remifentanil Fentanyl P = 0.44 P > 0.99 P = 0.09 Primary outcome (%) VAS 3 or BPS 6 Behavioural Pain Scale No differences in duration MV, complications and LOS Maintenace 90% of time Maintenance 80% of time Spies C. Intensive Care Med 2011;37:

34

35 Sleep disturbances in the ICU Prolonged sleep latencies Sleep fragmentation and frequent arousals Decreased sleep efficiency Predominance of stage 1 & 2 NREM sleep Decreased or absent stage 3 & 4 NREM and REM sleep

36 Consequences Impaired immune function and host defense Protein catabolism with negative nitrogen balance Increased psychological disturbances and decrease in quality of life measures

37 Impaired immune function Infection results in increase in amplitude or intensity of slow-wave NREM sleep Sleep deprivation results in decreased PMN and lymphocyte counts, dysfunctional NK cells and PMN s and impaired antigen specific defenses

38 Sleep deprivation in ICU Lightning practices Patient care activities Diagnostic procedures Noise Stress Environmental factors Sleep deprivation Pathophysiological factors Sedatives & analgesics Psychosis Organ dysfunction Inflammatory response Pain

39 Ventilator mode and sleep Cabello B. Crit Care Med 2008;36:

40 Effect of sedatives Benzodiazepines and propofol increase total sleep time by prolonging stage 2 sleep but they decrease SWS and REM sleep Zolpidem and zopiclone (γ-aminobutyric acid type A receptor agonists do not suppress SWS and have a less negative effect on REM sleep Dexmedetomidine enhances SWS

41 Sleep promotion in the ICU (1) Noise reduction Individual patient rooms, ear plugs, monitor alarm settings, conversation Diurnal lightning practices Reduce lightning during the night and use blindfolds Sleep promoting agents zolpidem, zopiclone or gaboxadol (increases SWS), dexmedetomidine or melatonin

42 Sleep promotion in the ICU (2) Avoid sleep reducing agents Benzodiazepines, opioids, inotropic agents, lipid soluble β-blockers, H2- receptor blockers, proton pump inhibitors, high-dose corticosteroids, β- lactam antibiotics, quinolones Adequate uninterrupted time for sleep Reduce nighttime assessment and monitor alarms