1 / 45

The Art of Sedation in ICU

The Art of Sedation in ICU. Yasser Zaghloul MD PhD, FCARCSI (Ireland). Sedation comes from the Latin word sedare . Sedare = to calm or to allay fear. Hypnosis. Analgesia. ± Muscle Relaxation. Sedation comes from the Latin word sedare . Sedare = to calm or to allay fear. Hypnosis.

robert
Télécharger la présentation

The Art of Sedation in ICU

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript


  1. The Art of Sedation in ICU Yasser ZaghloulMD PhD, FCARCSI(Ireland)

  2. Sedation comes from the Latin word sedare. • Sedare = to calm or to allay fear Hypnosis Analgesia ± Muscle Relaxation

  3. Sedation comes from the Latin word sedare. • Sedare = to calm or to allay fear Hypnosis Analgesia ± Muscle Relaxation

  4. Why sedation is necessary? • To improve patient comfort. • Reduce stress. • Facilitate interventions. • Allow effective ventilation. • Encourage sleep. • ?? Prevent post-ICU psychosis.

  5. Inadequate Sedation • All ICU patients suffer from severe sleep deprivation. • REM sleep is 6% ( Normal 25 %). • Stress  neuroendocrine response ( ACTH, GH, Aldosterone, Adrenaline, .....) • Release of cytokines  inflammatory response.

  6. Non-pharmacological interventions • Good nursing. • Psychological: - Explanation. - Reassurance. • Physical: - Touching & message. - Environment - Prevent constipation - Physiotherapy. - Tracheostomy.

  7. Sedation-Analgesia Medications • IV Anaesthetics: - Prpofol - Thiopentone. - Ketamine - Etomidate. • Benzodiazepines: - Midazolam. - Lorazepam

  8. Sedation-Analgesia Medications • Opiodis: - Morphine - Fentanyl. - Remifentanil • α-2 receptors agonists: • Clonidine. • Dexmedetomidine .

  9. Sedation-Analgesia Medications • Others: - Inhalation anaesthetics (Sevoflurane). - Phenothiazines. - Butyrophenones (Haloperidol). - Local Anaesthetics.

  10. Choice of the sedative drug • Short-term Vs long-term sedation. • Pain & painful Procedures. • Organ problems (Renal, hepatic, brain, CVS). • Drug withdrawal (Alcohol, heroin, .....) • Prescriber & Prescription.

  11. Which Medication? Soliman et al, Brit J Anaesth 2001;87:186-92

  12. IV Anaesthetics; Thiopentone • Acts on the GABAA. • Zero order kinetics (accumulation). • Provides a cerebral protection effect. • Main uses in ICU: - High ICP. - Status epilepticus

  13. OH (CH3)2CH CH(CH3)2 IV Anaesthetics; Propofol 2,6 di-isopropyl phenol Short-term sedation (< 48 h)

  14. IV Anaesthetics; Propofol • Mechanisms of actions: - Acts on GABAA receptors in the hippocampus. - Inhibits of NMDA. •  IOP, ICP & CMRO2.

  15. IV Anaesthetics; Propofol • Decreases (10 – 30%): - HR. - SBP, DBP & MAP. - SVR. - CI. - SV.

  16. Target concentrations with ‘Diprifusor’ TCI Full ‘Diprivan’ PFSis loaded correctly Finger grip Tag = PMR(Programmaable Magnetic Resonance*) Aerial ‘Diprifusor’ TCI SubsystemRecognition software/electronics‘Diprifusor’ TCI Software/2 microprocessors Pumpsoftware Pump hardware

  17. Calculated concentration (automatic calculation and display by system) Target concentration (selected by anaesthetist, displayed) 5 2 3 4 1 Target concentrations with ‘Diprifusor’ TCI 1200 8 End ↑ Tc Titration 6 6 Age Wt. Tc 4 Infusion rate (ml/h) Blood concentration (µg/ml) 100 4 50 2 0 0 16 0 4 8 12 20 24 28 Start; 6µg/ml Time (hours)

  18. IV Anaesthetics; Propofol • Propofol infusion syndrome: - Rare but fatal. - 1st described in children. - Infusion ≥ 5 mg/kg/hr or ≥ 48 hours.

  19. Propofol Infusion Syndrome • Clinical features: - Cardiomyopathy with acute cardiac failure. - Myopathy. - Metabolic acidosis, K+ - Hepatomegaly. • Inhibition of FFA entry into mitochondria  failure of its metabolism.

  20. IV Anaesthetics - Ketamine

  21. IV Anaesthetics - Ketamine • Phencyclidine derivative. • High lipid solubility (5–10 times > thiopental) crosses BBB faster. • Non-competitive antagonism at NMDA receptor

  22. IV Anaesthetics - Ketamine •  HR, BP. •  CBF, ICP & CMRO2. • Bronchial smooth muscle relaxant. • Excellent analgesic. • Dose: 5-30 µg/kg/min.

  23. Opioids; Morphine • Isolated in 1803 by the German pharmacist Friedrich Adam. • Named it 'morphium' after Morpheus, the Greek god of dreams.

  24. Opioids - Morphine • Plasma levels do not correlate with clinical effect. • Low lipid solubility causes slow equilibration across BBB. • Metabolized in the liver by conjugation. • Morphine-6-glucuronide (active).

  25. Remifentanil • Piperidine derivative. • Selective mu-receptor agonist. • Potency similar to fentanyl. • Terminal half-life < 10 min. • Rapid blood-brain equilibrium. • Metabolised by non-specific esterases.

  26. Remfentnil Acid 95% 1.5%

  27. Fentanyl 262 min Alfentanil 59 min Sufentanil 34 min Remifentanil 3.7 min Plasma concentration after long term infusion After 240 min Context –sensitive half-time 100 75 Time to 50% drop in concentration at effect site (minutes) 50 25 0 0 100 200 300 400 500 600 Duration of infusion (minutes)

  28. Unwanted side-effects of opioids Opioids Confusion Vasodilation Respiratorydepression Gut motilitydepression

  29. Benzodiazepines

  30. Benzodiazepines; Midazolam • Water-soluble  lipid soluble in the body. • Produces sedation, anxiolysis and amensia. • Withdrawal agitation.

  31. α2-Adrenergic agonists Clonidine Dexmedetomidine

  32. α2 – agonists • Sedation-hypnosis: by an action on α2-receptors in the locus ceruleus. • Analgesia: by an action on α2-receptors within the locus ceruleus and the spinal cord

  33. α2 – agonists; Dexmedetomidine • 94% protein bound. • Narrow therapeutic range (0.5 - 1.0 ng/mL) • It undergoes conjugation & N-methylation. • Approved only for sedation ≤ 24 h.

  34. α2 – agonists • Haemodynamics Effects: -  heart rate. - Initial  then  BP. -  SVR. -  CO • No respiratory depression

  35. Unwanted side-effects of sedative agents General Over sedation Delayed awakening/extubation • 2-agonists • Hypotension • Bradycardia Benzodiazepines Hypotension Respiratory depression Agitation/Confusion Propofol Hypertriglyceridemia CVS depression Hypotension • Ketamine • Hypertension • Secretions • Dysphoria

  36. Assessment of Sedation • Ramsay Sedation Score. • Motor Activity Assessment Scale • Richmond Agitation–Sedation Scale. • Sedation – Agitation Score. • Modified Glasgow Coma Score.

  37. Ramsay Sedation Score

  38. Bispectral Index

  39. Is any place for neuro-muscular Blockers in ICU?

  40. Mehta S et al. Crit Care Med 2006; 34: 374

  41. * Under sedation: Fighting the ventilator. V/Q mismatch. Accidental extubation. Catheter displacement. CV stress  ischemia. Anxiety, awareness. Post-traumatic stress disorder. * Over sedation: Tolerance, tachyphylaxis. Withdrawal syndrome. Delirium. Prolonged ventilation. CV depression.  neuro testing. Sleep disturbance. The Art of Sedation

  42. Thank You Yasser Zaghloul

More Related